Watching Women's Health

Vitamin D may reduce risk of urinary incontinence

The medical community's growing realization that many Americans are low in Vitamin D has led to an explosion of interest in this vitamin's effects on bones, muscle, pregnancy outcomes, cancer risks and other medical concerns. 

Vitamin D is a fat-soluble vitamin that aids the absorption of calcium from the GI system. In addition to helping mineralize bone, calcium is important in neuromuscular and immune system function.

Vitamin D is produced in skin that is exposed to sunlight. It naturally occurs in only a few foods, fatty fish and cod liver oil (a hardy few consider cod liver oil to be a food). According to the most recent National Health and Nutrition Examination Survey (NHANES), only 17% of US women get enough vitamin D from food alone.

Most health-conscious women protect their skin from the sun and obtain vitamin D from supplements and vitamin D fortified foods. Recently, I have been including serum vitamin D levels in blood work at annual exams, and have found many of my patients have low vitamin D levels, despite our ongoing discussions about adequate calcium and vitamin D intake.

Other risk factors for vitamin D deficiency besides low sun exposure include being over 50, having darker skin pigmentation and being overweight. Breastfed infants have also been found to be at risk, as adequate vitamin D can't be obtained from human milk alone.

A new paper in the gyn literature looked at how vitamin D levels relate to women's risks for pelvic floor disorders — urinary and rectal incontinence and pelvic organ prolapse. In the NHANES data, results from 1,881 women 20 and older included information on pelvic floor disorders and vitamin D.

The mean age of the surveyed women was 47.9 and more than 80% had suboptimal vitamin D levels. 23% reported symptoms of a pelvic floor disorder. Higher vitamin D levels were associated with a lower rate of pelvic floor disorders. The strongest inverse association was in women over 50 with urinary incontinence.  The authors conclude

Given the increase in the number of patients with pelvic floor disorders, further evaluation of the role of vitamin D is warranted, particularly future research to assess the relationship between vitamin D levels and pelvic muscle strength in women of all ages and racial/ethnic groups. Our findings suggest that treatment of vitamin D insufficiency and deficiency in both premenopausal and postmenopausal women could improve pelvic muscle strength, with a possible reduction in the prevalence of pelvic floor disorders including urinary incontinence.

It is encouraging to think that the hugely annoying problem of urinary incontinence could be improved by something as simple as supplementing vitamin D. If you have not had your vitamin D level checked, it is worth doing at your next annual exam. If you have problems with urinary incontinence, it may be worthwhile having it checked sooner.

Spend more of your day moving, having fun

More than two-thirds of adult Americans are overweight or obese, according to a recent national survey. Approximately 10% of children are also above a healthy weight. Fortunately, among both adults and children, the percentage who are overweight and obese is no longer increasing.

One way to address this national public health challenge is to get Americans moving again, through both individual and societal changes. Here are nine ways an individual can be more physically active.

1. Find physical activities you truly enjoy. This is the most important suggestion of all. If you are doing something you like to do, you are not working out, you are having fun. It takes planning, but not really discipline, to make an enjoyable activity part of your day.

2. Find ways to be active in all seasons. In Minnesota, staying active in the winter is a challenge. Many women occupy the summer with gardening, yard work, walking and cycling, but these activities fall by the wayside in the winter. It is actually not hard to dress for the weather and continue usual activities or switch to winter sports. Even in my state, only a handful of winter days are unbearable.

In other parts of the country, a hot and humid summer limits most outdoor exercise to early morning. Be realistic about where you live and either find ways to be out in all kinds of weather or move your activities indoors for part of the year.

3. Be active with friends. I first started exercising as a young adult by swimming at noon with a work friend. We later switched to running when the community pool became too crowded to swim laps. Our friendship made it easy for us to get fit together.

Most of my close adult friendships have been formed because we share physical activities as well as sensibilities. For the past two years, I have admired from afar four women who walk together every morning, regardless of weather. They are always happy and animated - clearly getting together is not a chore for them.

4. Go places under your own power. Day to day, most of us feel pressed for time.  Perhaps the most time-efficient way of getting more exercise is combining it with transportation. Try walking or cycling to work, run errands or get together with friends. To cover long distances, find ways to combine self-locomotion with public transportation.

Many baby-boomers who are downsizing houses would also like to downsize their car fleet as well as their clothing size. When moving, look for neighborhoods that are pedestrian and bicycle-friendly. At least one helpful website lets you analyze the walkability of any address in larger US cities.

Similarly, consider vacation spots that allow you to get around under your own power. This is not only economical but will help counteract the weight gain that seems inevitable with most vacations.

5. Get a dog and give it a great life.  A great life for a dog is a healthy, active life for you. A recent study showed people who walk their dogs see more improvement in their fitness than people who walk with humans. Unlike human companions, dogs don't come up with excuses not to walk. Dogs will happily go out in almost any weather and you find out you can, too.

6. Spend less time sitting. Sitting at a desk at work, watching TV, or at a home computer occupies most of the day for a lot of people. Along with sleeping, sitting in a comfortable chair is the least active thing our bodies can do. Most calorie expenditure charts show standing uses roughly twice as many calories as sitting, and calorie expediture goes up from there with more intense activities. Be creative about finding ways to sit less; when you do sit, try using an exercise ball part of the time (even though the TV comedy The Office made huge fun of this).

Wearing a pedometer is an easy way to quantify how much you are moving around during an average day and has been shown to increase sedentary women's activity levels.

7. Increase your activity gradually. Once you've made up your mind to be more active, don't risk injury by overdoing it in the first several weeks. Remember you're in this for the long haul. Give the weakest parts of your body time to catch up to the strongest. 

8. Mix things up. Humans like variety. If you involve yourself in a variety of activities, you are less likely to get tired of what you are doing and to have overuse injuries. Part of the beauty of living in a place with distinct seasons is engaging in different seasonal activities. For instance, here in Minnesota, we never get tired of cross-country skiing because, believe it or not, the winter is too short.

9. Have a mindset that exercise is a priority, not a luxury. To be healthy, we need physical activity just as we need fluids, nourishment, mental stimulation and sleep. Physical activity should be a normal part of virtually every day, not something we'll do if we have time and inclination. Each day, figure out a way to fit some sort of exercise into even the busiest schedule. 

I've gathered these ideas from talking with my friends and patients, and from my own experience of being physically active throughout my adult life. Even if you have never liked to "exercise," you'll do good things for your health (and have fun) if you move more and sit less.

Obesity replaces smoking as top US health burden

The good news is that smoking is no longer the biggest health threat to Americans.  The not-so-good news is that, while fewer people are smoking, many more, including record numbers of children, have become obese.

The medical definition of obesity is a body mass index (BMI) greater than 30. For example, for a woman who is 5'5", any weight above 180 lbs is in the obese range. BMI for normal weight ranges from 18.5-24.9; the overweight range is from 25-29.9. To be in the normal range, a 5'5" woman would weigh between 112 and 150, a fairly generous spread.

While smoking rates in the US have declined in recent years, obesity has been on the rise. Between 1993 and 2008, obesity in the US increased by 85%.

The risks from smoking and obesity are different. Smoking increases risk of premature death whereas obesity increases risks of morbidity, or ill health.  Both can result in fewer years of quality living, with obesity now edging out smoking as a robber of quality years.

If everyone in our country miraculously became a nonsmoker of normal weight, on average Americans would gain 5 quality years of life.

Obesity can limit normal activities through early arthritis, diabetes and heart disease.  And these progressive conditions lead to less and less physical activity. Like smoking, the problem of obesity is best addressed by prevention. Once a woman has become obese, it is a difficult condition to change.

Physicians regularly encourage smokers to quit and discuss approaches to weight loss with our overweight and obese patients. In my practice, I see smokers quitting and overweight women getting back into a normal weight range far more often than I see obese women succeed in losing weight. Their lack of success seems in large part due to the obesity-related physical ills that do not allow them to be physically active. 

Much has been written about the causes of obesity in the US. At or near the top of everyone's list is a sedentary life style that is so much more common now than even a few decades ago. In my next post, I'll discuss practical approaches to being more physically active.

Considering the end of life

A good friend died recently, so I've been thinking a lot about the ultimate health concern — dying.

It is, of course, a hard thing to contemplate, which is why most of us, even physicians, shy away from it. Our reluctance to think about and discuss the inevitable — as individuals, as medical professionals and as a society — means many of us will miss the experience of "dying well".

Dying Well, written by Ira Byock, powerfully describes his experiences as a Montana hospice physician. He says the process of dying can lead to personal growth and fulfillment.

Without adequate medical care, dying can be horrible. With skillful medical care and attention to the personal experience of the patient and the person's family, dying can be made bearable. When the human dimension of dying is nurtured, for many the transition from life can become as profound, intimate and precious as the miracle of birth.

This is not just wishful thinking — these are words Byock backs up professionally every day as he cares for dying patients and their families.  After caring for his dying father at home while in his medical training, Byock subsequently devoted his career to hospice care.

Many people jump from the concept of dying well to the concept of physician-assisted suicide. What Ira Byock and his colleagues do makes suicide as unreasonable for dying patients as it is for everyone else .

Byock says most people do not want to die in pain, do not want to die alone and do not want to lose their personal autonomy and dignity in death. All this can be accomplished with what we know now. If dying patients are cared for in a nurturing way, most can die at home, in peace with their families.

But this takes planning and resources. As Byock says,

...good deaths [are] not random events or matters of luck; they [can] be understood and...fostered.

Dollars that might be spent for intensive, yet futile, medical care in a hospital can be diverted to home care and hospice support. Our current health care system is poorly equipped to do this as it still favors reimbursing pointless end-of-life interventions for the dying, rather than nurturing care at home. Byock's book was published 12 years ago and we have made only a little progress with this universal health concern since he wrote Dying Well. 

Few of us will get a chance to do this last event over. My mother-in-law did. In her early seventies, she had a massive hemorrhagic stroke and spent a few weeks in the hospital, mostly in an inhospitable intensive care unit. She made an improbable recovery and returned home to her usual life.

Two years later, this most rational of women was diagnosed with an inoperable brain tumor. In the time since her stroke, she had made clear to the closest family member that she wanted no intervention for a terminal condition if it exchanged quality of life for only a little longer life. A few months later, she died in peace, at home, just as she chose.

With recent and earlier losses in mind, my husband and I are updating our wills and medical directives. It is an odd experience to read one's will, but far easier to do when death is presumably distant rather than imminent. We are taking particular care with expressing our end-of-life wishes.

Whether one believes in an afterlife or not, dying is a major event, and if circumstances allow, we want some say in how it takes place.

Most of us want pretty much the same things when we inevitably die. Let's hope our health care system can adapt itself to those wishes.

A conspiracy to make us fatter?

For the fourth year in a row, the general health of Americans has not improved. A nationwide report, America's Health Rankings, says continued tobacco use and increasing obesity are the main reasons our health improvement has flat-lined.

This report began in 1990 and for many years showed steady gains in Americans' health. The trend stopped in 2005. Now, among world nations, the US ranks 28th in life expectancy, 20th in child well-being and 19th in mortality from treatable conditions.

Depending on how we respond to our current economic woes, our national health could get worse. Smoking and over-eating are time-honored ways of dealing with stress. But if we can find other ways of managing stress, some of which also save money, we could actually get healthier.

One change we can make is to eat more home-cooked meals, which are almost always cheaper and  healthier than fast food or restaurant fare. But even recipes from scratch have become more calorie-laden over time.

A recent analysis of recipes in Joy of Cooking looked at 18 recipes that have been published in every edition since 1936. In that time span, average calories per recipe increased 47%, and average calories per serving increased 63%.

Over the same time, our plates, bowls and silverware are growing ever larger, along with portion sizes  in restaurants.  Women's clothing manufacturers have adjusted sizes, so today's size 10 is a 1990 size 14. This could be a brilliant conspiracy to make us all fatter.

I have an Asian food cookbook that assigns Asian and American portions for each recipe. A typical example is "4 American portions — 8 Asian portions". So an American is expected to eat twice as much as an Asian. The problem is, a lot of us do.

Cooking at home will benefit us most if we pay attention to our portions and then downsize them. At home, we often serve up food casually, giving men a bit more than women, then going back for seconds as our tastebuds dictate, before we even know if we're still hungry.

A new lifestyle phrase I like a lot is "eating mindfully." We can get satisfaction from less food if we use smaller plates and bowls, arrange our food artfully, then eat slowly and appreciatively. That way, even an Asian portion might seem like enough.

A little alcohol — good, bad – which is it?

Recently I wrote that moderate alcohol use, along with other habits, appears to reduce risk of stroke. Now a Washington Post article on another British study says even minimal alcohol use increases women's risk of breast, rectal, liver, esophageal and oropharynx cancer.

Between 1996 aand 2001, the Million Women Study (MWS) enrolled over 1.2 million UK women over the age of 50. Women undergoing breast screening were invited to participate. Like the Women's Health Initiative in the US, this study was designed to look at effects of postmenopausal hormone replacement.

A huge amount of questionnaire-based information has been collected, and MWS researchers are looking at how a variety of lifestyle factors influence women's health. During seven years of followup, any alcohol use — a drink a day or less — increased risk of some cancers. This study links minimal alcohol use to specific cancers more clearly than previous studies.

The link between breast cancer and alcohol is well-accepted. Drinking alcohol alters estrogen levels and about 3/4ths of breast cancers diagnosed today have estrogen receptors. It appears greater alcohol use is directly linked to greater breast cancer risk. Heavy use may increase one's risk by as much as 30%.

Similarly, the link between alcohol and liver cancer is not new. Again, heavy alcohol use has been thought to be the main risk factor.

In the MWS, greater risk of oropharynx cancer was noted only if women also smoked. Alcohol use as a cause of rectal and esophageal cancer is newer information. 

Overall, MWS estimated 13% of these cancers in women were due to drinking alcohol.

Why is it so hard to figure out exactly how alcohol affects our health? Humans are complex biological organisms and a substance that may be helpful in one organ system may be harmful in another. It is not really contradictory if alcohol is good for our hearts but bad for our livers.

Information obtained through questionnaires has limitations. People being people, some minimal alcohol users may have drunk more than they reported.

In clinic, we screen for alcohol use and it is a rare person who admits to more than an occasional drink. Probably the most reliable distinction in between people who drink any amount of alcohol and people who don't.

Living one's life simply to avoid disease seems like a joyless proposition. But when deciding how to live, most of us do want accurate information about the pros and cons of our choices. So next time, before you uncork that lovely bottle of wine, think for a moment about the results of this study.

How not to have a stroke

Many people say having a stroke is one of the medical events they want most to avoid. A British study provides some strategies for individuals who want to reduce their personal risk of stroke.

Researchers followed just over 20,000 men and women aged 40-79 for an average of 11 years. After controlling for other stroke risk factors, they identified four lifestyle habits that reduced risk.

These habits were: not smoking, some level of physical activity, moderate alcohol use and eating five fruits and vegetables daily. 

Physical activity was defined as either having an active job or getting at least 30 minutes of leisure exercise daily. Moderate alcohol use was having between 1 and 14 drinks per week.

Fruit and vegetable intake was verified by serum vitamin C levels. (How they determined serum vitamin C levels reflected food intake, not use of supplements, was not made clear.)

Each healthy behavior was found to reduce risk of stroke and the risk reduction was additive. If an individual practiced all four behaviors, risk of stroke was about half that of people without these habits.

More women than men practiced all four healthy habits. The four healthy habits provided stroke protection regardless of body mass index.  Refraining from tobacco had single greatest impact on women's stroke risk.

If you don't drink alcohol, few physicians would recommend that you start. But alcoholic beverages do have some health benefits for moderate users.

The key is to keep alcohol use moderate, since excessive use adds a host of other risks. Elsewhere, moderate alcohol use for women has been defined at a lower cutoff, somewhere between 7 and 11 drinks per week.

There are some stroke risks that we inherit and can't change. This study identifies four habits most of us can adopt to reduce whatever stroke risk we do have.

Multivitamins - take or toss?

Researchers continue to mine valuable information from the Women's Health Initiative (WHI). This US  study involved more than 160,000 postmenopausal women and ran from the middle 1990's through 2005.

The most recent WHI report analyzed whether taking multivitamins protected older women against cancer or heart disease. It also looked at whether taking multivits led to a longer lifespan.

Alas, the answer is no to all three questions.

Just over 40% of women studied took multivits. After approximately 8 years of follow-up, their rates of common cancers, cardiovascular disease and death were compared to those of women who did not take multivits. No significant differences were found.

This information comes not long after convincing evidence that vitamin C and E supplements do not protect against heart disease and may actually add risk. Yet many people continue to take these and other vitamins in hopes of doing something good for themselves.

It is likely that many older women will still take multivits despite this new report.

Why are we Americans so interested in vitamins and supplements? For one thing, it seems like an easy and inexpensive way to make up for dietary and lifestyle lapses. And, deciding to take supplements gives a sense of personal autonomy that feels different from taking a prescribed medication.

I recently wrote about vitamin D which has few natural food sources and appears to be best obtained through fortified foods or supplements. Also, many older women do not get adequate calcium through their diets and need to supplement that as well.

But the scattergun approach to vitamin supplementation appears to be of little value. Taking a multivit almost certainly does not make up for poor eating habits. This is hard to study, however, because food diaries are notoriously inaccurate.

The average American diet, however imperfect, is still replete with basic nutrients. Other lifestyle habits, such as exercise and tobacco use, also have a huge impact on our health.

I have been taking a multivit myself and still have most of a large bottle. Do I toss it or take the rest of the pills?

I think I'm going to toss it and delve deeper into the produce section of my grocery store. 

Vitamin D helps muscles too

It seems like every few years we get excited about the possible health benefits of a vitamin or supplement.  Recently, vitamin D has gotten a lot of attention.

Vitamin D appears to protect against osteoporosis by aiding absorption of calcium. Until recently, the recommended daily amount of vitamin D was 400 IU, the amount found in most multivitamins.  However, many people getting that daily amount have been found to be vitamin D deficient.

Vitamin D sources include a few foods (mainly fish), vitamin D fortified foods and supplements. Appropriate sunscreen use limits the Vitamin D we get from sun exposure.

Now, health organizations recommend greater daily intake of Vitamin D in the range of 800-1200 IU to prevent osteoporosis in older women.

It turns out adequate amounts of vitamin D are important for young women too. A recent British study of 12-14 year old girls showed 70% had low vitamin D blood levels. Low vitamin D levels correlated with lower jump velocity and height and less jumping power.

Adequate vitamin D is also important for leg strength in the elderly.  Whether supplementing vitamin D reduces falls is being investigated.

No supplement can take the place of healthy exercise and diet habits. But it is possible to have good habits and still be vitamin D deficient. If you don't regularly eat vitamin D fortified foods, supplementing vitamin D is probably beneficial.

Ask your doctor if (fill in the blank) is right for you

Today's news contained a brief story about a new $20 million direct to consumer advertising campaign involving Yaz, a popular oral contraceptive. 

Yaz is a good product with a unique progestin. It has been heavily promoted and I wondered what more Bayer could possibly have to say about it. Well, it seems they've said too much and the FDA wants Bayer to take some of it back.

This is probably an especially bitter pill for Bayer because Yaz's parent compound — Yasmin — is now available as a lower cost generic with similar benefits.

You can't watch TV for a half hour or flip through 10 pages of a magazine without being exposed to drug advertising. The US has allowed consumer drug advertising since 1996  (only New Zealand joins us in this practice).  In 2007, pharmaceutical companies spent over 5 billion dollars on consumer ads in the US.

Critics of consumer drug ads say they appeal to emotions, overstate drug benefits and understate side effects. It is the new drugs that are most heavily advertised, before their safety profiles are fully understood.

And some critics say these ads are "medicalizing" the human conditon, suggesting there is a pill for every problem.  

A 2004 study involving Colorado physicians reported most viewed consumer drug ads negatively because they gave no information on cost or alternative treatments and downplayed adverse effects.

Patients requesting a specific medication frequently require a longer clinic visit and may be dissatisfied if they do not get the requested drug, even if there are good reasons for not prescribing it.

Proponents of consumer drug advertising say the ads are educational. A few years ago, an editorial in the New England Journal of Medicine argued most ads provide the name and symptoms of a medical problem and little more.

The editorial quotes Canadian economist Stephen Leacock who said advertising is "the science of arresting the human intelligence long enough to get money from it." 

Prescription drug advertising in the US rose from $11.4 billion in 1996 to $29.9 billion in 2005. Pharmaceutical companies spend 6 times more money advertising to physicians than to consumers, though consumer advertising is growing more rapidly.

Both patients and physicians do need to be educated about new drugs and medical devices, but that education should not come mainly from the company selling the product. The medical community is actively discussing how physicians can best receive objective information about new products.

We'd all be better off if excessive promotional costs did not add to the price of new prescription medications. And every one of us can think of better ways to spend Bayer's $20 million actually delivering medical care.