Osteoporosis
It’s almost cliche. An elderly woman’s ‘hip fracture’ precipitates the beginning of the end of her life. Being incapacitated, and often requiring surgery, she is at increased risk because she already has advanced age-related cardiovascular disease and atherosclerosis. There may be discussions about quality of life if various procedures are performed versus avoided. If surgery is not performed, she may not walk. She may have pain. Being sedentary, with a fracture, thromboembolic events are considerably more likely. Surgery to repair the fracture is performed, and under general anesthesia, the patient suffers ischemic events to the brain. Cerebrovascular transient ischemic attacks may not be seen on imaging of the head. However, large cerebrovascular accidents would. The woman is confused post-operatively and never fully cognitively recovers. Her vascular dementia progresses until her demise within weeks to years.
Could this all too common vignette have been avoided? One simple fall could have a huge impact on the future of an individual. Osteoporosis is a progressive disease in which bone density is reduced, leading to increased bony fragility. Osteoporosis increases risk of low-trauma fracture (fracture sustained from standing height or less). Because postmenopause, older age, and female gender are all factors associated with a greater risk for osteoporosis or osteopenia it is recommended to screen all women 65 years or older. X-ray or CT specialized for bone density evaluation is used. Women younger than 65 may be screened if they have risk factors such as previous fractures, low body weight, cigarette smoking, excessive alcohol use, hypogonadism, premature menopause, gastrointestinal absorption disorders, or liver disease. For men screening may be prompted by history of loss of body height, history of endocrine or metabolic disorders, and long term steroid use.
Because most individuals reach their peak bone mass in their 20’s, it is important that children have healthy bone-forming years. This means that they should take in enough vitamin D and calcium. They should maintain body weight in the healthy range for their age and height. They should exercise as much as possible. It is a healthy choice to avoid smoking and alcohol consumption in the adolescent years for many reasons, but healthy bone growth is an important one. Use of glucocorticoids or anticonvulsants could also adversely affect bone growth. Chronic inflammatory disease and diseases affecting gastrointestinal absorption of nutrients can adversely affect bone formation during youth. Healthy children 9-18 years old, without known deficiency, are recommended 1300mg total daily calcium and at least 600 U vitamin D. Vitamin D3 is also better absorbed than D2. Calcium should be mostly dietary, however, and more than 500mg of elemental calcium supplementation per dose is likely not to be utilizable in the body.
Unfortunately, age related bone loss in both men and women may begin shortly after peak bone mass occurs. For women, the rate of bone loss seems to be highest during perimenopause. Decreased estrogen production is strongly associated with decreasing bone mineral density. The severity of bone loss may be mitigated by similar lifestyle factors as were needed to achieve peak bone mass in adolescence – high impact exercise most days of the week along with a healthful and varied diet. Supplementation with calcium and vitamin D may be more necessary at this age. Fall prevention becomes very important if osteopenia and osteoporosis do develop (an inevitability for many of us). It is recommended that adults quit smoking and take in only moderate alcohol, if any.
Most people are aware that dairy products are good sources of calcium. To estimate the amount of elemental calcium per serving, multiply by 300mg. Calcium citrate is better absorbed than calcium carbonate on an empty stomach. Excess calcium intake may be associated with kidney stones. Calcium may be found in dark green vegetables, some nuts. It may be in breads, cereals, soy products and fruit juices as fortification. For supplementation, up to 1500mg elemental calcium can be taken daily in divided doses of 500mg or less. A daily dose of at least 1000mg should be taken for healthy adults and 1200mg for postmenopausal women. Vitamin D is produced in the skin during exposure to sunlight. It is generally not found in the diet, but is found in fortified milk and infant formula. It is not excreted in breast milk so 400U of vitamin D daily is recommended for breastfed infants. The number of cups of milk x 100U may approximate the daily dietary D intake.
Lack of sun exposure is a frequent cause of D deficiency. Vitamin D deficiency has been associated with poorer prognosis in infectious and chronic disease states, and can increase risk of fractures. Muscle weakness, depression and fatigue may be signs of D deficiency. Low D increases parathyroid hormone production and leads to bone resorption. For healthy Alaskan adults, up to 5000U daily vitamin D3 supplementation may be considered. More may be required for those already deficient.
In addition to calcium and vitamin D supplementation various medications are available for those at risk, or already suffering from, osteoporosis. These all have potential adverse side effects so are available by prescription, after a discussion with a healthcare provider. Hormone replacement therapy, bisphosphonates, or raloxifene may be recommended; if not otherwise contraindicated.
Fifth Anniversary Party!
SUNDAY, APRIL 24, 2022 AT 6 PM – 9:45 PM
Brück Clift MD Fifth Anniversary Ball and 40th birthday party
Palmer Train Depot/ Community Center
Formal attire encouraged, but not required!
My Mohelet Certificate finally arrived!
Brit Milah is a ritual performed by Jews on the eight day of life. It combines a religious naming ceremony with the neonatoal circumcision, initiating a boy into Jewish life. I completed the course work this summer to perform the blessings and ritual, having already been proficient at the circumcision procedure. This was an important milestone for me as finding a mohel/mohelet (one who performs the Brit Milah) in Alaska or any rural area has always been a challenge. This achievement also pulls together my love of party planning, Judaism and the medical procedure itself.
Pfizer Covid-19 vaccine
Vaccinations are now available (by appointment) to those people 50 years or older with high risk health conditions and who are frontline essential workers. Also included are people of any age who work in childcare or school settings or who live in group homes or congregate living. Those working in healthcare and those 65 years and older are still encouraged to schedule for vaccine if they haven’t already had their first dose.
http://dhss.alaska.gov/dph/Epi/id/Pages/COVID-19/VaccineAvailability.aspx
Pfizer Covid-19 Vaccines
We have appointments available starting Februrary 9, 2021 to established patients 65 years and older or to patients who work in healthcare. Please call to schedule only if you fit into these categories because we must adhere to strict phases and tiers, but also have limited time to dispense the vaccines as they expire after 4 days. We will be getting them in on Mondays and dispensing them throughout the week during February. This is through the state’s public Vaccine Depot. Please schedule, rather than drop in, due to social distancing requirements and the limited availability and stability of the vaccine. You must receive the second dose from the same source as administered the first, so we will be scheduling the second dose at the same time as the first is administered. Patients who have had a first dose at another office may not receive their second through our clinic.
love
depression
Longevity
The average human lifespan is currently 72 years. Men average 69.8 years while women average 74.2 years, though women have much shorter reproductive capability than men. Since ancient times there have always been myths and legends about sources of eternal youth. There have been healers, and snake oil salesmen, true scientists and physicians that have claimed to improve lifespan, healthspan and fertility. Indeed, expectancy has increased dramatically since 1900, but we must beware of fraud. Even now, and in the future, advances in the fields of organ transplants, implantable devices, artificial limbs, and artificial intelligence have already begun to push the limit of available therapies; but access to experimental treatments, and the overall cost of certain types of interventions will create questions about access to care for ordinary diseases of aging. To achieve life extension without healthspan expansion would be pointless. Ideally we want to be healthy for as long as possible and then die quickly, avoiding the ravages of chronic disease. What is the current research on what can be done to extend healthspan (and hopefully life span) right now? Are there any drug treatments that show promise? What are the most important lifestyle changes we can make?
Aging is driven by many factors. At the cellular level aging is caused by damage to DNA and alterations to how it is expressed, along with the accumulation of molecular wastes. DNA also shortens every time a cell replicates; and the shortening end of DNA, known as a telomere, acts as a molecular clock. Inflammation is associated with oxidative stress that can damage DNA and proteins, as can toxins. The body must efficiently repair, recycle and clear damaged proteins and cells so that cellular waste products do not accumulate. Insulin plays a role in regulating blood sugar and causing the body to store fat, but has also been shown to act as a pro-aging molecule in animals like worms, independent of blood sugar. Animal models show that both insulin (which responds to consumption of sugar) and a pathway called mTOR (which responds to consumption of protein) are implicated in aging and can be targeted with drugs to increase lifespan.
These mechanisms largely explain why caloric restriction and fasting have been shown to reduce aging and increase longevity. Caloric restriction appears to slow the metabolism and the associated accumulation of toxic byproducts, reducing cellular damage. It increases insulin response. Fasting seems to suppress inflammation and promote a state where the immune system repairs and recycles damaged molecules, activating the sirtuin pathway for DNA and protein repair.
The benefits of exercise are widely known. Very large and convincing studies have shown no upper limit to the correlation between cardiovascular fitness and mortality. Individuals who can run on a treadmill longer demonstrate significantly lower all-cause mortality. Other studies have strongly correlated other factors, such as the ability to do more than 40 push-ups in males, with a significantly reduced risk of heart attack. In addition to maintaining the overall baseline functionality of the muscles, vasculature, and organs, exercise seems to be protective by stimulating the production of endogenous antioxidants such as superoxide dismutase and glutathione peroxidase which demonstrate antioxidant activity far in excess of that which can be achieved with dietary supplementation. For this reason antioxidant supplementation has lost popularity in life extension research in recent years.
Some specific foods and supplements have been shown to extend life and health span, mostly in animal models. While human trials are scant, food and supplements are available to everyone without a prescription. Foods and supplements that positively affect the sirtuin pathway have shown promise to improve the effects of aging in animal models. Resveratrol (found in grape seed extract and red wine) and some other related polyphenols activate this pathway. Sirtuins require a coenzyme, NAD+ (nicotinamide adenine dinucleotide), which increases the activity of sirtuins. Unfortunately, NAD+ decreases in abundance as people age. Increasing NAD+ concentrations in mice models through dietary supplementation has been shown to improve metrics of health and life span, like physical activity and life expectancy. NAD+ precursors include nicotinamide riboside (NR), nicotinamide mononucleotide (NMN), and niacin. Senolytics remove cells that have become senescent (or too old to function properly). These cells get in the body’s way and promote a toxic environment for the healthy cells. Fisetin is a flavonoid polyphenol that helps destroy senescent cells. It is found in many common fruits and vegetables. Eating fruits and vegetables that are high in nutrients and antioxidants and relatively low in calories (when compared to grains and processed foods) reduces the effects of aging and decreases risk for inflammatory processes and cancer. Polyphenols found in green tea have also been demonstrated to have absorbable antioxidant activity and to act as senolytics. Curcumin (found in turmeric) and Crocin (found in saffron) may delay cellular senescence and reduce inflammation via antioxidant mechanisms. Curcumin is thought to reduce the risk of some cancers’ formation and metastases. Crocin decreases the effects of UVB light on DNA, thus has potential to reduce skin damage (photoaging). Supplementation with collagen may reduce wrinkles and skin changes associated with aging. I recommend getting most of these foods through diet rather than dietary supplements.
A number of pharmaceutical drugs have shown promise in extending human health and life span. Metformin is a common first line type 2 diabetes treatment that has been shown to decrease mortality and morbidity from diabetes; and has shown protective effects in a variety of other conditions still being explored including cancers, kidney, cardiac, and Alzheimer disease; as well as in trials to treat aging and extend human lifespan. Metformin is a less toxic derivative of the molecule discovered in the medicinal plant Goat’s Rue. It has been around for decades, is available in generic form, and quite affordable. It acts by reducing blood sugar and inflammation as well as by improving lipid profile. It does not cause hypoglycemia because it acts in an insulin-independent manner. By reducing baseline blood glucose it decreases insulin resistance, lowering insulin secretion. When taken with meals it also reduces glucose absorption from the gut, preventing the absorption of calories. Acarbose, which also reduces glucose absorption from the gut, and pioglitazone, which increases insulin sensitivity, are other medications prescribed for diabetes that have been implicated as having life extending/anti aging potential. SGLT2 inhibitors like Farxiga, Jardiance, and Invokana also reduce blood sugars, the risk for cardiovascular events, and have been shown to be protective to the kidneys. These medications likely also act through some of the same mechanisms as caloric restriction.
One cannot help but reflect on the similarities between aging and poisoning. Smoking cigarettes and drinking alcohol, eating preserved meats, and using illicit drugs all promote aging because they are directly toxic both to tissues and at the molecular level. Alcohol alters lipid metabolism and promotes the deposit of fat in the liver. The polyphenols found in wine are linked to increased lifespan; but the damage that may be done to liver, heart and pancreas will likely reduce lifespan and healthspan in the setting of heavy drinking. These polyphenols can be found in other foods and supplements that are not also toxic. The medical community generally recommends a maximum of 7 alcoholic drinks in a week for women and 14 for men. In Britain (where alcohol usage is high) the NHS recommends taking at least one alcohol-free day weekly.
Getting enough sleep is critical. The body has a system called the glymphatic system that clears cellular wastes and recycles fluid in the brain, and this system works best when sleeping. Six to Eight hours of sleep a night is recommended for most adults. For some of us, our ability to sleep is diminished as we age. Daily exercise, time restricted feeding, and supplementation with melatonin (a neuroprotective antioxidant that aids in sleep) at night and NAD+ precursors in the morning can all improve circadian rhythm and reinforce good sleep habits.
Happiness and stress reduction are important to enjoying a long healthspan. To achieve this, I encourage nurturing social relationships. I also encourage goal oriented behavior; being more efficient, self disciplined, organized and deliberate in our actions. Seeking hobbies and educational pursuits. Risk for cardiovascular events and some cancers is increased with increased stress and misery. Being productive addresses anxiety and diminishes it directly. Boredom increases anxiety and reduces mental flexibility, potentially contributing to dementia. Exercise, in addition to the other benefits that it provides, decreases stress and produces natural endorphins that reduce pain and increases that overall satisfaction and sense of productivity that makes people feel good.
Fashion and Health
Clothing developed out of utility and ability at least 200,000 years ago. Initially naturally and readily available plant and animal products were used. Eventually the technology to improve those products developed into the clothing and textiles industry we know today. Clothing most likely had no aesthetic purpose initially; but was a barrier from weather, minor trauma, UV damage, bugs, parasites and even microbes (though they may not have realized it at the time).
Over time, as societies developed and communities evolved, people began to use clothing to communicate. It was used both as an art form and as a way to identify status in society. Personal protective gear and athletic/sportswear, both rooted in utility, have influenced fashion. However, in all of our self expression and trend following, there are health risks that may outweigh the general benefits of some clothing.
Tight underwear have been associated with lower sperm count in men, increased risk for jock itch and other dermatoses in both genders, bacterial vaginosis and vaginal yeast infections in women, and urinary tract infections (mostly in women). Thongs and G-strings are obvious culprits, but bikini and brief style underwear are generally problematic due to anatomic and physiologic reasons to both sexes. However, if going without underwear for the reasons above; a skirt, sarong or kilt is healthier for the crotch than pants. Friction from clothing against the body can be irritating.
Tight clothes and athleisure gear can increase heat and moisture retention, increase friction of fibers against skin, limit mobility and create neuropathic pain. Some fibers like nylon or lycra may exacerbate this problem. Wearing clothing too tightly exposes skin to detergents, fabric softeners, irritants, microbes or dyes that may be in or on those clothes. People are commonly sensitive to some fabrics, wool for example, so wearing it closer to the skin may be more uncomfortable. On the other hand, compression is appropriately used to treat various vascular and lymphatic complaints- usually to reduce swelling.
Corsets can improve posture and reduce the pressure that a bra puts on the shoulders, stabilizing the back and reducing some pain. If used for waist slimming, as they were for centuries, they could cause or worsen gastrointestinal problems, bowel pain and pelvic floor prolapse. They can also cause rib distortion and injury to internal organs. They can certainly lead to restricted depth of inspiration and associated respiratory complications. Long term use, may reduce core tone as the corset is relied upon for stability. Body shaping garments can have similar effects.
Bras have shortcomings as well. Though not known to be associated with breast cancer, underwires and bras in general are a frequent cause of discomfort and a mass effect in breast. Ill fitting bras can cause breast pain, back pain, or shoulder pain. They can cause the same problems that other tight fitting clothes do and can cut into the shoulders or torso, leading to skin compromise. A well fitted bra is worth the investment.
Fibers found in elastics can also be irritating. Thread tourniquets or elastic band tourniquets can form due to friction within a garment. This usually occurs in small children – they present with irritability and a swollen finger or toe (or genitalia in some cases). Loose fitting clothing is generally better except that wearing loose clothing to bed has been associated with higher risk during a fire (especially in children). Some fabrics may be associated with worse burns than others, but fabrics containing halogenated fire retardant materials may be associated with reproductive and neurodevelopmental toxicities.
Walking barefoot causes athlete’s foot through direct contact with the causative microorganisms. At the same time wearing footgear that doesn’t allow for ventilation increases moisture and heat entrapment and will exacerbate athlete’s foot by contributing to skin breakdown and providing a favorable environment. Footgear is important protective equipment, but it is also important to rotate frequently and occasionally take breaks from entirely. High heels and platform shoes can lead to serious musculoskeletal lower extremity and back injuries either chronically or acutely. They can also lead to falls. Tight toed shoes and gravity can worsen bunions; lead to corns and calluses, nerve pain, or bony distortions.
Buttons, beads, sequins, zippers, strings and cords can be dangers as choking or strangulation hazards. Anything not well affixed to the garment (or any jewelry) can be a choking hazard to a child. Zippers, beads and buttons may all be made from metals to which people are sensitive (like nickel). Kids also put buttons, beads and sequins in their noses, mouths, ears, butts and vaginas. These, as well as earrings and other jewelry, can also lead to problems such as infection, inflammation or obstruction. Rings on fingers have led to serious hand injuries, including skin avulsions and amputations. Zippers lead to numerous penis and scrotal injuries yearly from using them appropriately, but absentmindedly.
There are, of course, psychosocial consequences to the clothes we choose. These are subtle and subjective. The way we present ourselves affects how people interact with us: whether they even choose to interact with us sometimes. They can make us feel like part of a group or like outsiders: can be the cause for our acceptance or rejection relative to who we are and who we are with. There is no doubt that fashion can affect our happiness. Indeed there are many tales throughout history in which the outfit, uniform, disguise or costume makes all the difference. While they can promote hygiene and protect us from the elements, we should not overlook the common ways our wardrobes could threaten our health and safety.
Brück Clift, MD 