Know Your Risks

I can now scientifically prove what I have been telling people for years.  If you don't want to die from heart disease, take care of your risk factors.  Today, in the New England Journal of Medicine, a study was released showing that nonsmoking people in their 40-50's with normal blood pressure, blood sugar, and cholesterol levels had a five time lower risk of getting heart disease compared with those with at least two of those risk factors.  I have had patients come in to my office worried about their risk for heart disease, wanting to get some fancy test to see if they are at risk.  I tell them, of course you are at risk.  You smoke, you don't exercise.  Your cholesterol is up.  What they really want is to ignore their risk factors and have some test saying that everything is all right.  They don't want to change.  A test may be normal but that doesn't mean it will stay that way.  I have had patients present with heart attacks six weeks after a normal stress test.

All of these risk factors are modifiable.  They can be changed.  If you smoke, you can quit.  It is hard and you may have to try again and again, but you can quit.  Help is as easy as calling 1-800-QUIT-NOW.  If your blood pressure is up, it can be controlled.  Ideally through diet and exercise but medications may be necessary. More on this later.  Know what your blood pressure is.  It should be checked every year.  The same goes for levels of cholesterol and blood sugar.  If you don't know your levels, you don't know your risk.  You may be in your forties and feel fine.  However, the time to act is now to prevent problems in the future.  Get in to your physician and get checked out.  If you wait till you have symptoms of diabetes or heart disease it will be too late.

The great news is that if your risk factors are controlled you can spend your later years in good health.  You can enjoy yourself, take trips, be with the grandchildren.  No, none of us are immortal, but we all want to enjoy the time we have here in this life.  The human body is an amazing organism.  It is a precious gift from God.  Let's take good care of it.  It is the only one we have.

Earning My Ice Cream

If you have read many of my posts you must wonder if we even own an ice cream scoop.  I am constantly talking about fruits and veggies.  I extoll the virtues of avoiding processed foods.  Fats and sugars?  Must stay away at all costs.  What could be worse for you than ice cream?  It is loaded with sugar and is full of fat.  I tell my patients that it is the diabetic double whammy.  My daughter, a competitive swimmer is achieving her best times ever this year.  I asked her what was going on, "did you give up ice cream?" It truly is not good for you.  All true, but...I love ice cream.  I admit it.  In fact, I must give ice cream credit for much of how I view health and nutrition.

If ever my family had any reason to celebrate, ice cream was involved.  Sporting events, good grades, giving a talk in church, all were a reason for ice cream.  Anyone ever eat the cylindrical scoops from Lucky's?  Keeping the triple decker upright was always tricky.  We could never get Mom and Dad to spring for the triple, though, that had to be from paper route money.  Ice cream never lasted more than a few days in our home.  With three boys and my father (the biggest sneak of us all), the carton never lasted long.  Now mind you, we would get in trouble if found skimming off the top.  We all thought we had mastered the art of taking a spoon and taking off only the top layer so as to avoid detection.  No obvious divots could be found.  Oh, how sneaky we were!  Sure.  I have no doubt that Mom knew exactly what we were doing.  Especially, since you could never really just take off the top layer.  Once started, the layers quickly started to add up.

As I grew older and started to buy my own food, I started talking myself into the Bill Cosby rationale of healthy eating.  Let's see, ice cream has milk.  We all need milk every day.  It has calcium.  It is good for our bones.  It must be something that I should have every night.  It would "settle my stomach."  And so for several years I ate ice cream pretty much every night.  I reasoned that it was better than being addicted to heroin.  As the waist began to expand, my energy level start to sag, I had to admit that perhaps the ice cream was not helping me out.  I decided to give it up.  That lasted until the next time it was offered to me.  Like a chain smoker I would quickly go back to a bowl every night.  As I kept trying to stop my habit but failing, I finally settled on a dietary plan that I could stick with and still have my ice cream.


I decided that instead of feeling guilty for eating ice cream, I would go back to my childhood and use it as a reward.  I decided that during the week I would eat healthy.  I would eat at least 4-5 servings of fruits and vegetables a day.  I would not eat candy, treats, dessert, soda or even my beloved....ice cream.  I decided that if I did this in conjunction with exercising at least four days during the week I could eat whatever I wanted on the week end.  In the beginning I craved the treats so badly I would get headaches, sweaty and a bit dizzy.  When the weekend would come I ate way too much.  By Sunday night I was bloated, had a headache and couldn't wait for Monday to begin so that I had a reason to regain my will power.  With time, I learned to control myself better.  I now may enjoy a bowl of ice cream (which I did while writing this post!) but since I behaved during the week, I can savor it.  I enjoy it.  I've earned it.

Care With Caffeine

The road proceeds straight off in the distance tapering to a fine point on the horizon like the tip of an arrow.  Mile after mind numbing mile, the Kansas landscape passes broken only by the highway patrolmen stationed every fifteen miles to ensure that the state coffers don't run dry.  It starts as a few blinks but then the eyelids began to gain weight.  Gravity takes over and they start to sag.  The blinks become longer and I break down and realize that it is time to use some caffeine.  In my mind there are only two reasons to ingest caffeine: to keep my family alive on a long car trip across the country and to occasionally treat a headache.

First off, let us understand and realize that caffeine is a drug.  I have talked to many patients who are appropriately leery of taking prescription medications but don't think twice about the amount of caffeine they ingest.  One patient responding to how much caffeine he typically drinks by saying, "two a day."  I answered, "well, that's not too bad."  He looked down and a bit sheepishly clarified, "two....pots"  Well, that explained his chronic headaches, his indigestion and having to urinate constantly.  Caffeine is chemically in the xanthine family of drugs.  You can buy caffeine in pill form.  Just because it is also found in some of the food and beverages that we drink does not make it any less of a drug.  Remember, at one point cocaine was in Coca Cola.

As a medication, then, what effects does it have on the body?  Its two major effects is as a stimulant and a vasoconstrictor.  It causes blood vessels to tighten and the heart rate to speed up.  It acts quickly but tolerance develops after just a few days.  This is why it both treats and causes headaches.  Through its vasoconstricting effects on the blood vessels of the scalp and face, vascular headaches (such as migraines) can be aborted.  However, if used on a regular basis, the body will no longer respond or will respond just transiently and then be followed by a rebound phenomenon, triggering more headaches.  The same is true for its effect on fatigue.  The quick surge of wakefulness rebounds into lethargy and the dreaded brain fog.  Many respond by redosing the caffeine, making matters even worse.  My philosophy is to keep my system as free from caffeine as possible so that when I want to use its effects to my benefit, it will work for me.  I try not to use a medicine containing caffeine (like excedrin) more than three times a month.

One of caffeine's effects that has been used to our advantage is its ability to relax the airways in asthmatics.  However, given its short duration, its deleterious effects on the heart,  and the fact that we now have better, less toxic agents to achieve the same goal, it is no longer used for that purpose.  In regards to the heart, caffeine may increase the blood pressure a bit but mostly it causes the heart rate to speed up.  This accounts for the "buzz" from energy drinks.  Potentially dangerous heart arrhythmias may result.  This metabolic stimulation is used by manufacturers to promote products for weight loss.  Echinacea falls in this same category.  Many think that if it is "natural" it is safe.  Not so.  The only safe way to increase your body's metabolism is through cardiovascular exercise.  Any weight loss achieved through caffeine will come right back as soon as the product is stopped.

In addition to its affect on headaches, promoting chronic fatigue and over stimulating the heart, caffeine can also contribute to heartburn by affecting the sphincter muscle of the lower esophagus.  This muscle normally constricts when we are not swallowing, keeping acid in the stomach where it belongs.  Caffeine weakens that muscle.  Lastly, caffeine is a bladder irritant and a mild diuretic.  Bottom line?  If you are running to the bathroom more than you think you should, pay attention to how much caffeine you are ingesting.

In summary, just be careful with this medication.  Used sparingly for infrequent periods, it may have beneficial effects.  If used on a regular basis, it is likely to cause problems.  Here is a quick test to know if you are using too much caffeine.  If you ever refer to your caffeinated beverage by using a possessive pronoun such as "my coffee" or "my diet coke," you need to cut back.

Medicine for Your Bones

As stated in my first post on bones, the cornerstone of bone health is to make sure that there is enough material (calcium) delivered to the building site in conjunction with a regular stimulus to rebuild (weight bearing exercise).  For some, this is all that will be needed but if medications are needed, they will be much more effective in the setting of a proper calcium supply and regular exercise.  The medications used to treat weak bones fall in three main categories.  Each category has its advantages and each has downsides as well.  They can be separated broadly as 1) hormonally acting medications 2) bisphosphonates and 3) stimulators of bone growth.

It has long been recognized that the female hormone estrogen protects against bone loss.  It is after menopause that bones start to rapidly become more brittle.  For years, women were treated with estrogen after menopause.  It was felt that this kept their bones strong, reduced hot flashes and had beneficial effects on heart disease.  With time and further studies it has been shown that these hormones may actually promote heart disease and they certainly have an adverse effect on increasing one's risk for breast cancer.  The use of these medications has appropriately dropped off.  There are a group of medications that are similar to estrogen that are in use, the most common being Evista.  It is similar to estrogen in improving bones.  It likely is protective in breast cancer.  It is not certain what the effects are on the heart but it may make hot flashes worse.  Like estrogen, it may increase the risk of blood clots in the legs.  Though Evista is not typically used first line it is a reasonable choice in the right patient.

Bisphosphonates are the mainstay of treatment for osteoporosis.  This includes Fosamax (alendronate), Actonel (residronate) and Boniva (ibandronate).  These medications work by decreasing the activity of osteoclasts (the bone eaters).  By so doing, the osteoblasts have a chance to catch up and bone growth occurs.  Without question, they have shown to decrease the rate of fractures of the hip and spine.  However, there are some important points to understand in regards to the safety and long term use of these medications.  First, they are not easily absorbed and must be taken on an empty stomach.  They can be quite irritating to the esophagus and can cause an ulcer.  It is, therefore, important to take the medicine sitting upright and to stay upright for at least 30 minutes afterwards. There have been reports of a condition called osteonecrosis of the jaw with the use of these medications.  This is bone degeneration under the teeth.  It is mostly seen in patients who have been given these drugs for cancer and in very large doses through an IV.  It is exceedingly uncommon as part of a treatment plan for osteoporosis.  Lastly there have been news reports stating that there may be an increased risk of femur (leg) fracture if the medicines are used for a long period of time (more than ten years).  It turns out that these reports have been over blown but an important consideration remains.  Remembering that the medicine works by blocking absorption, if there is no action by the osteoclasts (bone eaters), eventually new bone will be put down on top of old bone.  Depending on one's level of bone loss when therapy was started, I recommend a "holiday" off of the medicine after 5 or ten years to make sure that bone turnover is occurring.

For patients who have severe osteoporosis with fractures that has not been adequately treated with the above medications or who cannot tolerate those medications, a relatively new therapy called Forteo can be given.  This works through parathyroid hormone actions and stimulates new bone growth.  It works quite well but should not be given for more than two years.  It is a daily injection that has to be given by the patient  and is quite expensive, thus limiting its use.  Another new medication is available called Prolia which I would only recommend be given by physicians well versed in osteoporosis.  If you have any questions, please let me know.

Measuring Bone Health

The ultimate goal of maintaining bone health is to prevent fractures.  We use a test called a bone density to help assess fracture risk.  It is a rather simple test to have done.  It requires no needles and is not painful.  It is similar to taking an x-ray but instead of taking a picture it takes a measurement.  The measurements are averaged and compared to the bones of young healthy adults.  The comparison is quantified mathematically in the form of a logarithm, called a T score.  Now before you roll your eyes and stop reading this, all you need to know is that the further you get away from zero, the worse you get.  Zero is the normal for that young healthy adult.  Osteoporosis (brittle bones) is labeled at -2.5 and osteopenia begins at -1.0.  Since it is logarithmic, -2.0 doesn't mean it is twice as bad, it means it is twenty times as bad and -3.0 is three hundred times as bad.

Ideally a bone density scan should be done on the same machine by the same technician.  There is significant variation between different types of machines.  The least accurate measurements are from the ones that look at the heel or the wrist.  Those should only be done as a quick screen and if abnormal should prompt a full evaluation with the standard scan done on the hip and spine.  The heal and wrist scans should not be used as a determinant to guide therapy.  Our bones are not uniformly thick, therefore variations in where the beam is directed can results in different values.  The technicians are trained to perform the test in the same area but if it is possible, having the same technician will lead to the most precise results.


One condition that will affect the accuracy of the test is arthritis of the spine.  In this condition, there is a build up of calcium deposits on the sides of the bone which will make the bone appear to be thicker and stronger than it really is.  In those patients who have a significant amount of arthritis, the scan should only be done on the hip.  Arthritis of the hip does not have the same problem because the measurement is not taken through the joint where the build up occurs.

It is important to understand that the number on the test is not the only determinant of your fracture risk.  A person with a nontraumatic hip fracture may have a T score of -2.2.  That would put them in the thin but not brittle group.  However, this person has already had a fracture so the future risk of additional fractures is going to be much higher.  Regardless of the T score, this person has osteoporosis.  Someone else with the same score and no history of fracture would be at a much lower risk.  Other risk factors should be considered such as whether a person is a woman who has gone through menopause, one's level of activity, whether or not a person is a smoker, one's family history is important and body size and composition.  A tool to add risk factors to one's T score to more accurately measure fracture risk is called the FRAX calculator.  This can be easily computed on line.  A score of 3% or higher is considered to be high risk and would warrant treatment.

Who should be screened for osteoporosis and how frequently does a bone density need to be repeated?  Men without risk factors are typically not screened.  Women should be screened for a baseline at menopause, repeating the test every two to five years depending on the score and their overall risk.  Those at higher risk due to medical conditions, certain medications, unprovoked fractures, etc should be screened earlier.  If in doubt, discuss this with your physician.  You should know your risk.  If you are at an above average risk for fracture, taking care of your bones now can prevent horribly painful conditions later when it will be too late to build back your bones.