Toned Bodies

How much calcium should I take, and do I need to take Vitamin D to get the calcium benefits?

Calcium requirements vary, so check with your health-care provider before you begin taking any supplements. As a general rule, the recommended daily allowance of calcium for most American men and women, from adolescence through adulthood, is 1,000 to 1,200 milligrams per day. Pregnant women and women who are breast-feeding should take a bit more: 1,200 to 1,500 mg per day. Postmenopausal women who are not taking estrogen should take closer to 1,500 mg per day.



Vitamin D helps with the absorption of calcium, and most people should take between 400 and 800 international units per day—400 of this can come from a multivitamin, while the other 400 can come from milk or other sources.

What about constipation?

 
Calcium supplements can back things up a bit, so try getting your calcium from food sources. Low-fat dairy products are probably best. But if dairy doesn’t agree with you, try calcium-enriched juice, cereal, or bread. Calcium carbonate is often the bad actor in the constipation issue, so you might consider taking calcium citrate. This switch may involve a few more pills and a bit more cash, but let’s face it: There are few things in life more underrated than a good bowel movement.

Menopause And Bone Loss And Aging

Menopause seems to be one of those It topics these days. If I’m not talking about it at work, I’m reading about it on the newsstands. The fact that many of my friends are getting their AARP cards in the mail doesn’t help, either. There’s so much written about menopause, and a lot of what’s written isn’t necessarily science-based. All this tends to create confusion about what menopause really means.
One of the concerns I hear about most is bone loss and osteoporosis. I tell my patients that osteoporosis is largely preventable for most patients, and there’s plenty that can be done before menopause to improve your chances of keeping your bone density. Prevention is the key when it comes to bone loss, because while there are good treatments for osteoporosis, there aren’t really any cures.
A combination of steps is the best approach to holding onto your bone density. I make it a point to remind my patients to be sure they get the recommended daily amounts of calcium and vitamin D. National surveys indicate many American women and girls consume less than half of the recommended calcium and vitamin D. Depending on your age, you should have between 1,000 and 1,300 mg of calcium per day. If you’re not getting enough calcium, discuss calcium supplements with your doctor.

Weight-bearing exercise is another great step toward osteoporosis prevention. This includes walking, elliptical exercise, stair climbing, and weightlifting. Doing this type of exercise a minimum of three times each week will reduce your chances of bone loss later in life, and improve your health today.
Of course, you should avoid smoking and excessive amounts of alcohol. This will not only preserve bone, but is also good advice for an overall healthy lifestyle. Enough said on this one.
For some women, a bone mineral density (BMD) test is a great way to detect osteoporosis and estimate your fracture risk. Talk to your doctor about if and when you need one. For women at risk of bone loss, the BMD test is painless, accurate, and another good way to take charge of your health

Transmitted Infections

There’s been a lot of talk recently about being contagious. But what does "contagious" really mean and what’s the responsibility that goes along with being contagious? There are some people who wade fearlessly into a room full of sneezing, coughing, snotty children and others who use antibacterial lotion after any contact with solid matter.

Back in the day, when a child in the neighborhood came down with chicken pox, all of his friends were sent to visit. Our moms knew that getting chicken pox as a child was a better deal than getting it as an adult.
At the other extreme is Ebola virus—highly contagious and frequently lethal. No one will be dropping by to pick this up. Putting yourself at risk for Ebola would border on lunacy, and exposing someone to Ebola would be reprehensible.

Somewhere in between falls Andrew Speaker—the lawyer from Atlanta who flew to his wedding on commercial flights despite having tuberculosis—a man who’s had more than his 15 minutes of fame (or infamy).

I’m still not sure what upsets people most about this. Was it that he had drug-resistant TB? If so, does that mean that we’d all be OK sharing row 16 with someone who had regular TB? Was it that he was putting hundreds, if not thousands, of people at risk with his careless globetrotting? Well, in real life people don’t get TB from a handshake or a shared bathroom.

TB is spread by coughing and sneezing, and then only by people with relatively advanced disease. Media reports indicate that Speaker was neither coughing nor sneezing and his disease was not advanced.
What bothers me most about this incident is our protagonist’s willingness to put others at risk (albeit a small one) when he probably knew, at some level, it wasn’t the right thing to do. It’s easy to do the right thing when it’s easy. It’s harder to tell your fiancée that you’re getting married at the Elvis chapel, instead of in Europe, because you’re just not sure how contagious you are.

Osteoporosis

More than 2 million American men have osteoporosis, and an additional 12 million are at risk, according to the National Osteoporosis Foundation. Male osteoporosis seems to be a disease ahead of its time: under-diagnosed, under-treated, and under-researched. Data from NIH’s ongoing National Health and Nutrition Examination Survey indicate that the number of men affected will roughly double to nearly 5 million men by 2020. A study in the Archives of Internal Medicine confirms the lack of awareness regarding male osteoporosis, with fewer than three percent of men, compared with 42 percent of women, receiving treatment.

Despite the large number of men affected, male osteoporosis is often a back-burner issue, as physicians and patients concentrate on hypertension, diabetes, and prostate problems. Thus, osteoporosis may remain clinically unnoticed until fractures occur, which may be too late for some patients, as the mortality rate for men with hip fractures (31 percent) is double that of women (17 percent). (These numbers are age-dependent: far lower for a 30-year-old who falls skiing, and a bit higher for a 95-year-old man who falls in the bathroom.)
Men have more dense bone, which is why fewer men than women are affected by osteoporosis, and why they usually present ten years later.

Risk factors for osteoporosis in men include heredity, smoking, excessive alcohol use, low calcium intake, inadequate physical exercise, prolonged exposure to certain medications (such as steroids to treat asthma or arthritis), and disorders that decrease testosterone levels. Like women, men should be thinking about osteoporosis if they notice a loss of height, change in posture, or the sudden onset of severe back pain. Fractures that occur in the absence of a fall or trauma should also raise suspicions.

The good news is that bone loss and fracture risk can both be reduced by taking up healthy habits—an improved diet and weight-bearing exercise.
Most American men have an inadequate daily calcium intake, so be sure to have a daily elemental calcium intake of about 1200 milligrams.
Vitamin D is also important for strong bones, and men should have between 10 and 20 micrograms (400 and 800 international units) each day.
 

Treatment with bisphosphonates, which has been shown to increase bone density, should be discussed with a physician. Male osteoporosis is on the rise, but there are steps you can take to keep you and your bones healthy. If you think you’re at risk, make sure you talk about it with your doctor. It’s the "manly" thing to do.

Hormone Therapy

In the beginning, we thought estrogen was good for women. After all, when estrogen therapy was first studied, investigators thought they were seeing less heart disease and Alzheimer’s among the women who took estrogen.

Why? Because when researchers looked at women who did and didn’t have heart disease or Alzheimer’s, and asked these women to recall their hormone use, those without these problems were more likely to have taken estrogen. Thus hormone replacement therapy (HRT) was deemed a good thing. However, as time went on, the disadvantages of these "looking backwards" studies became more obvious: A woman who took HRT to stay healthy might also be more likely to eat right, exercise, and not smoke.

This concern (among others) gave rise to the Women’s Health Initiative (WHI), the most comprehensive "forward-looking" study of HRT. The WHI followed two groups of postmenopausal women, randomly giving half of the group HRT and the other half placebo. The results showed a slight increase in heart disease and possibly a slight increase in Alzheimer’s in the group taking HRT. But many pro-estrogen physicians were unconvinced by the negative WHI results, and they’ve been reanalyzing the data. One approach they’ve taken is to study those women who entered the WHI just as they were starting menopause, rather than look at the entire WHI group, which included much older women. Some of these analyses suggest women who start HRT earlier do better than those who start it later.

In a new study with a slightly different twist—the WHI Memory Study—investigators again looked at women in the WHI. This time they asked if they could relate the development of Alzheimer’s disease to estrogen use before the women entered the WHI. The results suggest that early estrogen may protect against Alzheimer’s, however this study needs to be taken in context.

First, all the news reports for this study are based on a short presentation at a national meeting, accompanied by only a brief written description of the study. Until it is published in a peer-reviewed journal, we won’t be able to fully evaluate the methods or the data. This is not a criticism, it’s just part of the scientific process. Exciting results get talked about at national meetings and generate quick media attention, but the full story comes out a few months later.

Second, the investigators relied on women’s recollection of their estrogen use. These recall studies are tricky, even for the most careful investigators, since self-reporting is often inaccurate. And it was this concern, in part, that led to the WHI in the first place. I’m not saying that these concerns invalidate the results of this study. Instead, I’m urging caution before embracing the results of any "study of the month."

So, does estrogen prevent Alzheimer’s? Maybe. Does it matter when you take estrogen? No one is really clear on that either. What we do know is that the difference among those taking estrogen and those abstaining isn’t large. My own feeling: If preventing Alzheimer’s is the only reason you’re taking estrogen, you probably shouldn’t bother. I suspect you’d be better off taking a daily walk and doing Sudoku.

Communication With The Doctor Better

Communication is the foundation of all good relationships. Sometimes I get a sweet note in my lunch, other times I find a sticky note, “viola lesson at 6”, and sometimes when I pass the chair of internal medicine in the hospital he says, “Let’s talk this afternoon in my office.” Clearly some forms of communication are more direct than others, and others are more desirable.

Likewise, the doctor/patient relationship is also built on the cornerstone of communication. I love it when patients bring a list of questions to their office visit. Those questions give us a chance to talk about issues important to the patient, keep the extraneous chatter about weather to a minimum, and I can send them on their way with peace of mind. The list of questions makes us a team and allows us to work together. If you’ve read an article related to your health, and you’re wondering what I think about it, by all means, bring it with you. Warning: Not all doctors like this, so proceed with caution.

Yesterday I was reminded that listening is a really important component of great communications. I had an adult patient come to her appointment with her mom, which I have to say is fairly atypical. During the actual exam, the mom left the exam room and I asked the patient if there was a reason why she brought her mom along. She said, “We have a rule in our family that no one ever goes to the doctor alone, that way there’s two sets of ears listening to what the doctor says.” Simple and Smart.

Now, there are some patients who skip the list of questions and like to get right to it. Last month I had a patient who started our office visit with, “Hey doc, look at this!” and dropped his pants to show me a festering imperfection which needed some antibiotics. Medical school teaches us a lot of things, but covering our surprise when patients suddenly flash their privates is not one of them—that’s why we always knock on the door before entering the exam room. Doctors are people too; a little warm-up goes a long way.

Successful Dieting Secrets

As an endocrinologist, I spend a lot of time talking about carbohydrates with patients who are trying to manage their diet—it goes with the territory.
But let me tell you, fat seems to get equal talk time during my office hours.
And even when I’m not talking about fat with patients, I’m thinking about it myself.

I’m a guy who works out six times a week, has a family history of heart disease, eats veggies and fish, and yet I still build holidays and birthday celebrations around sour cream–based dips.
So when the Dietary Modification Trial—a recent study by the Women’s Health Initiative (WHI)—suggested that the link between dieting and fat intake may not be as strong as we think, I was prepared to run, not walk, to the closest Whole Foods for some full-fat onion dip.

Hey, a guy can dream... but simple science still stands to reason that if you consume more calories than you burn, you’re going to gain weight. I agree with the WHI study on several fat-related issues, and a big one is that it's tough reducing fat in your diet, and no fun at all to self-report fat intake accurately. 
The WHI women assigned to the low-fat group had a goal to reduce their fat intake from 38 percent to 20 percent, but the group only made it to 29 percent.

Fat Does Not Become The Enemy

Whenever my patients bring up diet, they ask about fat. It’s an important topic because trans fats, high cholesterol, obesity, diabetes, and atherosclerosis all seem to go hand in hand. Dr. Atkins devotees say fat is fine; Dr. Ornish aficionados say it should be avoided at almost all costs. But a recent study by the Women’s Health Initiative (WHI) suggests that the link between dieting and fat intake may not be as strong as we think.

The WHI study was begun in 1993 with nearly 50,000 women between the ages of 50 and 79 years. In one part of the WHI, half the women were asked to eat as usual and given generic diet-related education material. The other half were assigned to follow a low-fat diet and participate in a variety of nutritional counseling sessions. The goal of the low-fat-diet group was to reduce their fat intake from 38% of calories to 20%.

In reality, though, they only got it down to 29%. After following these guidelines for eight years, researchers found that the women did not have any additional protection against cancer or heart disease, and their weight was about the same as those following their usual diet.

What’s most striking here is not the result, but the fact that even though these women agreed to participate in a study with a goal of 20% fat intake, and were given significant assistance, they were only able to bring it down to 29%. My patients' experiences, and I admit my own, support how difficult it is to control total fat intake. That’s why I encourage my patients to monitor what kinds of fats they eat, not just how much fat. I recommend a diet low in saturated fat, trans fat and cholesterol.

Diabetes

As an endocrinologist, I see an ever-growing number of patients with diabetes and heart disease. Many of my patients with prediabetes or diabetes do not realize the negative effect that disease has on their hearts. There is now good evidence that heart disease actually begins just as glucose levels start to rise. Thus early treatment of even prediabetes makes a lot of sense.
The risk factors for heart disease can be rattled off by almost anyone who watches Grey’s Anatomy: high cholesterol, smoking, high blood pressure, family history, and of course diabetes. However, the famous Framingham Heart Study suggests diabetes is playing an even greater role in the development of heart disease. Researchers from the Framingham study collected data on more than 9,500 individuals ages 45 to 64 during two different periods of time and compared risk factors for heart disease and cardiovascular events, including heart attacks. The initial study found that between 1952 and 1974, heart disease was complicated by type 2 diabetes in 5.2 percent of patients. However, that number jumped to 7.8 percent for individuals in the later group (between 1975 and 1998).
This study raises some important red flags. First, it points to the growing epidemic of diabetes in our country. As Americans become heavier, and more sedentary, the number of people with diabetes (with and without heart disease) continues to grow. About 65 percent of patients with diabetes will die from cardiovascular disease.