Our expert is Lucy Faulconbridge, PhD, Assistant Professor of Psychology and Director of Research at the Center for Weight and Eating Disorders at the University of Pennsylvania’s Perelman School of Medicine. Her research focus is the co-morbidity of obesity with mental illness, particularly depression.
BARIATRIC SURGERY CAN BE EXTREMELY HELPFUL AS A LAST RESORT
Bariatric surgery is generally only available for severely obese individuals who have not succeeded in controlling their weight using diet and exercise. Almost all of our patients at Penn have tried traditional diet programs and lost significant amounts of weight, but they aren’t able to keep the weight off. For them, being overweight is more than carrying extra pounds; it can mean significant psychological and medical issues, such as depression, heart disease, diabetes, severe sleep apnea, a great deal of physical pain, and a shorter life. For these individuals, bariatric surgery is a tool that by itself isn’t going to solve their problems. However, by following the post-operative recommendations, which include eating a diet high in protein and low in carbohydrates, with five or six small meals throughout the day, and with exercise, bariatric surgery can help patients to lose significant amounts of weight and to keep it off over the long-term. This means both a longer life and a higher quality of life.
GUIDELINES FOR BARIATRIC SURGERY
Per the recommendations of the American Society for Metabolic and Bariatric Surgery, patients are eligible for bariatric surgery if they have a BMI of 35 along with co-morbidities such as high blood pressure or diabetes, or if their BMI is 40 or more even without co-morbidities. However, more and more surgeons are allowing individuals with lower BMIs to get the surgery.
BARIATRIC SURGERY ISN’T ALWAYS A SUCCESS
Although it is not widely talked about, bariatric surgery failure rates are higher than you would think. A recent study published in JAMA Surgery (2012) showed that nearly 20% of Roux-en-y gastric bypass patients failed to lose at least 50% of their excess BMI by both the 1- and 2-year follow-ups. The person who doesn’t follow the lifestyle recommendations and instead drinks milkshakes all day long is going to regain the weight. It’s a misconception that “I’ll get the surgery and not have to do anything.” There’s also a 0.5% risk of death either during the surgery or within 30 days of the surgery. Many people don’t realize that this is a serious surgery that involves a massive change to their lifestyle.
WHAT WORKS FOR WEIGHT CONTROL ISN’T EASY OR SEXY
Our recommendations for a healthy lifestyle haven’t changed much in 50 years: have three balanced meals a day; eat a range of low- calorie foods while limiting high-fat and high-sugar foods; and enjoy your food without making it your primary means of enjoyment. In other words: moderation. This is not a sexy answer, and it’s not an easy answer, but it really is the best answer we have right now.
DON’T BLAME YOUR PATIENT
We know that a huge amount of stigma is associated with being overweight, and it comes not only from the public, but also from health care providers. Your patient doesn’t want to be overweight, and being judgmental only makes him or her feel guilty, depressed, less likely to want to come back, and it may lead to binging. Instead, recognize that in the current environment, it’s truly challenging to maintain a healthy body weight.
CHANGE NEEDS TO COME BOTH THROUGH EDUCATION AND AT THE POLICY LEVEL
In this country, making the choice to eat healthy is very hard, given that high-calorie, highly processed food is available everywhere all the time. This can be addressed at the policy level, for example by changing the food that’s available in schools or taxing soft drinks. But education is also tremendously important. I have clients who come in thinking that drinking a typical soft drink is like drinking water. They’ve never been taught that there are often as many as 140 calories in just one 12-ounce can. They also need to know that eating a small orange may involve something in the range of 45 calories, versus eating a candy bar, which could easily be 250 calories. Choosing an orange over a candy bar doesn’t make a difference in weight for one day, but we quickly develop habits, and 20 years of eating a candy bar instead of an orange makes an enormous difference.
Your thoughts? Comment below.
HEALTH OF AMERICAN WOMEN: IT’S PROBLEMATIC
Our expert is Steven Woolf, MD, MPH, Professor, Department of Family Medicine and Population Health, Virginia Commonwealth University. Dr. Woolf has served as Director of the VCU Center on Society and Health since he established it in 2007. He has published more than 170 articles in a career focused on evidence-based medicine and the development of evidence-based clinical guidelines, with a special focus on preventive medicine, cancer screening, quality improvement, and social justice.
Be sure to attend Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. Steven Woolf will be one of the many outstanding presenters.
THINGS ARE NOT WHAT YOU EXPECT
IN U.S. HEALTHCARE
There’s a widespread perception that the United States has the best health care in the world. After all, we spend more on health care per person, we have cutting-edge technology, excellent researchers, and really sophisticated health centers. Yet in spite of all this, our life expectancy is shorter, and our disease rates are higher than the rest of the industrialized world. This is seen across all sectors and all age groups up to age 75. In addition, we see patterns for women that are particularly worrying. In the 1980s, when it comes to life expectancy, U.S. women were somewhat in the normal range compared to the rest of the industrialized world. Today, women in the U.S. are at the bottom. We spend $2.8 trillion per year on health care, yet women in 42% of U.S. counties are dying at higher rates than they were a generation ago.
MULTIPLE FACTORS CONTRIBUTE TO THE DECLINE IN U.S. HEALTH OUTCOMES
I chaired a panel of the National Research Council and the Institute of Medicine that was charged with looking for an explanation for this decline in health outcomes. We did a deep dive and looked at such factors as: the health care system; health behaviors; socioeconomic conditions; the physical and social environment, such as the built environment and the way cities are organized; and public policies and social values. In each of these domains we found that the U.S. lagged in comparison to other industrialized countries. The bottom line is that unless we take bold transformative action, U.S. health outcomes are likely to deteriorate further.
THE HEALTHCARE PROVIDER CAN HELP AT THE NATIONAL LEVEL
The decline in life expectancy in the U.S. is a huge public health concern, especially as it concerns women, and yet it’s hard to get research funding to study the causes. We spend research funds on such things as nanotechnology and gene mapping, but we’re not dealing adequately with social factors that have a much greater impact on our population. When it comes to women’s health, we’re dealing with a problem that threatens half the population and that will shape the health trajectory for the next generation because the health threats to women also extend to their children. We need more research to figure out what is going on. Health care providers can have an impact nationally by working with their professional groups, since professional groups can have a large impact on public policy.
HEALTHCARE PROVIDER CAN HELP AT THE COMMUNITY LEVEL
Health care providers can have a major impact on local policy. When a healthcare provider speaks up when the community is deciding about more physical activity in the schools, or healthier food in the cafeteria, or where a bus depot will be located, the community listens. When policy issues that affect health are being decided, they should attend community meetings or accept invitations from local radio, television, or newspapers for a chance to be interviewed on the subject.
HEALTHCARE PROVIDERS CAN HELP AT THE INDIVIDUAL LEVEL
Healthcare providers can help their patients by looking beyond the walls of the clinic and taking into account the environment in which their patients live. Let’s say a mother comes to a pediatrician with an obese child. The pediatrician could say, “Johnny needs to exercise more, so make sure he goes out and plays for 30 minutes a day.” A pediatrician who doesn’t realize that Johnny lives in a high crime area will also not know that the mother would be crazy to let him play outside. Imagine a scenario in which the electronic medical record alerts the pediatrician to the neighborhood conditions for this patient and identifies a community resource center that offers indoor after-school exercise options. The pediatrician’s advice would be more meaningful: “I know you’re not comfortable with Johnny playing outside. But there’s a community center at the corner of 7th and Vine, where he can exercise indoors. I’ll print this information out for you.”
Your thoughts? Comment below.
Our expert is Harmony R. Reynolds, MD, Saul J. Farber Assistant Professor of Medicine, Cardiovascular Clinical Research Center, NYU Langone Medical Center. Dr. Reynolds specializes in Coronary Artery Disease and Women’s Heart Health. Don’t miss her talk at Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015, in Washington, DC.
NOT EVERYONE WITH AN ABNORMAL STRESS TEST NEEDS AN ANGIOGRAM OR REVASCULARIZATION
It may seem logical that opening a narrowed artery or bypassing it would prevent heart attacks and prolong life. However, recent clinical trials in stable patients, such as COURAGE and BARI-2D, show that stents and bypass surgery did not prolong life or prevent heart attacks in the stable patients studied. Most heart attacks are triggered by plaques which did not cause severe narrowing before the event.
Most angina is caused by plaques which cause significant narrowing. There is then a disconnect between the treatment of symptoms and the prevention of death and heart attack. The “rusty pipe” concept is not the best one for patients to understand coronary artery disease. In fact, soft plaque rather than “hardening of the arteries” may be the bigger concern. Women need to know that medications and lifestyle changes change plaque on a microscopic level to make it less dangerous, and that this is a major focus of treatment. Those with moderate to severe ischemia on a stress test may be eligible for the ISCHEMIA trial, which tests a routine invasive strategy of cardiac cath and revascularization plus medical therapy vs. a conservative strategy of medical therapy alone, with cath reserved for worsening symptoms or acute coronary syndromes. Learn more at www.ischemiatrial.org
WHEN WOMEN HAVE ACUTE CARDIAC COMPLAINTS, DON’T MISS THE OPPORTUNITY TO ADDRESS LONG-TERM RISK REDUCTION
Many women who complain of symptoms that may be cardiac in origin turn out to have a non-cardiac problem. Still, heart disease is the leading killer of women and attention to risk factor modification is important for everyone. Take the opportunity while she is thinking about her heart to educate your patient about the risk factors for heart attack and stroke, and give her concrete ideas about how to make changes in diet and lifestyle. This is some of the most important work we do as physicians! The woman who avoids a heart attack because of the time you spent telling her how to eat healthy and exercise may not know to thank you, but we all know what a big impact this one-on-one attention can have.
WOMEN CAN HAVE HEART ATTACKS THAT DON’T SHOW UP
IN AN ANGIOGRAM OR IN ST SEGMENT ELEVATION
Twenty-five percent of the heart attacks that women experience show no ST segment elevation or blockage. In contrast, only 3-10% of men have heart attacks without ST elevation or blockage. One explanation is that there was obstruction temporarily, with a totally blocked artery, but then the woman’s body was able to open it up again, but only after damage occurred. Another possibility is that damage occurred due to do a temporary blockage caused by vascular spasms that no longer show up by the time the angiogram is done. Still another possibility is that in women, the blood clot that forms on an active plaque may break up into the smaller vessels, that is, a level that’s too small for an angiogram to pick up. An angiogram that can show the trunk of the vascular tree and the big branches may not be fine-grained enough to show what’s going on at the microvascular level.
YOUR PATIENT SHOULD KNOW THAT A HEART ATTACK THAT DOESN’T REGISTER ON AN ANGIOGRAM OR IN ST SEGMENT ELEVATION
IS NOT A BENIGN CONDITION
While this is not quite as serious as more overt forms of heart attack, roughly 2% of women who have a heart attack without blockage or ST elevation will experience another attack in the next 1-12 months. There’s a temptation for her to dismiss this kind of attack, not taking it as seriously as she should. However, she should know that even if she didn’t have the typical symptoms in the hospital, she nevertheless did have a heart attack and that her treatment should include, as appropriate, the same medications and lifestyle changes that would accompany a more typical heart attack.
WOMEN NEED TO BE EDUCATED THAT WHEN THEY HAVE HEART ATTACK SYMPTOMS, MINUTES COUNT
There are many cases of women who are experiencing heart attack symptoms who delay going to the hospital so they can first take care of their loved ones, and some even try to clean the house before they leave for the hospital! Women need to learn that when it comes to the possibility of a damaged heart muscle or increased risk of death, the minutes really do count. There can be false alarms, but doctors and emergency rooms are ready for this and women are not “bothering” anyone by coming in with chest pain even if they are not sure if it is a heart attack. Given the seriousness of possible outcomes, this is what to recommend.
OF THE SEVEN MAJOR LIFESTYLE MODIFICATIONS, WORK WITH HER ON THE ONES SHE’S MOST LIKELY TO CHANGE
The American Heart Association lists seven health factors that can help prevent heart attacks. The Simple Seven are: Get Active; Eat Better; Manage Blood Pressure; Lose Weight; Reduce Blood Sugar; and Stop Smoking. However, asking her to take on all of these at once may be too hard for her. Instead, we recommend trying to discover which of the seven health factors she is most motivated to change. If she is not motivated to change a particular factor, you’re not going to get very far with her. Spend a couple of minutes with her finding the area where she is most motivated to change. Then help her set an easy goal, one so easy that she is sure to achieve it by the next visit. When she’s achieved that goal, go to the next step, and then the next and after a while, she will have achieved big changes in small increments.
RECOMMEND THE WEB SITE “MY LIFE CHECK” TO YOUR PATIENTS
The American Heart Association and the American Stroke Association have created a helpful website that’s consumer-friendly, easy to understand, and motivational. It’s called “My Life Check– Life’s Simple 7,” and your patient can find it at: http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US.
Recommend that she visit it for additional encouragement and understanding.
MUSCULOSKELETAL PROBLEMS IN WOMEN
Our expert is Sheila Dugan, MD, Associate Professor of Physical Medicine & Rehabilitation, Rush Medical College, Chicago, IL. Dr. Dugan will be speaking at Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015, in Washington, DC. Be sure to register!
If there is a medical topic you would like to see explored here, please let me know!
CONSIDER MUSCULOSKELETAL PROBLEMS WHEN MAKING DIAGNOSES
When a woman comes in with pain, consider the possibility that her pain has a musculoskeletal cause. I’ve seen many cases of women who’ve been to as many as a dozen specialists over the years but none diagnosed the musculoskeletal problems that were causing the pain. These patients may feel depressed because of the pain but also worried about their sanity, given that the specialists haven’t been able to find what’s wrong. When these women get a correct diagnosis, it’s a life-changing experience for them.
WHEN MAKING A DIAGNOSIS FOR THE CAUSE OF PAIN,
TAKE THE PATIENTS’ HISTORY
As a typical example of why I take a patient’s history when she complains of pain, take the case of a woman who came into my office complaining of pain above her pubic bone. There are a number of tests that might seem appropriate in the absence of further information, such as a colonoscopy or checking for an ovarian cyst. However, if you take her history and learn that just recently she slipped on ice and fell, and then if you start touching the rectus abdominus, and you find that this is exactly where it hurts, and then when you ask her to hold a sit-up position and she tells you that this increases the pain, these are strong indications that the problem is muscular. Having taken her history, and taking anatomy into account, you may be able to get to a correct diagnosis rapidly without subjecting her to unnecessary, expensive, and time-consuming tests.
CHECK PELVIC FLOOR MUSCLES AFTER CHILDBIRTH
After delivery, it’s important to get a sense of how the pelvic floor muscles are recovering. Unfortunately, pelvic floor problems tend to be invisible and undertreated, and left untreated, they may set the woman up for urinary incontinence later in life. Urinary incontinence is the number one reason for women entering nursing homes, so doing something to prevent it early on is important. To check the pelvic floor muscles, palpate to see if the woman is having pain, and do this both through the vagina and the rectum. If there’s a problem, refer her to a pelvic floor physical therapist.
PRACTICE TRIAGE FOR MUSCULOSKELETAL PROBLEMS
Learning to figure out which problems need referral for surgical care and which can be treated in house is an important skill for the primary care provider. An anterior cruciate ligament (ACL) tear can be a devastating injury and is likely to require surgical care. On the other hand, many if not most knee problems can be treated in house. The reason to be careful about not sending knee patients for surgical care if they’re not true candidates for surgery is that the patient is likely to end up at the back of the line for treatment. In a hospital setting, I’ve come across patients who had waited for months before being seen.
ENCOURAGE EXERCISE AND GOOD POSTURE
Exercise and good posture are important at any age, but post-menopause, the costs of poor posture and lack of exercise show up in a significant increase in complaints of pain. Poor posture can result in compression fractures in the spine, and the habit of leaning forward can mean the arms aren’t hanging from the shoulders in the right position, and this in turn can mean rotator cuff pain. Further, the frailty associated with sarcopenia (muscle loss) and osteoporosis can be devastating. Exercise can slow both muscle loss and bone loss, and strengthening the back can mean better posture.
Your thoughts? Comment below.
Premenopausal Women with Low Bone Density
Our expert is Elizabeth Shane, Professor of Medicine and Vice Chair of Medicine for Clinical and Epidemiological Research at Columbia University’s College of Physicians and Surgeons. Her research interests include premenopausal osteoporosis, bone disease associated with HIV/AIDS, bone loss due to medications and gastrointestinal diseases, and the use of high-resolution imaging to investigate the effects of various drugs and diseases on bone quality and strength.
You can hear Dr. Shane at the upcoming conference, Women’s Health 2015: The 23rd Annual Congress, April 16-19, 2015 in Washington, DC.
LOW BONE DENSITY CAN OCCUR IN PREMENOPAUSAL WOMEN
Although osteoporosis is mostly a disease of older women, under certain circumstances, premenopausal women may also be vulnerable. There are disease states and medications that cause low bone density in premenopausal women including: celiac disease, cystic fibrosis, rheumatoid arthritis, epilepsy, eating disorders, and any disease with increased inflammation. In addition to diseases and medications that can cause low bone density, certain lifestyle habits such as smoking, excessive drinking, inadequate calcium and vitamin D, and insufficient exercise, may contribute to or exacerbate premenopausal bone loss. Some cases are genetic. In others, the cells that form new bones do not function well. Fractures can also affect women in the third trimester of pregnancy or during breastfeeding. In other cases, we just don’t know the cause.
TESTING FOR LOW BONE DENSITY IN PREMENOPAUSAL WOMEN
In most cases, we discourage premenopausal women from having bone density exams. For one thing, it’s difficult to interpret the results in a younger woman. Even though she may be at the lower end of the bell-shaped curve for bone density, that doesn’t necessarily mean a woman is at short-term risk for fractures. Further, a thin, petite woman may have a falsely low reading because the scan is two-dimensional, capturing height and width, but not the depth of a bone. Also, small women don’t need large bones because their bones are not bearing a lot of weight. On the other hand, there are situations in which measuring bone density is highly appropriate. If a premenopausal woman has any of the diseases that are known to have a bad effect on the skeleton, or if she has had a fracture that’s not easily explained by the degree of trauma (a low-trauma fracture), then a bone density scan should be performed. A low-trauma fracture is defined as one that occurs with trauma equivalent to a fall from standing height or less, for example, a woman who breaks a bone after a fall on a sidewalk. This is in contrast to a high-trauma fracture that comes from falling down a flight of stairs or a motor vehicle accident.
WHEN A MEDICAL EVALUATION IS NEEDED
In cases where there is an unexplained broken bone, and low bone density is found on a bone density scan, it is very important do a thorough medical evaluation to make sure that there isn’t a treatable underlying cause. Celiac disease, for example, can be asymptomatic and may only present with fractures. Diagnosing an unsuspected underlying disease, such as asymptomatic celiac disease, and treating it specifically is much more effective than treating the low bone density itself. If a woman has celiac disease, it is usually much more effective to put her on a gluten-free diet than to give her medications to increase bone density.
LIFESTYLE APPROACHES TO TREATING LOW BONE DENSITY
If an individual has low bone density but no fractures, I usually recommend some lifestyle changes along with observation rather than medications. Lifestyle changes that may help prevent fractures and improve bone density include: quitting smoking, reducing or eliminating alcohol use, and engaging in plenty of weight-bearing exercise, such as walking, jogging, running, dancing, or using an elliptical machine. Interestingly, lifting weights doesn’t have a large effect on bone density, even though it’s a good thing to do for other reasons.
The individual should make sure she’s getting adequate calcium and vitamin D, preferably from her diet. WebMD has useful information on sources of dietary Vitamin D and calcium, http://www.webmd.com/food-recipes/guide/calcium-vitamin-d-foods. However, too much calcium could be harmful, so she should make sure that the total between diet and supplements is not much more than 1000 mg per day. Similarly, too much Vitamin D can also be harmful. I usually recommend 1000 IU daily and then adjust to maintain the blood level at around 30 ng/ml.
BE CAUTIOUS ABOUT PRESCRIBING MEDICATIONS FOR LOW BONE DENSITY
Prescribing medications for women of childbearing age who have low bone density is complicated because some medications can cross the placenta. Biophosphonates are a Category C drug, meaning they should be avoided in pregnancy. Teriparatide and denosumab should not be used during pregnancy. To further complicate the issue, bisphosphonates may persist in the bones long after the patient is no longer taking them, and can still cross the placenta even after they are discontinued. A woman of childbearing age should agree to use contraception if it is medically necessary to treat her low bone density pharmacologically.