I am truly amazed at the sheer number of patients I see that ask about weight loss. Most are interested in advice on diet, but a growing number turn to prescription medications in order to achieve their desired results. Over 400,000 deaths per year are attributable to obesity. With obesity overtaking smoking as the number one cause of death in this country, our focus has shifted to greater reliance on preventative medicine.
Traditional weight loss programs tend to suffer the same eventual fate – lack of sustainability. Multiple studies have demonstrated their ultimate failure at three to five years out. Most of these diets are difficult to adhere to for the long term as well; just ask anyone who has ever tried the Adkins diet. Diet pills like adipex or bontril have potential inherent risks, from elevations in blood pressure and pulse to overt valvular heart disease. Weight loss is not as simply as eating less and exercising more as there are huge variations in hormonal and genetic influences. At the core, however, is an overall reduction in caloric intake.
What then are we to do? Our office has embraced a new weight loss program that may offer patients an opportunity to lose weight safely and efficiently without the use of potential harmful medications. The program, called HealthPointe 2.0, has been used in over 25,000 patients in California with impressive results. Typical patients have lost an average of 1-3 pounds per week, or 18-30 pounds in a six week period. Many patients with diabetes or hypertension have been able to decrease, or in some cases, discontinue, many of their medications.
Weight loss is achieved through a fine balance of ensuring three meals a day with the addition of frequent protein based snacks that effectively rev up an individual’s metabolism. Uniquely, it is the snacks that allow a decrease in hunger and allow the body’s metabolism to return to a more normal state. Overweight patients often skip meals in order to decrease total intake, but then snack inappropriately with the wrong foods. In essence, they are actually slowing their metabolism – storing more fat and burning up their body’s protein stores. This results in continued weight gain and fatigue.
Since its inception in our clinic, we have seen quite impressive weight loss. While we readily admit that this diet may not be effective for everyone, it has little risk. After six weeks, patients can gradually add foods (and the amount of those foods) to their diet. The rationale is that once the metabolism has increased, a patient can then begin to eat more normally.
With New Year’s around the corner, there is no better time to work towards a healthier future. Without exception, weight loss is the cornerstone to better health and self-confidence. Diet pills are not the answer and are a potential risk down the line. We need to get more pro-active and get active! Weight loss takes a concerted effort; nothing ventured, nothing gained.
If you have any questions about the HealthPointe system or are interested in taking the Healthpointe challenge, feel free to contact me at 209-2996.
Medical Myths
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Dear Dr. Spence,
Q: Is there any validity to the recommendations to drink eight glasses of water per day to maintain health and hydration status?
A: Another valid question. Much of what we do as practitioners revolves around tradition. Physicians before us did things a certain way, and they in turn passed those methods to the younger generations. “It’s always been done that way” has been the adage used for nearly a century. But with a push towards evidence based medicine, many of the old traditions have been scrutinized ,and ultimately, debunked. The above question is no exception. We have always been led to believe that healthy adults should drink eight glasses of water per day. In 2002, a physician at Dartmouth attempted to track down the source of this recommendation. Not only could he not find a source, he could not find any evidence in the literature supporting it. In 2008, the University of Pennsylvania went so far as to say that, though well-intentioned, drinking eight glasses of water per day provided no increased health benefits. There was no weight loss, no elimination of toxins, no improvement in skin tone nor cure for constipation.
Q: How does one tell if they are dehydrated?
A: Typically, thirst dictates hydration status. Some have speculated that by the time you are thirsty, you are well past the point of dehydration. In actuality, thirst kicks in when you are still within the normal limits of hydration. Signs of dehydration may include, dry mouth, morning headaches or dark colored urine. Many people think darker urine is a sign of infection, but in most instances it is a consequence of hydration status only. Drinking too much water can actually be harmful in that it may cause dangerously low levels of sodium in the blood. Low sodium can cause anything from cramps and fatigue, to seizures and coma.
Q: Is it true that caffeine and alcohol are horribly dehydrating?
A: Research suggests that these have very little dehydrating effect though both act as diuretics. It is felt that the water in both beverages (coffee or alcohol) makes up for any potential losses. The most common issue resulting in dehydration is diarrhea as it may lead to rapid dehydration. This is one of the most common causes of mortality worldwide; death secondary from dehydration as a result of a severe gastrointestinal illness. Of course, exercise is a major contributor to dehydration. The American College of Sports Medication recommends consuming ½ to one cup of water for every twenty minutes of exercise. If you have lost weight from vigorous exercise, then one should drink two to three cups for every pound of weight lost.
All in all, increasing daily water consumption by a cup or two per day is not a bad idea, but overdoing it can be detrimental. As all things, there appears to be a delicate balance between too much and not enough.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Dear Dr. Spence,
Q: Is there any validity to the recommendations to drink eight glasses of water per day to maintain health and hydration status?
A: Another valid question. Much of what we do as practitioners revolves around tradition. Physicians before us did things a certain way, and they in turn passed those methods to the younger generations. “It’s always been done that way” has been the adage used for nearly a century. But with a push towards evidence based medicine, many of the old traditions have been scrutinized ,and ultimately, debunked. The above question is no exception. We have always been led to believe that healthy adults should drink eight glasses of water per day. In 2002, a physician at Dartmouth attempted to track down the source of this recommendation. Not only could he not find a source, he could not find any evidence in the literature supporting it. In 2008, the University of Pennsylvania went so far as to say that, though well-intentioned, drinking eight glasses of water per day provided no increased health benefits. There was no weight loss, no elimination of toxins, no improvement in skin tone nor cure for constipation.
Q: How does one tell if they are dehydrated?
A: Typically, thirst dictates hydration status. Some have speculated that by the time you are thirsty, you are well past the point of dehydration. In actuality, thirst kicks in when you are still within the normal limits of hydration. Signs of dehydration may include, dry mouth, morning headaches or dark colored urine. Many people think darker urine is a sign of infection, but in most instances it is a consequence of hydration status only. Drinking too much water can actually be harmful in that it may cause dangerously low levels of sodium in the blood. Low sodium can cause anything from cramps and fatigue, to seizures and coma.
Q: Is it true that caffeine and alcohol are horribly dehydrating?
A: Research suggests that these have very little dehydrating effect though both act as diuretics. It is felt that the water in both beverages (coffee or alcohol) makes up for any potential losses. The most common issue resulting in dehydration is diarrhea as it may lead to rapid dehydration. This is one of the most common causes of mortality worldwide; death secondary from dehydration as a result of a severe gastrointestinal illness. Of course, exercise is a major contributor to dehydration. The American College of Sports Medication recommends consuming ½ to one cup of water for every twenty minutes of exercise. If you have lost weight from vigorous exercise, then one should drink two to three cups for every pound of weight lost.
All in all, increasing daily water consumption by a cup or two per day is not a bad idea, but overdoing it can be detrimental. As all things, there appears to be a delicate balance between too much and not enough.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
“Sweet” or “Bittersweet”?
A swirling controversy is amongst us – specifically the taxation of soft drinks and sugared beverages. Its supporters argue that soda and the like are paving the way towards obesity and heart disease. Taxation of these goods may, therefore, improve general health while at the same time dramatically increase state and federal revenue. Detractors maintain the obesity crisis will not be solved through increased taxation and only serves to punish those who consume small amounts of sugared beverages.
Statistically, our consumption of sugared beverages has sky-rocketed in the last quarter century. Since 1977, the per capita intake of caloric drinks has doubled in the United States. The average daily caloric intake is estimated at approximately 172-175 calories per adult and child. Unfortunately, patients recognition that sugared beverages constitute “empty calories” and contributes to weight gain has been less than impressive.
Multiple studies have evaluated the effect of soft drink consumption on obesity and cardiovascular health. In particular, a two year study involving middle school students showed a 60% increased risk of obesity for every additional serving of sugared beverages per day. Another eight year study involving women showed that by increasing consumption of sugared beverages over the study’s final four years, a woman could expect a 17.6 pound weight gain versus 6.2 pounds in the groups that did not increase their consumption.
The massive Nurses Health Study evaluated 91,249 women over eight years and revealed a two fold increase in diabetes mellitus among women who consumed one or more sugared beverage per day. Half the risk appeared to be attributable to greater body weight. Heart disease was increased 23% and jumped to 35% with consumption of two or more servings per day.
Health risks are felt to be secondary to a variety of causes, from elevated triglyceride levels and blood pressures, to decreased HDL (good cholesterol) and an increase in insulin resistance. Medical costs for obese patients are estimated at 147 billion dollars per year – nearly 10% of all U.S health care costs!
Suggested taxation is one cent per ounce of beverage. This would increase the cost of a 20 ounce bottle by about 20% or so. In turn, it is estimated that this would raise 14.9 billion dollars in federal revenue with 928 million dollars raised in Florida alone. Taxes would be levied on the companies themselves, which would then be passed on to the retailer. Consumers would then become aware of the cost increase at the point of sale which may discourage them from their purchase. If a typical consumer changed to a no-calorie substitute, he would shave nearly 175 calories from his diet per day (as noted above). This could decrease total caloric intake by 63,875 per year, or 18.25 pounds!
The backlash from corporate America has been strong. Pepsi threatened to move their headquarters from New York after an 18% tax on sugared beverages was proposed. The beverage industry has created an American Against Food Taxes group to fight the potential governmental taxations. It would appear that their efforts confirm their belief that taxation of sugared beverages will dramatically reduce consumption. Of course, reduced consumption equals reduced profits.
It is clear that a simple reduction in calories may have a huge impact on general health in this country. The question is whether or not taxation of these goods is the best way of achieving these gains.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Statistically, our consumption of sugared beverages has sky-rocketed in the last quarter century. Since 1977, the per capita intake of caloric drinks has doubled in the United States. The average daily caloric intake is estimated at approximately 172-175 calories per adult and child. Unfortunately, patients recognition that sugared beverages constitute “empty calories” and contributes to weight gain has been less than impressive.
Multiple studies have evaluated the effect of soft drink consumption on obesity and cardiovascular health. In particular, a two year study involving middle school students showed a 60% increased risk of obesity for every additional serving of sugared beverages per day. Another eight year study involving women showed that by increasing consumption of sugared beverages over the study’s final four years, a woman could expect a 17.6 pound weight gain versus 6.2 pounds in the groups that did not increase their consumption.
The massive Nurses Health Study evaluated 91,249 women over eight years and revealed a two fold increase in diabetes mellitus among women who consumed one or more sugared beverage per day. Half the risk appeared to be attributable to greater body weight. Heart disease was increased 23% and jumped to 35% with consumption of two or more servings per day.
Health risks are felt to be secondary to a variety of causes, from elevated triglyceride levels and blood pressures, to decreased HDL (good cholesterol) and an increase in insulin resistance. Medical costs for obese patients are estimated at 147 billion dollars per year – nearly 10% of all U.S health care costs!
Suggested taxation is one cent per ounce of beverage. This would increase the cost of a 20 ounce bottle by about 20% or so. In turn, it is estimated that this would raise 14.9 billion dollars in federal revenue with 928 million dollars raised in Florida alone. Taxes would be levied on the companies themselves, which would then be passed on to the retailer. Consumers would then become aware of the cost increase at the point of sale which may discourage them from their purchase. If a typical consumer changed to a no-calorie substitute, he would shave nearly 175 calories from his diet per day (as noted above). This could decrease total caloric intake by 63,875 per year, or 18.25 pounds!
The backlash from corporate America has been strong. Pepsi threatened to move their headquarters from New York after an 18% tax on sugared beverages was proposed. The beverage industry has created an American Against Food Taxes group to fight the potential governmental taxations. It would appear that their efforts confirm their belief that taxation of sugared beverages will dramatically reduce consumption. Of course, reduced consumption equals reduced profits.
It is clear that a simple reduction in calories may have a huge impact on general health in this country. The question is whether or not taxation of these goods is the best way of achieving these gains.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Increasing Hair Loss
Dear Dr. Spence,
I am a 52 year old female who has been having increasing hair loss. I’m afraid if I don’t do something at once, I’ll soon be completely bald. Help! What do you suggest I do?
Signed,
Imma Shining
-- Dear Imma,
There are many causes of hair loss. It is important to understand the principles of hair growth before one can understand the principles of hair loss. Hair grows in cycles of two to six years with an average growth of one centimeter per month during each cycle. It is normal to lose approximately 100 hairs per day which can be disconcerting for some people that are not aware of this. This, in part, may explain why hair growth can recuperate after a period of apparent loss.
As noted, there are numerous causes of hair loss, or alopecia. The most common is known as telogen effluvium (doctors always need fancy words to explain common conditions!). In telogen effluvium, an increased number of hairs enter the telogen, or resting phase and these hairs eventually fall out approximately three months later. The normal hair loss of 100 per day dramatically increases and may cause a loss of up to 30-50% of total body hair. Telogen effluvium is typically precipitated by some form of stressful event three months prior to the complaint. Stressful events may include surgery, childbirth, illness, injury or even severe psychologic stress. Other possible causes include thryoid disease (overactive or underactive) and iron deficiency. Medications may be the culprit and can include antiepileptics, hormones, blood thinners and some blood pressure medications.
Alopecia areata causes hair loss in circular patches and is typically a result of chronic illness like diabetes mellitus, thyroid disease or lupus. It can happen at any age and treatment usually consists of treating the underlying disease process. Other causes of hair loss include nutritional deficiencies, syphilis, medications and repeated trauma to the hair though braids, perms, use of hair curlers or twisting.
For physicians, the general evaluation revolves around a thorough history and physical. In some cases, bloodwork may be of some value and often includes thyroid testing as well as evaluation of iron stores and hormone levels (testosterone etc.). As noted, most cases are secondary to telogen effluvium and will resolve over time once the stressor has passed.
Finally, once all is said and done, many women are simply suffering from female pattern hair loss which is characterized by thinning over the central area of the scalp with widening of the midline part. Nearly 50% of women will experience female pattern hair loss in their lifetime. Treatment consists of over the counter minoxidil. It may take three to six months to see results. The higher concentration solutions (5%) do not offer any clear benefit and may be more likely to cause dryness, itching and possible skin irritation. I recommend the 2% solution.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
I am a 52 year old female who has been having increasing hair loss. I’m afraid if I don’t do something at once, I’ll soon be completely bald. Help! What do you suggest I do?
Signed,
Imma Shining
-- Dear Imma,
There are many causes of hair loss. It is important to understand the principles of hair growth before one can understand the principles of hair loss. Hair grows in cycles of two to six years with an average growth of one centimeter per month during each cycle. It is normal to lose approximately 100 hairs per day which can be disconcerting for some people that are not aware of this. This, in part, may explain why hair growth can recuperate after a period of apparent loss.
As noted, there are numerous causes of hair loss, or alopecia. The most common is known as telogen effluvium (doctors always need fancy words to explain common conditions!). In telogen effluvium, an increased number of hairs enter the telogen, or resting phase and these hairs eventually fall out approximately three months later. The normal hair loss of 100 per day dramatically increases and may cause a loss of up to 30-50% of total body hair. Telogen effluvium is typically precipitated by some form of stressful event three months prior to the complaint. Stressful events may include surgery, childbirth, illness, injury or even severe psychologic stress. Other possible causes include thryoid disease (overactive or underactive) and iron deficiency. Medications may be the culprit and can include antiepileptics, hormones, blood thinners and some blood pressure medications.
Alopecia areata causes hair loss in circular patches and is typically a result of chronic illness like diabetes mellitus, thyroid disease or lupus. It can happen at any age and treatment usually consists of treating the underlying disease process. Other causes of hair loss include nutritional deficiencies, syphilis, medications and repeated trauma to the hair though braids, perms, use of hair curlers or twisting.
For physicians, the general evaluation revolves around a thorough history and physical. In some cases, bloodwork may be of some value and often includes thyroid testing as well as evaluation of iron stores and hormone levels (testosterone etc.). As noted, most cases are secondary to telogen effluvium and will resolve over time once the stressor has passed.
Finally, once all is said and done, many women are simply suffering from female pattern hair loss which is characterized by thinning over the central area of the scalp with widening of the midline part. Nearly 50% of women will experience female pattern hair loss in their lifetime. Treatment consists of over the counter minoxidil. It may take three to six months to see results. The higher concentration solutions (5%) do not offer any clear benefit and may be more likely to cause dryness, itching and possible skin irritation. I recommend the 2% solution.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
N- acetylcysteine
I read with interest a recent article discussing the potential benefits of N- acetylcysteine, an amino acid that has been used in treatment primarily of tylenol toxicity. The effects are based on its ability to act as a potent antioxidant which may support the body’s ability to fight infections or stress. It appears to protect cells from toxins by detoxification of various toxic substances.
The most interesting clinical application is in the treatment and prevention of influenza. With more and more threat of the pandemic H1/N1 swine flu, N-acetylcysteine may be a useful adjunct to current therapy. Compared to placebo pills, N-acetylcysteine users were less likely to have clinical influenza (or at least symptoms of it). Secondly, when those patients actually did develop influenza, it was a much less severe case. It appeared that immunity at a cellular level improved significantly. Though not part of any official CDC recommendations, it may be an option for those who are at higher risk of developing the H1/N1 strain, or any influenza strain for that matter.
A second use of N-acetylcysteine is for patients with chronic lung disease (COPD or emphysema). A study of over 1300 patients found there was a reduction in cough severity and amount of phlegm produced. Those same patients had less likelihood of developing shortness of breath and associated heart failure. Furthermore, based on actual lung testing, they had improvement in their overall lung function. It was shown that in the N-acetylcysteine group, there was nearly 50% less loss of lung function when compared to those not on the supplement. This may be exciting news for patients with chronic lung disease. Many of the available inhaled treatments do not provide total relief. Addition of N-acetylcysteine may be useful in preventing future attacks of acute bronchitis.
Dosing is generally 1200 mg twice per day. Generally at lower doses, the drug is well-tolerated. Side effects may include nausea, vomiting, diarrhea, skin rash, flushing and abdominal pain. Larger doses are used to treat acetaminophen toxicity (tylenol poisoning). At these doses, side effects may include headache, itching, fever and severe allergic reactions. Any patient on nitroglycerin for heart disease should use caution as this combination may result in significant drops in blood pressure. N-acetylcysteine is available over the counter in doses of 600 mg. As noted, standard dosing is two capsules twice per day.
In short, N-acetylcysteine, by acting as a potent antioxidant, may improve symptoms of chronic lung disease and may also be a useful adjunctive medication in the prevention and treatment of viral influenza. It may also protect against kidney damage when given prior to certain imaging procedures (i.e. CT scans that use intravenous contrast). I did not expand on this fact in a deliberate attempt to not bore my readers to tears. There you have it.
The most interesting clinical application is in the treatment and prevention of influenza. With more and more threat of the pandemic H1/N1 swine flu, N-acetylcysteine may be a useful adjunct to current therapy. Compared to placebo pills, N-acetylcysteine users were less likely to have clinical influenza (or at least symptoms of it). Secondly, when those patients actually did develop influenza, it was a much less severe case. It appeared that immunity at a cellular level improved significantly. Though not part of any official CDC recommendations, it may be an option for those who are at higher risk of developing the H1/N1 strain, or any influenza strain for that matter.
A second use of N-acetylcysteine is for patients with chronic lung disease (COPD or emphysema). A study of over 1300 patients found there was a reduction in cough severity and amount of phlegm produced. Those same patients had less likelihood of developing shortness of breath and associated heart failure. Furthermore, based on actual lung testing, they had improvement in their overall lung function. It was shown that in the N-acetylcysteine group, there was nearly 50% less loss of lung function when compared to those not on the supplement. This may be exciting news for patients with chronic lung disease. Many of the available inhaled treatments do not provide total relief. Addition of N-acetylcysteine may be useful in preventing future attacks of acute bronchitis.
Dosing is generally 1200 mg twice per day. Generally at lower doses, the drug is well-tolerated. Side effects may include nausea, vomiting, diarrhea, skin rash, flushing and abdominal pain. Larger doses are used to treat acetaminophen toxicity (tylenol poisoning). At these doses, side effects may include headache, itching, fever and severe allergic reactions. Any patient on nitroglycerin for heart disease should use caution as this combination may result in significant drops in blood pressure. N-acetylcysteine is available over the counter in doses of 600 mg. As noted, standard dosing is two capsules twice per day.
In short, N-acetylcysteine, by acting as a potent antioxidant, may improve symptoms of chronic lung disease and may also be a useful adjunctive medication in the prevention and treatment of viral influenza. It may also protect against kidney damage when given prior to certain imaging procedures (i.e. CT scans that use intravenous contrast). I did not expand on this fact in a deliberate attempt to not bore my readers to tears. There you have it.
Polypill on the Horizon?
At the recent American College of Cardiology meeting, phase 2 results of the Indian Polycap Study (TIPS) were presented. Within this landmark trial, investigators have been evaluating the positive effects of a polypill that contains three blood pressure lowering agents, a cholesterol reducer (statin) and an aspirin. It has been estimated that use of the polypill could reduce coronary heart disease by 62% and stroke by 48%. The polypill represents one of three strategies in development by the World Health Organization to reduce cardiovascular disease, the other two being weight loss and smoking cessation.
TIPS took 2053 patients and placed them in one of eight study groups and evaluated them over the course of 12 weeks. The other groups included aspirin alone, aspirin plus statin, and combinations with all blood pressure agents. All were Indian patients with an average blood pressure of 134/85 and bad cholesterol (LDL) of 117, both of which are quite good by most standards. Results were impressive with most patients having substantial blood pressure drops and cholesterol lowering. The big question is whether high-risk individuals should be on this combination as a preventative measure. One also wonders if all patients should consider medications like this for health maintenance. It may be years before all the data is back, but it is certainly thought provoking.
Honey for Cough?
Controversy surrounds the use of over the counter cough and cold medications, especially in children. There is no convincing evidence that any of them provide benefit, and, in fact, they may be harmful secondary to side effects and the potential for overdose. It has been estimated that more than 7000 emergency room visits occur annually due to adverse drug events related to the use of children’s cough and cold medications. One third of these are associated with simple dosing errors. Once again, the World Health Organization has stepped in and recommended the use of honey to soothe cough in children older than one year. No formal study has evaluated honey versus standard medicines like dextromethorphan, though it appears better than no treatment. Given the relative safety of honey consumption, its potential use in treating upper respiratory infections is certainly intriguing. I would certainly recommend giving it a try before resorting to OTC purchases. At a minimum, parents should be educated on these issues. We all believe that there medicine can cure anything, but the reality is that they all have the potential to do more harm than good.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
TIPS took 2053 patients and placed them in one of eight study groups and evaluated them over the course of 12 weeks. The other groups included aspirin alone, aspirin plus statin, and combinations with all blood pressure agents. All were Indian patients with an average blood pressure of 134/85 and bad cholesterol (LDL) of 117, both of which are quite good by most standards. Results were impressive with most patients having substantial blood pressure drops and cholesterol lowering. The big question is whether high-risk individuals should be on this combination as a preventative measure. One also wonders if all patients should consider medications like this for health maintenance. It may be years before all the data is back, but it is certainly thought provoking.
Honey for Cough?
Controversy surrounds the use of over the counter cough and cold medications, especially in children. There is no convincing evidence that any of them provide benefit, and, in fact, they may be harmful secondary to side effects and the potential for overdose. It has been estimated that more than 7000 emergency room visits occur annually due to adverse drug events related to the use of children’s cough and cold medications. One third of these are associated with simple dosing errors. Once again, the World Health Organization has stepped in and recommended the use of honey to soothe cough in children older than one year. No formal study has evaluated honey versus standard medicines like dextromethorphan, though it appears better than no treatment. Given the relative safety of honey consumption, its potential use in treating upper respiratory infections is certainly intriguing. I would certainly recommend giving it a try before resorting to OTC purchases. At a minimum, parents should be educated on these issues. We all believe that there medicine can cure anything, but the reality is that they all have the potential to do more harm than good.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Insomnia Part 2
Dear Dr. Spence,
Why can’t I seem to get a good night sleep? What can I do other than pop pills every night?
Signed,
Sleepless in Marianna
In my last writing I had been discussing some of the causes and implications of insomnia. The solution to improving sleep hygiene, however, is more complex. There are many options available to patients. Some are by prescription, some are over the counter remedies and some are just plain common sense. First and foremost, of course, is fixing any problem that may have led to the insomnia originally. If a patient is depressed for example, proper therapy may be an antidepressant as opposed to a sleep aide.
Changing sleep habits is a simple and occasionally effective way of combating the problem. Maintaining regular sleep and wake times are crucial at helping regulate the body’s natural circadian rhythms. Many people incorporate behavioral therapy into the mix. Techniques include muscle relaxation, breathing exercises and cognitive therapies that try to replace worry about sleep with more positive thoughts.
There are of course some basics when it comes to sleep hygiene. You should keep the same sleep schedule regardless of whether it is a weekend or not. Try to avoid the temptation of sleeping in once Saturday and Sunday roll around. You should sleep as much as you need to in order to feel rested. If you cannot sleep for fifteen minutes, it is recommended that you engage in another activity for a while (i.e. reading a book or watching T.V.) Do not read, eat, watch T.V. or work in bed. The bedroom should be a place of comfort; cool with minimal distractions like noise or light. Get rid of the computers and T.V. Those who engage in regular exercise generally report better sleep. Lastly, limiting alcohol and/or caffeine at bedtime can also help prevent insomnia.
Finally, medications can be used if all else fails. Over the counter medications like valerian and melatonin have been used for years with varying degrees of success. Most studies do not support their efficacy. Your physician can prescribe a host of agents that may help induce sleep. Popular agents like lunesta and ambien can be beneficial but may be potentially addictive and may be problematic in older adults due to their sedative properties. Rozerem claims to work by helping maintain the natural sleep architecture through sleep-wake cycles and does not appear to have the adverse effects or dependence that is seen with other agents. Your physician can assist you in finding the right medication for you.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Why can’t I seem to get a good night sleep? What can I do other than pop pills every night?
Signed,
Sleepless in Marianna
In my last writing I had been discussing some of the causes and implications of insomnia. The solution to improving sleep hygiene, however, is more complex. There are many options available to patients. Some are by prescription, some are over the counter remedies and some are just plain common sense. First and foremost, of course, is fixing any problem that may have led to the insomnia originally. If a patient is depressed for example, proper therapy may be an antidepressant as opposed to a sleep aide.
Changing sleep habits is a simple and occasionally effective way of combating the problem. Maintaining regular sleep and wake times are crucial at helping regulate the body’s natural circadian rhythms. Many people incorporate behavioral therapy into the mix. Techniques include muscle relaxation, breathing exercises and cognitive therapies that try to replace worry about sleep with more positive thoughts.
There are of course some basics when it comes to sleep hygiene. You should keep the same sleep schedule regardless of whether it is a weekend or not. Try to avoid the temptation of sleeping in once Saturday and Sunday roll around. You should sleep as much as you need to in order to feel rested. If you cannot sleep for fifteen minutes, it is recommended that you engage in another activity for a while (i.e. reading a book or watching T.V.) Do not read, eat, watch T.V. or work in bed. The bedroom should be a place of comfort; cool with minimal distractions like noise or light. Get rid of the computers and T.V. Those who engage in regular exercise generally report better sleep. Lastly, limiting alcohol and/or caffeine at bedtime can also help prevent insomnia.
Finally, medications can be used if all else fails. Over the counter medications like valerian and melatonin have been used for years with varying degrees of success. Most studies do not support their efficacy. Your physician can prescribe a host of agents that may help induce sleep. Popular agents like lunesta and ambien can be beneficial but may be potentially addictive and may be problematic in older adults due to their sedative properties. Rozerem claims to work by helping maintain the natural sleep architecture through sleep-wake cycles and does not appear to have the adverse effects or dependence that is seen with other agents. Your physician can assist you in finding the right medication for you.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
There is No Such Thing As a “Free Lunch”
I have had several patients ask me about the recent change in the pharmaceutical industry’s indiscriminate practice of giving gifts to physicians. It has long been known that drug reps were a great source for an assortment of pens, staplers, coffee mugs, and even years ago, elaborate fishing and golf trips. I daresay I haven’t purchased a pen in over seven years and have provided many a nurse with the latest gadget. Recently, the Pharmaceutical Research and Manufacturers of America (Pharma) has noted that branded gifts “are not based on informing physicians about medical and scientific issues” and subsequently banned all gifting to doctors. No more pens. No more note pads. The pharmaceutical companies have always hoped that use of their pens may ultimately influence physician prescribing habits, thus increasing their bottom line. This practice has come under great scrutiny as research suggests that they may be right!
Further, even the practice of drug sampling has been examined. Drug reps typically leave a slew of their expensive “branded” products for doctors to dispense. It is quite handy to be able to provide the samples to patients as a “free trial”. The reality is that these free trials result in greater long-term prescription costs given that cheaper generic medications may be equally effective. According to studies, out of pocket costs for prescription drugs increased 47% for patients who received free medications to try when compared to those who were not offered samples.
As alluded to above, when physicians have access to samples, they tend to prescribe more expensive medications. Medication sampling accounts for $16 billion a year, or roughly half of the industry’s marketing budget. The annual cost of prescription drugs is $227.5 billion per year, or 10% of all health care spending in the United States. This is a disturbing trend, certainly. I personally make every attempt to limit an individual’s expenditure and will only use branded drugs if I feel it is absolutely necessary. I’m a consumer, too, and would hate to feel ripped off if there was a cheaper, equally efficacious alternative.
The pharmaceutical industry also offers a litany of articles supporting the use of their products, many with skewed data and funded by the very company marketing the drug. Is it any wonder their studies so convincingly advocate use of their medication? Most physicians cannot be bothered to systematically examine each article and therefore, they tend to take the data at face value. This may, in turn, result in the skyrocketing use of $200 a month meds As Mark Twain said, “There are lies, damned lies, and statistics”.
Now, where’s my free lunch!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Dear Dr. Spence,
What’s all the flack about flaxseed oil? I have intolerance to zocor and lipitor. Can flaxseed oil improve my cholesterol?
Signed,
The Lorax
Dear Lorax,
Flaxseed oil is a natural plant food that contains large amounts of omega-3 fatty acids that have proven beneficial in lowering triglycerides and other heart parameters. Compared to canola and corn oil that have 10% and 1% omega-3s respectively, flaxseed oil has 57% omega-3s.There have been numerous studies evaluating the cholesterol lowering effects of flaxseed. Though not as powerful an LDL (bad cholesterol) buster, it may drop triglycerides by 36%. The potential positive effects of flaxseed do not stop at triglycerides, however.
It has been estimated that nearly 30-40% of all cancers could be prevented through dietary and lifestyle interventions. Flaxseed oils, which contain certain phytoestrogens known as lignans, have value in blocking hormone dependent cancers such as breast and prostate cancer. With prostate cancer, flaxseed may increase levels of enterolactones, an active product that may confer some benefit. In one large study from Sweden, men with the highest enterolactone levels were 82% less likely to develop prostate cancer.
Given that flaxseed is rich in phytoestrogens, it would make sense that it may provide relief to the millions of women who suffer the discomforts of menopause, i.e. hot flushes. The Mayo Clinic demonstrated that flaxseed oil significantly decreased the occurrence of hot flushes in those women who chose not to take estrogen therapy. Estrogen’s potential link to breast cancer has left many wondering what the best therapy for menopause may be. Phytoestrogens exert both estrogenic and anti-estrogenic effects that may improve the annoying symptoms without increasing worrisome side effects. With more and more women opting for more natural protection against menopausal symptoms, flaxseed may provide a welcome alternative.
Flaxseed is also a rich source of dietary fiber. Soluble fiber forms a matrix with water that adds bulk to stool and promotes more regular bowel movements and freedom from constipation. Insoluble fiber in flaxseed may help slow the release of sugar into the bloodstream after a meal, preventing spikes in blood sugars, certainly a benefit in any diabetic or overweight patient. One ounce of flaxseed contains 32% of the fiber recommended by the United States Department of Agriculture (USDA).
Patients should use ground flaxseed and sprinkle it on cereal, yogurt, salads or vegetables. In fact, a simple internet search can provide hundreds of healthy recipes that may incorporate flaxseed into the daily diet.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
What’s all the flack about flaxseed oil? I have intolerance to zocor and lipitor. Can flaxseed oil improve my cholesterol?
Signed,
The Lorax
Dear Lorax,
Flaxseed oil is a natural plant food that contains large amounts of omega-3 fatty acids that have proven beneficial in lowering triglycerides and other heart parameters. Compared to canola and corn oil that have 10% and 1% omega-3s respectively, flaxseed oil has 57% omega-3s.There have been numerous studies evaluating the cholesterol lowering effects of flaxseed. Though not as powerful an LDL (bad cholesterol) buster, it may drop triglycerides by 36%. The potential positive effects of flaxseed do not stop at triglycerides, however.
It has been estimated that nearly 30-40% of all cancers could be prevented through dietary and lifestyle interventions. Flaxseed oils, which contain certain phytoestrogens known as lignans, have value in blocking hormone dependent cancers such as breast and prostate cancer. With prostate cancer, flaxseed may increase levels of enterolactones, an active product that may confer some benefit. In one large study from Sweden, men with the highest enterolactone levels were 82% less likely to develop prostate cancer.
Given that flaxseed is rich in phytoestrogens, it would make sense that it may provide relief to the millions of women who suffer the discomforts of menopause, i.e. hot flushes. The Mayo Clinic demonstrated that flaxseed oil significantly decreased the occurrence of hot flushes in those women who chose not to take estrogen therapy. Estrogen’s potential link to breast cancer has left many wondering what the best therapy for menopause may be. Phytoestrogens exert both estrogenic and anti-estrogenic effects that may improve the annoying symptoms without increasing worrisome side effects. With more and more women opting for more natural protection against menopausal symptoms, flaxseed may provide a welcome alternative.
Flaxseed is also a rich source of dietary fiber. Soluble fiber forms a matrix with water that adds bulk to stool and promotes more regular bowel movements and freedom from constipation. Insoluble fiber in flaxseed may help slow the release of sugar into the bloodstream after a meal, preventing spikes in blood sugars, certainly a benefit in any diabetic or overweight patient. One ounce of flaxseed contains 32% of the fiber recommended by the United States Department of Agriculture (USDA).
Patients should use ground flaxseed and sprinkle it on cereal, yogurt, salads or vegetables. In fact, a simple internet search can provide hundreds of healthy recipes that may incorporate flaxseed into the daily diet.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
The Daily Dose
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Dear Dr. Spence,
What is Bell’s palsy?
Signed,
Lotta Drooping
Dear Lotta,
Bell’s palsy is an acute paralysis of the facial nerve that typically results in the fairly sudden onset of facial drooping on one side, as well as possible taste loss and inability to close the eye on that same side. It is unclear as to what is the cause of this entity, though many suggest it is viral in origin. It is cause for great distress as its symptoms closely mimic that of an acute stroke. Bell’s palsy affects roughly 20 to 30 people per 100,000 each year. Most of the time, full recovery of the paralysis occurs, but up to 30% can have residual symptoms, including facial weakness or pain.
The great debate has been how to treat these patients, as the literature has yielded conflicting results. A new study from the New England Journal of Medicine does shed light on the controversy. In the past, practitioners have used steroids, anti-viral medications like acyclovir, or both. The study consisted of 551 patients who were placed in one of four different treatment groups – acyclovir and placebo, steroid and placebo, steroid and acyclovir or placebo alone. After three and nine months analysis, those individuals in the steroid arm had a greater likelihood of making a full recovery. There was no benefit to adding the anti-viral agent acyclovir to the mix. In essence, if caught early enough (within the first 72 hours), steroids like prednisone are a valuable addition to treatment of Bell’s palsy.
Dear Dr. Spence,
I have tried nearly every diet on earth. What do you think is the best for me?
Signed,
Gotta Stuffless
Dear Gotta,
From the standpoint of weight loss, nearly all diets have been shown to be approximately equivalent after about one year. I have extolled the virtues of the Mediterranean diet for some time. Heavily based on fruits, vegetables, lean meats, red wine, olive oils, fish and nuts, the Mediterranean diet has been proven to reduce mortality in varying patient populations and may also result in a small degree of weight loss. The Lyon Heart Study looked at 300 patients adhering to the diet and showed a 73% risk reduction for heart attack and a 70% risk reduction in overall death (relative risks). Another Italian study showed similar, though not nearly as impressive, results as the Lyon study. The difficulty with adhering to this diet is the inherent cost. Certainly, fresh fruits and vegetables are more expensive than some canned and packaged products. Sometimes, cost can trump the long-term benefits of a healthier living.
What is Bell’s palsy?
Signed,
Lotta Drooping
Dear Lotta,
Bell’s palsy is an acute paralysis of the facial nerve that typically results in the fairly sudden onset of facial drooping on one side, as well as possible taste loss and inability to close the eye on that same side. It is unclear as to what is the cause of this entity, though many suggest it is viral in origin. It is cause for great distress as its symptoms closely mimic that of an acute stroke. Bell’s palsy affects roughly 20 to 30 people per 100,000 each year. Most of the time, full recovery of the paralysis occurs, but up to 30% can have residual symptoms, including facial weakness or pain.
The great debate has been how to treat these patients, as the literature has yielded conflicting results. A new study from the New England Journal of Medicine does shed light on the controversy. In the past, practitioners have used steroids, anti-viral medications like acyclovir, or both. The study consisted of 551 patients who were placed in one of four different treatment groups – acyclovir and placebo, steroid and placebo, steroid and acyclovir or placebo alone. After three and nine months analysis, those individuals in the steroid arm had a greater likelihood of making a full recovery. There was no benefit to adding the anti-viral agent acyclovir to the mix. In essence, if caught early enough (within the first 72 hours), steroids like prednisone are a valuable addition to treatment of Bell’s palsy.
Dear Dr. Spence,
I have tried nearly every diet on earth. What do you think is the best for me?
Signed,
Gotta Stuffless
Dear Gotta,
From the standpoint of weight loss, nearly all diets have been shown to be approximately equivalent after about one year. I have extolled the virtues of the Mediterranean diet for some time. Heavily based on fruits, vegetables, lean meats, red wine, olive oils, fish and nuts, the Mediterranean diet has been proven to reduce mortality in varying patient populations and may also result in a small degree of weight loss. The Lyon Heart Study looked at 300 patients adhering to the diet and showed a 73% risk reduction for heart attack and a 70% risk reduction in overall death (relative risks). Another Italian study showed similar, though not nearly as impressive, results as the Lyon study. The difficulty with adhering to this diet is the inherent cost. Certainly, fresh fruits and vegetables are more expensive than some canned and packaged products. Sometimes, cost can trump the long-term benefits of a healthier living.
Celiac disease
Dear Dr. Spence,
I have problems with frequent diarrhea and abdominal pain. A friend suggested I may have celiac disease. I’ve never heard of it. Could I have it?
Signed,
BM
Dear BM,
I have problems with frequent diarrhea and abdominal pain. A friend suggested I may have celiac disease. I’ve never heard of it. Could I have it?
Signed,
BM
Dear BM,
Celiac disease is an inability to digest gluten, the primary component found within wheat and wheat like products. Resultant symptoms include anything from diarrhea, bloating and abdominal pain to joint pain, extreme fatigue and infertility. Interestingly, patients may even present with functional constipation as their main symptom. Most, however, have symptoms that mimic those of irritable bowel syndrome. The prevalence of celiac disease is estimated to be at 1% of the general population, though most people have never heard of it.
Diagnosis is centered initially on blood testing, specifically antibody testing. Patients with iron deficiency anemia may have a 3-9% likelihood of celiac disease which is comparable to the 3-8% of diabetics afflicted. Diagnosis is often confirmed via intestinal biopsy. It is important to make a diagnosis early as mortality is increased if delayed greater than ten years. These patients are at risk for malignancy, specifically lymphoma.
Management of celiac disease involves elimination of gluten from the diet entirely – this includes discontinuation of wheat, rye or barley products. Most of the time, assistance from a registered dietician is crucial at maintaining adherence to the dietary restrictions. Continued problems with diarrhea etc. are usually the result of inadvertent gluten consumption. My experience is that many patients do have substantial problems in maintaining a gluten-free diet, but a positive attitude is a critical factor in success.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Osteoporosis II – Prevention and Treatment
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Previously, I commented on the diagnosis and potential courses of both osteoporosis and osteopenia. This installment focuses more on actual prevention and treatment options for those patients so affected.
Calcium has long been recommended for prevention of osteoporosis. Doses of at least 1200 mg per day have been suggested, but effectiveness at reducing fractures is unclear. Calcium carbonate is inexpensive but should be taken with meals to enhance absorption. Calcium citrate, though more expensive, can be taken without food. Commonly, dosing may be limited by constipation or stomach issues. Absorption can be impaired when used in conjunction with thyroid medications, blood pressures medications (specifically ACE inhibitors like lisinopril) or iron, and dosing should be separated by several hours at a minimum.
Vitamin D is critical, as I have mentioned in previous articles. Doses of 800-1000 IU per day are needed. The number needed to treat to prevent one hip fracture is 45 over 2-5 years of treatment. Given its benefit at potentially decreasing risk of stroke and certain cancers, there is no reason that patients should not supplement. This is one of the few supplements that I take personally!
For the most part, therapy revolves around a group of medications known as the bisphosphonates. Included in the class are fosamax, boniva and actonel. These medications inhibit bone turnover and therefore increase bone mineral density and strength. Trials demonstrate a reduction in spine and hip fractures with both actonel and fosamax. The number needed to treat over three years to prevent one fracture is 91 for fosamax and 79 for actonel. Despite weekly and monthly dosing schedules that are now available, noncompliance remains an issue with many patients stopping the medication entirely. Problems surround use of bisphosphonates in that they can cause significant problems with heartburn and esophageal symptoms. They must be taken with a full glass of water and patients must remain upright for at least 30-60 minutes after dosing. A newer option is once yearly intravenous infusion with reclast. Many patients like the convenience of once a year administration and the decreased likelihood of side effects. Cost can be problematic, but we have found that any patient with medicare and a supplemental insurance (i.e. AARP) will have near complete 100% coverage.
Concern has arisen over the potential for destruction of bone at the jaw. The complication is rare and has generally only been noted after intravenous use in patients diagnosed with cancer.
Other medications exist as far as treatment goes, but they are less commonly used and not worth discussing given constraints of space and for fear of completely losing any or all readership I may have secondary to boredom. What about hormones like estrogen? The Women’s Health Initiative trial did report that estrogen did reduce the risk of vertebral and hip fractures with a number needed to treat of 385 over five years. The benefits, however, do not outweigh the risks of estrogen therapy which include increased likelihood of breast cancer, stroke and heart disease. Generally, I do not recommend hormone therapy for treatment of osteoporosis unless the patient has compelling reasons to do so, like horrible hot flashes.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Previously, I commented on the diagnosis and potential courses of both osteoporosis and osteopenia. This installment focuses more on actual prevention and treatment options for those patients so affected.
Calcium has long been recommended for prevention of osteoporosis. Doses of at least 1200 mg per day have been suggested, but effectiveness at reducing fractures is unclear. Calcium carbonate is inexpensive but should be taken with meals to enhance absorption. Calcium citrate, though more expensive, can be taken without food. Commonly, dosing may be limited by constipation or stomach issues. Absorption can be impaired when used in conjunction with thyroid medications, blood pressures medications (specifically ACE inhibitors like lisinopril) or iron, and dosing should be separated by several hours at a minimum.
Vitamin D is critical, as I have mentioned in previous articles. Doses of 800-1000 IU per day are needed. The number needed to treat to prevent one hip fracture is 45 over 2-5 years of treatment. Given its benefit at potentially decreasing risk of stroke and certain cancers, there is no reason that patients should not supplement. This is one of the few supplements that I take personally!
For the most part, therapy revolves around a group of medications known as the bisphosphonates. Included in the class are fosamax, boniva and actonel. These medications inhibit bone turnover and therefore increase bone mineral density and strength. Trials demonstrate a reduction in spine and hip fractures with both actonel and fosamax. The number needed to treat over three years to prevent one fracture is 91 for fosamax and 79 for actonel. Despite weekly and monthly dosing schedules that are now available, noncompliance remains an issue with many patients stopping the medication entirely. Problems surround use of bisphosphonates in that they can cause significant problems with heartburn and esophageal symptoms. They must be taken with a full glass of water and patients must remain upright for at least 30-60 minutes after dosing. A newer option is once yearly intravenous infusion with reclast. Many patients like the convenience of once a year administration and the decreased likelihood of side effects. Cost can be problematic, but we have found that any patient with medicare and a supplemental insurance (i.e. AARP) will have near complete 100% coverage.
Concern has arisen over the potential for destruction of bone at the jaw. The complication is rare and has generally only been noted after intravenous use in patients diagnosed with cancer.
Other medications exist as far as treatment goes, but they are less commonly used and not worth discussing given constraints of space and for fear of completely losing any or all readership I may have secondary to boredom. What about hormones like estrogen? The Women’s Health Initiative trial did report that estrogen did reduce the risk of vertebral and hip fractures with a number needed to treat of 385 over five years. The benefits, however, do not outweigh the risks of estrogen therapy which include increased likelihood of breast cancer, stroke and heart disease. Generally, I do not recommend hormone therapy for treatment of osteoporosis unless the patient has compelling reasons to do so, like horrible hot flashes.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Osteoporosis
Dr. Spence:
Please tell me all about Osteoporosis.
Thanks,
Imma Bender
Osteoporosis I – Definitions and Evaluation
Osteoporosis remains a significant health risk in this country. Estimates suggest that nearly eight million women and two million men in the United States have osteoporosis and another 34 million may have osteopenia, considered a precursor to osteoporosis. It is characterized by low bone mass and structural deterioration of bone strength resulting in an inherent increased risk of fracture. Shockingly, about 1 in 2 white females will suffer an osteoporotic fracture in her lifetime. Should you fracture your hip, mortality increases 10-20% at one year. Twenty five percent of patients with hip fractures will require long-term nursing home care.
It is suggested that all women greater than 65 years of age and all men greater than 70 should be screened for osteoporosis. Other patients that should be screened are those adults who have had a previous fracture or have certain clinical factors that place them at increased risk. These factors include low body weight, history of falls, excessive alcohol use or use of certain medications (i.e. steroids like prednisone, or anti-seizure medications like dilantin).
Screening is traditionally done by bone mineral density testing (DEXA scan) which measures bone strength at the hip and lower spine. Heel testing, as done in some offices, is reasonable, but follow-up on abnormal screens is recommended. A so-called "T-score" is generated that arbitrarily compares your bone strength with that of a 30 year old female. Any T score less than -2.5 meets the definition of osteoporosis whereas scores of -1.0 to -2.5 represents osteopenia.
There are various secondary causes of osteoporosis that should be note. Though most elderly patients have pure osteoporosis as a result of age and loss of estrogen production, there are secondary issues that may require different treatments. For example, reversal of a patient’s vitamin D deficiency may improve bone mineral density and may be all that is required for formal therapy. Other common conditions that may cause osteoporosis include hyperthyroidism, diabetes, emphysema, kidney failure and rheumatoid arthritis. Again, many prescribed drugs may ultimately result in loss of bone mass.
Treatment should generally be initiated for any patient with a calculated bone mineral density of less than -2.5 or any patient who has suffered a hip or vertebral fracture. Guidelines further suggest treatment for those with osteopenia. My experience has shown, however, that insurance companies are less to apt to cover the costs of therapy in cases of osteopenia. Given that treatment may very well prevent progression to overt osteoporosis, it seems ludicrous that insurance companies would block access to potentially valuable medication, but this is typical of our spiraling healthcare system. This is a topic for a whole separate discussion!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Please tell me all about Osteoporosis.
Thanks,
Imma Bender
Osteoporosis I – Definitions and Evaluation
Osteoporosis remains a significant health risk in this country. Estimates suggest that nearly eight million women and two million men in the United States have osteoporosis and another 34 million may have osteopenia, considered a precursor to osteoporosis. It is characterized by low bone mass and structural deterioration of bone strength resulting in an inherent increased risk of fracture. Shockingly, about 1 in 2 white females will suffer an osteoporotic fracture in her lifetime. Should you fracture your hip, mortality increases 10-20% at one year. Twenty five percent of patients with hip fractures will require long-term nursing home care.
It is suggested that all women greater than 65 years of age and all men greater than 70 should be screened for osteoporosis. Other patients that should be screened are those adults who have had a previous fracture or have certain clinical factors that place them at increased risk. These factors include low body weight, history of falls, excessive alcohol use or use of certain medications (i.e. steroids like prednisone, or anti-seizure medications like dilantin).
Screening is traditionally done by bone mineral density testing (DEXA scan) which measures bone strength at the hip and lower spine. Heel testing, as done in some offices, is reasonable, but follow-up on abnormal screens is recommended. A so-called "T-score" is generated that arbitrarily compares your bone strength with that of a 30 year old female. Any T score less than -2.5 meets the definition of osteoporosis whereas scores of -1.0 to -2.5 represents osteopenia.
There are various secondary causes of osteoporosis that should be note. Though most elderly patients have pure osteoporosis as a result of age and loss of estrogen production, there are secondary issues that may require different treatments. For example, reversal of a patient’s vitamin D deficiency may improve bone mineral density and may be all that is required for formal therapy. Other common conditions that may cause osteoporosis include hyperthyroidism, diabetes, emphysema, kidney failure and rheumatoid arthritis. Again, many prescribed drugs may ultimately result in loss of bone mass.
Treatment should generally be initiated for any patient with a calculated bone mineral density of less than -2.5 or any patient who has suffered a hip or vertebral fracture. Guidelines further suggest treatment for those with osteopenia. My experience has shown, however, that insurance companies are less to apt to cover the costs of therapy in cases of osteopenia. Given that treatment may very well prevent progression to overt osteoporosis, it seems ludicrous that insurance companies would block access to potentially valuable medication, but this is typical of our spiraling healthcare system. This is a topic for a whole separate discussion!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
The Daily Dose 2/26/09
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Dear Dr. Spence,
Please tell me about the flu. I am a health care worker and am concerned about contracting the disease.
Signed,
Hacker
Dear Hacker,
The flu, or influenza, is a virus that is responsible for a substantial number of infections every year in the United States. In fact, is it estimated that 5 to 20% of the U.S. population is affected by the flu on a yearly basis and more than 200,000 people are hospitalized each year for complications related to the flu. More than 36,000 people die annually. It is highly contagious and, therefore, steps at prevention are globally recommended (i.e. flu vaccines).
The flu causes a host of symptoms. I should know as I had it last week! Most prominently, flu is characterized by high fever, often not relieved substantially by ibuprofen or acetaminophen (Tylenol). Other symptoms include sore throat, headache, severe muscle aches, runny or stuffy nose, and fatigue which is often quite dramatic. In my office, the typical scenario is a patient who presents with rapid onset of high fever, malaise, and the feeling that they were "hit by a truck". Complications may include bacterial pneumonia, dehydration or worsening of other disease such as asthma or congestive heart failure.
As it is spread from direct contact with an infected individual or through respiratory droplets, universal precautions such as hand washing are mandatory! A person may pass on the disease to others one day prior to having symptoms and up to five days afterward. Treatment may inhibit viral replication and prevent spread to others and is therefore generally recommended.
More importantly, prevention via vaccination is a must. We typically recommend the vaccines to nearly all patients, though there are certain subsets of the population who are certainly at greater risk. All children age 6 months to 19 should get the vaccine, as should patients over the age of 50 or anyone with specific medical conditions. All healthcare workers, pregnant women and nursing home patients should get the vaccine as well (note to self!). The vaccine consists of an inactivated or killed virus that is given by injection. The Center for Disease Control attempts to predict the particular flu strains for the upcoming year and the vaccine reflects these predictions. Unfortunately, it is never foolproof. Many patients refuse to get a flu shot claiming they "got the flu" after administration. I try to assure them that one does not get the actual flu given that it is a killed virus. It is possible to feel bad and get a "flu-like" illness, but there is a big difference.
For those who are completely needle-phobic, a nasal influenza vaccine does exist. It is a weakened live virus, again incapable of causing flu. It is recommended for healthy non-pregnant patients between the ages of 2-49.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Dear Dr. Spence,
Please tell me about the flu. I am a health care worker and am concerned about contracting the disease.
Signed,
Hacker
Dear Hacker,
The flu, or influenza, is a virus that is responsible for a substantial number of infections every year in the United States. In fact, is it estimated that 5 to 20% of the U.S. population is affected by the flu on a yearly basis and more than 200,000 people are hospitalized each year for complications related to the flu. More than 36,000 people die annually. It is highly contagious and, therefore, steps at prevention are globally recommended (i.e. flu vaccines).
The flu causes a host of symptoms. I should know as I had it last week! Most prominently, flu is characterized by high fever, often not relieved substantially by ibuprofen or acetaminophen (Tylenol). Other symptoms include sore throat, headache, severe muscle aches, runny or stuffy nose, and fatigue which is often quite dramatic. In my office, the typical scenario is a patient who presents with rapid onset of high fever, malaise, and the feeling that they were "hit by a truck". Complications may include bacterial pneumonia, dehydration or worsening of other disease such as asthma or congestive heart failure.
As it is spread from direct contact with an infected individual or through respiratory droplets, universal precautions such as hand washing are mandatory! A person may pass on the disease to others one day prior to having symptoms and up to five days afterward. Treatment may inhibit viral replication and prevent spread to others and is therefore generally recommended.
More importantly, prevention via vaccination is a must. We typically recommend the vaccines to nearly all patients, though there are certain subsets of the population who are certainly at greater risk. All children age 6 months to 19 should get the vaccine, as should patients over the age of 50 or anyone with specific medical conditions. All healthcare workers, pregnant women and nursing home patients should get the vaccine as well (note to self!). The vaccine consists of an inactivated or killed virus that is given by injection. The Center for Disease Control attempts to predict the particular flu strains for the upcoming year and the vaccine reflects these predictions. Unfortunately, it is never foolproof. Many patients refuse to get a flu shot claiming they "got the flu" after administration. I try to assure them that one does not get the actual flu given that it is a killed virus. It is possible to feel bad and get a "flu-like" illness, but there is a big difference.
For those who are completely needle-phobic, a nasal influenza vaccine does exist. It is a weakened live virus, again incapable of causing flu. It is recommended for healthy non-pregnant patients between the ages of 2-49.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
The Daily Dose- 2/5/09
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
As suggested previously, allergy season is nearly upon us. My last article touched on methods of allergen avoidance what to look for, or avoid, in over the counter remedies. Along that same vein, I will now focus on physician driven treatments, i.e. drug and injection therapy, and finish with some comments about allergies in general, hopefully dispelling some popular misconceptions about management.
If OTC medications fail, what next?
Despite your best intentions, mere avoidance coupled with OTC medication may fall flat. At this point, your primary physician may be necessary to assist in controlling your symptoms. Most of the time, allergies should be controlled within one to two weeks from initiation of therapy. There are several options available. First, standard prescription strength antihistamines remain the most commonly used agent. Antihistamines like allegra or xyzal block the release of histamine, a chemical responsible for the itching, sneezing, etc. Second, nasal steroid sprays such as nasonex or flonase can be used to decrease inflammation and symptoms of nasal stuffiness or runny nose. Finally, leukotriene inhibitors like singulair block the chemical effects of leukotrienes which are released in response to an allergen contact.
Do I need allergy shots?
The same applies – if medications do not control symptoms over time, then you may need to consider stepping up to allergy injections. Generally, these are administered once or twice per week and therapy may last for several years. Patients will require antihistamines in addition to the shots, at least in the beginning.
Will steam cleaning carpet reduce allergies?
Only one study has formally evaluated this issue. No benefit was seen. To remove dust mites and pet allergens, it is suggested that all carpeting be removed. The coolness of the concrete floor beneath combined with indoor humidity increase the allergen load substantially. Certainly, removing carpets is an extreme measure, not to mention a potentially expensive one.
What about washing your pets? Using a HEPA filter?
As it turns out, neither has any proven efficacy. It takes 12-16 weeks to reduce cat allergens down to the level of a house without a cat! Outside of getting rid of the animal, keep it out of bedrooms and remove upholstered furniture and carpets from the house. HEPA filters have been studied extensively and were found to be ineffective. Despite removing cats from the bedroom, applying an impermeable mattress cover and running the cleaners 90% of the time, one study showed no difference in allergy symptoms over six months.
What’s new in allergy treatment?
A new type of treatment known as sublingual immunotherapy may replace allergy shots completely. Treatments are given 1-2 times per week, but drops are given under the tongue. No needles necessary! The drops are slow release formulations which allow patients to build up resistance over time with less potential for side effects, such as anaphylaxis (severe allergy reaction).
Sublingual immunotherapy is currently under investigation in trials and may take some time to reach the mainstream, but the wait may well be worth it.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
As suggested previously, allergy season is nearly upon us. My last article touched on methods of allergen avoidance what to look for, or avoid, in over the counter remedies. Along that same vein, I will now focus on physician driven treatments, i.e. drug and injection therapy, and finish with some comments about allergies in general, hopefully dispelling some popular misconceptions about management.
If OTC medications fail, what next?
Despite your best intentions, mere avoidance coupled with OTC medication may fall flat. At this point, your primary physician may be necessary to assist in controlling your symptoms. Most of the time, allergies should be controlled within one to two weeks from initiation of therapy. There are several options available. First, standard prescription strength antihistamines remain the most commonly used agent. Antihistamines like allegra or xyzal block the release of histamine, a chemical responsible for the itching, sneezing, etc. Second, nasal steroid sprays such as nasonex or flonase can be used to decrease inflammation and symptoms of nasal stuffiness or runny nose. Finally, leukotriene inhibitors like singulair block the chemical effects of leukotrienes which are released in response to an allergen contact.
Do I need allergy shots?
The same applies – if medications do not control symptoms over time, then you may need to consider stepping up to allergy injections. Generally, these are administered once or twice per week and therapy may last for several years. Patients will require antihistamines in addition to the shots, at least in the beginning.
Will steam cleaning carpet reduce allergies?
Only one study has formally evaluated this issue. No benefit was seen. To remove dust mites and pet allergens, it is suggested that all carpeting be removed. The coolness of the concrete floor beneath combined with indoor humidity increase the allergen load substantially. Certainly, removing carpets is an extreme measure, not to mention a potentially expensive one.
What about washing your pets? Using a HEPA filter?
As it turns out, neither has any proven efficacy. It takes 12-16 weeks to reduce cat allergens down to the level of a house without a cat! Outside of getting rid of the animal, keep it out of bedrooms and remove upholstered furniture and carpets from the house. HEPA filters have been studied extensively and were found to be ineffective. Despite removing cats from the bedroom, applying an impermeable mattress cover and running the cleaners 90% of the time, one study showed no difference in allergy symptoms over six months.
What’s new in allergy treatment?
A new type of treatment known as sublingual immunotherapy may replace allergy shots completely. Treatments are given 1-2 times per week, but drops are given under the tongue. No needles necessary! The drops are slow release formulations which allow patients to build up resistance over time with less potential for side effects, such as anaphylaxis (severe allergy reaction).
Sublingual immunotherapy is currently under investigation in trials and may take some time to reach the mainstream, but the wait may well be worth it.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
The Daily Dose 1/8/09
If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
Dear Dr. Spence,
I recently read in the paper that a new study suggests that all patients may benefit from cholesterol lowering medications regardless of any individual risk. Should I be taking zocor or lipitor or is this all media hype?
Signed,
Statin-less
Dear Statin-less,
The study you are referring to is the JUPITER trial, recently published in the New England Journal of Medicine. The study involved nearly 18,000 patients and showed that giving a cholesterol lowering statin drug to seemingly healthy people with normal cholesterol levels could cut the risk of heart attack, stroke and death by nearly 50%. These findings provide the best evidence to date that a statin can reduce cholesterol and inflammation within arteries. The patients in the study had normal cholesterol but they all had elevated levels of C-reactive protein, a potential marker of artery inflammation and heart disease.
Half of the patients in the trial were given crestor; the other half received a placebo. Those in the crestor group experienced 54% fewer heart attacks, 48% fewer strokes and 20% fewer deaths – findings so impressive that the study was stopped after only two years so that those taking a placebo could be offered the study drug.
A separate analysis speculates that giving statins to everyone in the United States whose heart risk matches those in the study could prevent about 250,000 heart attacks, strokes, bypass surgeries and deaths in the next five years.
The patients in the JUPITER trial all had LDL cholesterol levels less than 130 mg/dl. Crestor significantly reduced the incidence of major cardiovascular events despite the fact that they were well below the threshold for treatment. Most would not be considered candidates for statins at all. LDL levels were less than 55 mg/dl in 50% of the study participants on crestor with 25% below 44 mg/dl. This raises the question of exactly how low LDL should be in order to prevent deleterious outcomes. Levels that low approximate those of a newborn. One could argue that anything above that level may incrementally increase risk.
Other questions remain. In an accompanying editorial in the New England Journal of Medicine, risk of cardiac events was only reduced from 1.8% in the placebo group to 0.9% in the crestor group; thus 120 patients were treated for 1.9 years to prevent one event. Is that worth it? The theoretic cost to prevent that one event may be on the order of hundreds of thousands of dollars. Would a generic medication like zocor be an equivalent substitute? As of yet, the answer is not known. Caution must be taken when interpreting the data, but it certainly deserves thought. I suspect, in one sense, these agents provide more benefit than just cholesterol lowering. Time will determine whether they should be as readily available as over the counter supplements (which some have suggested).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Dear Dr. Spence,
I recently read in the paper that a new study suggests that all patients may benefit from cholesterol lowering medications regardless of any individual risk. Should I be taking zocor or lipitor or is this all media hype?
Signed,
Statin-less
Dear Statin-less,
The study you are referring to is the JUPITER trial, recently published in the New England Journal of Medicine. The study involved nearly 18,000 patients and showed that giving a cholesterol lowering statin drug to seemingly healthy people with normal cholesterol levels could cut the risk of heart attack, stroke and death by nearly 50%. These findings provide the best evidence to date that a statin can reduce cholesterol and inflammation within arteries. The patients in the study had normal cholesterol but they all had elevated levels of C-reactive protein, a potential marker of artery inflammation and heart disease.
Half of the patients in the trial were given crestor; the other half received a placebo. Those in the crestor group experienced 54% fewer heart attacks, 48% fewer strokes and 20% fewer deaths – findings so impressive that the study was stopped after only two years so that those taking a placebo could be offered the study drug.
A separate analysis speculates that giving statins to everyone in the United States whose heart risk matches those in the study could prevent about 250,000 heart attacks, strokes, bypass surgeries and deaths in the next five years.
The patients in the JUPITER trial all had LDL cholesterol levels less than 130 mg/dl. Crestor significantly reduced the incidence of major cardiovascular events despite the fact that they were well below the threshold for treatment. Most would not be considered candidates for statins at all. LDL levels were less than 55 mg/dl in 50% of the study participants on crestor with 25% below 44 mg/dl. This raises the question of exactly how low LDL should be in order to prevent deleterious outcomes. Levels that low approximate those of a newborn. One could argue that anything above that level may incrementally increase risk.
Other questions remain. In an accompanying editorial in the New England Journal of Medicine, risk of cardiac events was only reduced from 1.8% in the placebo group to 0.9% in the crestor group; thus 120 patients were treated for 1.9 years to prevent one event. Is that worth it? The theoretic cost to prevent that one event may be on the order of hundreds of thousands of dollars. Would a generic medication like zocor be an equivalent substitute? As of yet, the answer is not known. Caution must be taken when interpreting the data, but it certainly deserves thought. I suspect, in one sense, these agents provide more benefit than just cholesterol lowering. Time will determine whether they should be as readily available as over the counter supplements (which some have suggested).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
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