Medsarticles. Medical Weblog

Discuss fully with your physician the different ways of using hormones. Oestrogens are most often in tablet form and taken by mouth. They may be from natural sources or artificially produced synthetics. Hormones can also be injected or implanted beneath your skin, or placed under the tongue (sublingual) or applied as a dermal patch (sticking plaster) applied to non-hairy skin or near the buttocks, allowing the drug to be absorbed through the skin directly into the bloodstream at a constant rate. When oestrogen is taken on its own, doctors refer to it as ‘unopposed’, and current opinion is that it should be balanced by taking progestin (the synthetic form of progesterone) a few days each month to mimic the normal premenopausal ovarian cycle. Progestin now plays an important part in a hormone replacement programme. With this system, some of the risks of side effects are lessened, but the drawback is that you may menstruate every month. Drug manufacturers are now producing ‘conjugated’ oestrogens with a balanced formula.

Ask your doctor if your treatment would be for a short term only, or whether long-term therapy is being considered, what the minimum dosage would be, and whether your risk of bone loss is sufficiently high that it outweighs the risk of side effects. The best evidence suggests that 0.625mg of conjugated oestrogen daily (not the mega-doses once prescribed) in addition to adequate dietary calcium, is necessary to maintain skeletal mass in white women. Your doctor can adjust the prescription to suit your personal needs. Since studies on dosage have been based almost entirely on white women, treatment of women from other racial backgrounds is best determined on an individual basis.

*54\114\2*

Unfortunately, because osteoporosis is a silent disease, it has always been a problem that there are few outward signs until bones have become so weak that they can suddenly fracture.

Have you measured your height lately? Are you shorter than you used to be, or stooped? As spinal vertebrae fracture, collapse and are crushed together, height is lost between hips and neck and your posture changes. Height measurements should be a part of your routine medical examinations, with every doctor’s surgery having a scale on the wall for measurements to be made regularly. Do you know how tall you were at skeletal maturity, about the age of twenty-five? You can roughly calculate your early adult height by measuring your armspan, since that width is usually (but not always) nearly equal to your earlier height at adulthood. Deduct this armspan measurement from your present head-to-heel height for a rough estimate of height loss.

Do you have transparent skin? On the back of your hand, if the skin is loose and lacking pigment so you can see the edges of small as well as large veins, this transparency indicates collagen deficiency in the outer layers of your skin. As one of the components of bone is collagen, it has been concluded that skin thickness has a correlation with bone thickness. However, this is also an indication of rheumatoid arthritis. Skin thickness can be measured with calipers in your doctor’s surgery.

Do you have gum disease? Gum disease can be a sign of poor dental hygiene – but sometimes it is a warning of osteoporosis. Many adults, especially middle-aged women, lose their teeth with pyorrhoea. Periodontal disease or pyorrhoea affects the tissues supporting your teeth – the gums, ligaments attaching teeth to your jaw and sometimes the alveolar bone. Where there is loss of bone in the jaw, gums can recede, teeth are not securely held in their proper place and change position, inviting bacteria to the exposed areas between gums and teeth. If too much alveolar ridge is lost, even dentures cannot be properly seated. Ask your dentist about X-rays of your jaw as they can be a useful indication of the bone density elsewhere in your body.

If you think your bones may be at risk, other tests can be done to evaluate bone mass, depending to some extent on the equipment available in your neighbourhood, and how your physician prefers to approach the problem. Sometimes doctors will take blood and urine samples for analyses of calcium in the blood and calcium excreted in urine and thus lost from your body. These tests do not provide a diagnosis of primary osteoporosis with any degree of certainty, because of variations resulting from food intake, metabolism, heavy use of laxatives, and the possibility of other bone disease.

Although spinal, hip and jawbone X-rays are frequently used, they are perhaps not sufficiently sensitive to discern early bone loss, the problem being that in standard X-ray imaging the hard dense outer layer of bone tissue (cortical bone) can hide the inner honeycomb-type bone (trabecular bone). With osteoporosis, cortical bone gets thinner, and trabecular bone more porous, but unless 30 per cent of bone mass is lost, radiologists might have difficulty in detecting osteoporosis. In some cases, X-rays may reveal that one or more vertebrae have already fractured, even though you have not been conscious of any back pain. Many patients with osteoporosis do have pain, however: either a chronic ache along the spine or pain from spasm in the back muscles. This occurs when the muscles of the back must take an increased share of the load of supporting the upper half of the body, after the spine has partially collapsed. Then the muscles will ‘complain’ periodically.

If you live in a large city or near a big hospital, the preferred method of evaluation is a CAT scan. Computerized Axial Tomography is a way of seeing bones with multiple X-ray exposures combined by computer into one picture. By modifying a CAT scanner, which produces a cross-sectional image of your body, or part of your body, doctors can get a reading on the amount of bone density. A modified scanner, differentiating and separating images of trabecular (where bone loss is more severe) and cortical bone, can tell the amount of bone mineral present, whether there is some degree of osteoporosis, and monitor it so there are no further complications.

In certain clinics, it may be possible to have tests using other types of X-ray equipment: radiogrammetry, radiographic photo-densitometry or photon absorptiometry, to measure bones in fingers or forearms, since if you do have osteoporosis it will be occurring in many places simultaneously.

Single proton absorptiometry measures the density of forearm bones or the heel. The bone is penetrated by a narrow beam of photons from a radioactive source. Radiation exposure is quite low, under lOmrem. This test is useful if you are over 75, and if you have had large changes in bone density due to medical treatments.

Dual photon absorptiometry is similar, except that the radioactive source produces two beams, for a more precise measurement. It can be used to measure the hip, the spine and other skeletal sites. Radiation exposure is about 30mrem. This test is appropriate if you are middle-aged, because it measures the hip and spine. However, it is less useful than a CAT scan if you are over 75 or have calcium deposits or bone degeneration around the spine.

Dual energy radiography is still being developed, but promises greater precision and lower radiation. Total body neutron activation analysis, performed in a very few research laboratories, is a method for measuring the total calcium in your body, and your skeleton in particular.

If your doctor considers further examination necessary, he will investigate what is available in your area, what diagnostic equipment is in nearby clinics, hospitals and research centres, and the costs involved if you have private treatment. Usually at least two separate tests are necessary, to discover the rate at which your body is being depleted of calcium and your rate of bone loss.

*6\114\2*

Allergies

Sometimes so-called ‘allergies’ are psychological reactions to foods rather than actual physical reactions to real allergies. Milk may be involved in food allergy, although milk protein allergy is an uncommon sensitivity generally found in formula-fed newborn babies, which usually disappears at about the age of four. Milk allergy, as with other allergies, may develop in later years, but this is rare. Allergic reaction to the protein in milk can cause severe diarrhoea, asthma, sneezing or skin rash in susceptible infants after consuming cow’s milk. When these symptoms are observed, a paediatrician will immediately change the milk-based formula to one based on predigested protein. Milk products should be entirely eliminated from the diet. Thus label reading is important since milk is often used in convenience foods.

Lactose intolerance

Many people say that ‘milk doesn’t agree’ with them. It’s an astonishing fact that, although precise numbers are not available for Britain, at least 30 million Americans are unable to drink milk or consume other dairy products without suffering cramps, bloating and gas. What is the problem? It could be lactose intolerance, pertaining to the natural sugars in milk. The gastric symptoms are very similar for milk protein allergy and for lactose intolerance.

Milk contains a combination of glucose and galactose called milk sugar or lactose. (Cow’s milk has 4 to 5 per cent; human milk 6 to 7 per cent.) In your intestinal tract are enzymes on the surface of the cell lining that work to digest the different sugars in the diet; and it is the enzyme lactase that is necessary to split the sugars in milk, for absorption through the intestinal wall. A shortage of lactase can give many people some difficulty in digesting large quantities of milk and milk products. This is lactose intolerance. If you have insufficient lactase enzymes, and eat large quantities all at one time of foods containing lactose, much of the undigested milk sugar stays in your intestines, with the bacteria present there growing on it and producing gas, similar to the way sugar in wine is fermented by yeast. The result is nausea, stomach ache, cramps, diarrhoea and bloating, that can last up to ten to twelve hours.

Three different types of lactase deficiency are known:

Congenital lactase deficiency is very rare. In this case, babies are born with limited or no ability to produce lactase, so all lactose-containing foods must be eliminated from the diet.

The most common type is caused by a gradual decrease in lactase production after the age of two years, an inherited condition which affects millions of people. Members of certain ethnic groups show a definite decline in lactase with age, although lactase production during infancy and early childhood is adequate. But by the time they are teenagers, they have typical symptoms of lactose intolerance. By adulthood, 70 to 75 per cent of blacks, 70 per cent of adult Jews, almost all Orientals and 15 per cent of American Indians and Eskimos are lactase-deficient. Even among Caucasian populations of Northern European ancestry, lactase deficiency occurs in approximately 5 to 20 per cent of young adults.

Officially, lactose intolerance in the UK has only been noted as a problem for people of African origin, with an estimated incidence of about 1 per cent of the total population. However, according to recent research, most humans have lost much of their ability to make lactase by the time they become young adults, so the problem is clearly shown to be related to ageing. It has been estimated that approximately 80 per cent of the world population is deficient in lactase to some degree. (Consequently it made little sense when the US Government attempted to ship large surplus quantities of dried milk powder to undernourished populations in the Third World, and when the big food corporations producing milk-based baby formulas tried to market their products to poor nations in Africa – a problem compounded by the poor unsanitary sources of water with which to reconstitute the milk and to dilute the formula.)

Many experts believe that lactase deficiency is inherited since some ethnic groups have a high incidence of deficiency while others have a low incidence. Ethnic groups who live in different parts of the world have similar prevalence. For instance, Jews living in the United States have a similar prevalence of lactase deficiency to those living in Israel, and American blacks have a deficiency comparable to that of African blacks.

It is believed that in primitive times, humans seldom drank milk after being weaned. But when some of the world’s populations took up dairying, as in Scandinavia and Northwestern Europe, the people continued drinking milk into adulthood and most of them maintained their capacity to produce lactase. On the other hand, in Southern Europe, Africa and Asia, where milking has been a very recent activity, lactase deficiency is very high, starting as early as the age of three.

The third type of lactase deficiency is not hereditary and may not be permanent, but a temporary condition due to stomach surgery, certain drugs (such as some for arthritis) and antibiotics (particularly penicillin) or radiation treatment in the area of the abdomen. In some cases, where there has been severe damage to the lining of the small intestine, healthy cells are producing lactase but the total produced is insufficient to handle large amounts of lactose. If damaged tissue subsequently recovers to promote growth of healthy lactase-producing cells, lactose tolerance will return to normal.

Your doctor can give you tests in his surgery to check lactose deficiency, or if it is necessary to examine a section of intestinal tissue, an analysis of a small biopsy can be made. But you can do some simple testing for yourself at home.

Early in the day, try drinking two glasses of milk all at once on an empty stomach, and note your system’s reactions; with this amount of milk, you will react within an hour or two if you have tolerance. Or cut out all sources of lactose from your diet to see if symptoms disappear, and if they return when consumption of lactose is resumed.

So far, no method has been found to restore general lactase levels. Basic biochemical studies to understand the working of the enzyme lactase have been difficult because it is fragile, but once your problem is identified you will know how to handle it, and very likely you won’t have to give up milk and milk products.

If you are sensitive to milk, be sure to check the label of all processed foods for milk, dry milk, buttermilk, cream, casein or dried whey among the ingredients. Be aware that lactose can be found in the following foods, although small portions may often be tolerated.

Drinks:

Milk (whole, lowfat, cream, buttermilk) and yogurt. Instant coffee, instant cocoa, instant breakfast drinks. Cream liqueurs and cordials.

Cheeses:

All cheeses, especially lowfat and creamed cottage cheese, gjetost and ricotta.

Meats:

Sausages and luncheon meats containing dry milk.

Liver sausage.

Liver, brain and sweetbreads. Breaded meat, poultry and fish.

(Kosher meat products and food are milk-free when marked ‘pareve’)

Fruits and vegetables:

Canned, frozen products in ‘cream’ sauces, and instant potatoes.

Grain products:

Breads, cereals, crackers, biscuits, pancakes and waffles made with milk.

Prepared mixes for biscuits and scones. Desserts:

Ice-creams, ice-milk, sherbet made with milk, and milk-based puddings, custards and junkets.

Cakes, pie-crusts, pie-fillings made with milk or cream. Other:

Cream soups, cream sauces and gravies. Caramels, chocolates, butterscotch and toffee. Dietetic and diabetic products. Milk-based baby foods Some drug preparations.

Lactose intolerance is not like an allergy, where the reaction is unrelated to dose, so you should not have to avoid milk. You need the nutrients of milk, especially its calcium, all your life particularly in later years. The best approach is to determine your own personal level of tolerance to milk, bearing in mind the following:

The quantity added to coffee or tea generally gives no trouble. Very often, small amounts of milk drunk throughout the day are no problem if taken slowly and in moderation, say 1.5 cup at a time, and not with other milk products at the meal.

If milk is combined with other foods, the concentration of lactose is reduced, and the stomach’s emptying time is slowed down.

If milk is served at room temperature or slightly warmed, you will probably tolerate it better than if it is ice-cold. Thus, hot milk is more digestible in cocoa or hot chocolate, cream sauces, cream soups and chowders, puddings and custards.

Researchers have now developed lactose-reduced milk, cottage cheese and low-lactose milk powder, now available at some dairies, although these products already treated with lactase may not yet be available in many supermarkets.

You can treat fresh milk yourself with lactase enzyme products: one is called ‘LactAid’, widely available as drops or tablets, without prescription, from chemists or health-food stores in the UK and around the world. When ‘LactAid’ is added to milk, after 24 hours the enzyme has broken down 70 per cent of the lactose to make it predigested; after several days, the lactose is reduced by 90 per cent. If added to milk in double the amount specified on the label, the lactose content can be reduced by 95 per cent. This enzyme product will break down lactose in whole milk, lowfat, skimmed, cream, baby formula, goat’s milk, condensed and evaporated milk. Enzyme-treated milk can afterwards be used any way you would use ordinary milk, although it does taste sweeter because glucose and galactose (the sugars making up lactose) taste sweeter than lactose. Consequently diabetics should first check with their doctors before using lactase-treated milk products.

You can take milk digestant tablets containing lactase just prior to eating a lactose-containing food. These tablets are sold in health-food stores or at chemists.

Frequently, fermented milk products such as buttermilk, sour cream and yogurt are better digested because the fermentation process uses up some of the lactose to grow, producing lactic acid making the characteristic tart taste. This is perhaps why people in other countries who have lactase deficiency usually eat yogurt and other cultured milks. Commercial yogurt has about 60 per cent of the lactose found in the same amount of milk, although there is some variation between brands; in home-made yogurt, you can reduce the lactose content further by prolonging the fermentation period. The advantage of yogurt is that its healthful bacteria produce the enzym lactase in the acid-alkaline environment in the stomach, making the nutrients better absorbed.

Cured cheeses such as natural Cheddar, Gouda and Edam are usually more digestible, because much of the lactose is lost during production. Other low-lactose cheeses are Brie, Camembert, Gruyere, Limburger, Monterey Jack and Port du Salut. Avoid cheeses with the highest lactose content such as lowfat and creamed cottage cheese, gjetost and ricotta.

Another way to avoid lactose-containing foods but still consume calcium is to use soya milk, soya flour and tofu, as detailed earlier.

You can obtain your calcium from supplements in addition to food.

*43\114\2*

In water supplies. Fluorides are chemical combinations of fluorine and other common elements. Fluoride is an important mineral needed for good bones, blood, teeth, nails, skin and hair.

When fluoride is taken during childhood or adolescence, it is incorporated into the structure of developing teeth, making the enamel more resistant to acids produced by bacteria, as well as strengthening bone tissue. Fluoride is rapidly taken up by bone and is known to stimulate bone growth, and it has been used successfully in experiments treating sufferers of osteoporosis. Harvard studies have shown that elderly people suffer less calcium loss from bones and fewer hip fractures when fluoride is in their drinking water.

Fluoride can occur naturally in water in certain localities, dissolving from rocks where the water is flowing. The optimum level is considered to be 1 part fluoride to a million parts of water (1 ppm), which provides a fluoride intake of about 1 milligram per day. Some regions have as little as 0.1 ppm and a few have as much as 5 to 10 ppm. The average level of natural fluoride in UK drinking water is low – only about 0.2 ppm. People who drink water containing higher levels of fluoride, such as 5 ppm, may have mottling of teeth but virtually no tooth decay and good strong bones. Moderate bone ‘fluorosis’ can be beneficial for greater skeletal strength among elderly people, and moderate fluoride supplements can prevent the onset of osteoporosis.

Too much fluoride can be as harmful as too httle, however, although bone fluorosis generally occurs only where the fluoride level of water is more than 10 ppm (10 mg of fluoride per day). For instance, in the Punjab region of India, where the naturally present fluoride is extremely high, bone changes are connected with severe joint and nerve disease.

Fluoridation of public water supplies continues to create controversy, and perhaps you’ve heard about other possible adverse effects of fluoride. Fluoride is toxic at excessive levels, but 2500 ppm is required for fatal poisoning – many times higher than that in fluoridated water. And although you may hear rumours and reports that fluoride is associated with human cancer, there is no scientific truth or medical basis. Studies have tried to link fluoridated drinking water with Mongolism (Down’s Syndrome), but have failed for lack of scientific evidence. The US Consumers Union medical panel has concluded that there is no scientific controversy over fluoridation safety, and finds it economical and beneficial.

Water Authorities in the UK have twenty-three different schemes for fluoridation of our water supplies, for about 9 million people or 17 per cent of the population. Check to see if your community water supply is naturally fluoridated, or if it has been amended to the approved level of 1 ppm of fluoride. If you have a reverse osmosis system in your home to provide purified drinking water, this could be removing fluoride. Check this with your dealer. And ask your physician or dentist about the fluoride needed by you and your family, and before giving fluoride tablets to your children.

Commercial companies that sell bottled drinking water sometimes offer the option of water that has been treated with fluoride to the 1 ppm level, at a small extra cost compared to regular drinking water.

If your children are relying on fluoridated water as their source of fluoride, make sure they are actually drinking it, and not consuming the more tempting soft drinks.

Fluoride in foods. Although water is the main source of fluoride in the diet, it also occurs in various foods – sardines, whole fish, and tea, for instance. Food can contribute up to 25 per cent of your daily fluoride intake, particularly if fluoridated water is used in processing or the crops are grown in regions naturally high in fluoride. Tea leaves have the highest fluoride levels found in plants: 6 cups of an average brew in England supplies about 1 mg. A relatively high concentration of fluoride has been found in wine from grapes growing near active volcanoes in Italy.

In other parts of the world, fluoride has been specially added to foods: in Hungary and Switzerland it has been added to salt. Experiments have also tried the fortification of fluoride in flour, milk, fruit juices and sugar.

*30\114\2*

There are many reasons why some people choose to adopt vegetarianism: sometimes it is because meat is hard to obtain or too expensive; it may be due to religious beliefs, objections to killing animals or a fear of chemicals used to fatten livestock; it may be as a political protest against ‘agribusiness’; some people may simply not care for the taste of meat, or find it difficult to chew with poor teeth. For whatever reason, vegetarianism is becoming increasingly popular, with several supermarket chains and major restaurants catering to the bigger demand for healthy meatless meals.

While care should be taken to avoid deficiencies in certain nutrients, studies of lacto-ovo-vegetarians indicate they have only about half the bone loss of meat-eaters, so the inference is that a high intake of protein from meats may contribute to bone loss. (The problem of high protein intake is covered in the next section.)

Strictly speaking, a vegetarian is a person who refuses to eat meat, poultry or fish. A lacto-vegetarian allows dairy products and an ovo-vegetarian permits eggs; a lacto-ovo-vegetarian eats both milk products and eggs. The most liberal vegetarians are those who eat fish, poultry, eggs and dairy products, fruits and vegetables, but exclude the red meats (beef, lamb or pork).

However, some vegetarianism is more extreme – and the more restrictions are observed, the greater the potential for general undernutrition: a fruitarian is limited to only raw or dried fruits, nuts and sometimes honey. A vegan or strict vegetarian eats only plant food, no animal flesh nor other animal food such as eggs or dairy products. These diets are usually low in calcium and vitamin D when dairy products are not eaten, and the loss is not made up by other sources of calcium found in vegetables. When vegan mothers breast-feed their babies, some cases of rickets (osteomalacia) have occurred, so many are now turning to soya milk that has been fortified with calcium and vitamins.

One of the most restrictive diets is the Zen macrobiotic system of cereals, soups, and hardly any fruits, with a restriction of fluids. Over a period of time, such severe diets can lead to scurvy, anaemia, protein deficiency, loss of kidney function, loss of calcium, with severe bone reduction and emaciation. A recent study in Boston found that growth was retarded in a group of children consuming a strict macrobiotic diet.

For handy guides to healthy meatless eating, read The New Vegetarian by Michael Cox and Desda Crockett (Thorsons), and The Best of Vegetarian Coqking by Janet Hunt (Thorsons).

*19\114\2*