Sunday, December 01, 2019

Who Knew?   

 Onions are gaining a reputation as a super-food.  Researchers  found that post-menopausal women who ate onions daily had a notably higher bone density than those onion-slackers who maybe/maybe not ate onions every so often.  Onion flavonols, worthy molecules found in all fruits and vegetables, inhibit the development of osteoclasts, the cells that breakdown bone.  And who knew that the outer peels of onions, including that brown or purple paperish outermost layer, have the highest content of favorable flavonols.  I boil these layers in water and use the resulting broth in soup. 
We all have hourglass figures;   
Your sand just settles in different places.   

 Octavia Spencer      
 Silicon (Si) is the eighth most common element in the world, and the second most common element in soil (oxygen is first).  The majority of naturally occurring Si is present in highly stable minerals as silica and silicates--think sand. These minerals are highly stable, resistant to dissolving into chemical forms that could be absorbed by the gastrointestinal tract, in other words, not bio-available.  Si is beneficial in many ways to the life cycle of plants and is an essential component in their cell walls supporting structural integrity of plant growth.  Turns out it’s an important component in our skeleton and connective tissue as well.   There’s no official recommended daily allowance for silicon, but the figure 25 mg/day has been thrown out recently as a good guess.  Here are suggestions to reach that goal. 

 Si food content is highest in whole grains, vegetables,  So what’s good for breakfast?  A standard serving of oatmeal is ½ cup of oats with a silica content of 10 mg.  For lunch?  Nothing more satisfying, or perhaps disappointing, than sitting down to a cup’s worth of steamed green beans, another 10 mg.  If you’re a fan of India Pale Ale, rejoice at happy hour because a can of IPA delivers 18 mg.  These suggestions are based on information from various web-sites found when searching for “foods high in sililca.”  As noted above, however, that which resides in plants and beer (which is made from plants) is not necessarily bio-available.   

 Researchers in the UK, well-apprised of the Si content of various substances, set out to examine just how much is really absorbed through the GI tract in fasting, healthy test subjects.  A number of high Si-containing substances were tested, including 1) OSA or ortho-silicic acid found in small amounts in soil and naturally in water , 2) monomethyl silanetriol or MMST available as a supplement called LivingSilica, 3) bananas, 4) green beans, 5) choline stabilized OSA (CH-OSA) which also comes as a supplement called Biosil,  and 6) alcohol-free beer.  Absorption, based on testing urinary excretion of Si post-ingestion, was highest for MMST and alcohol free beer (64%) followed by green beans (44 %), OSA (43 %), ChOSA (17 %), and bananas (4%).    

 Si not only is incorporated into bone matrix but also contributes to collagen formation which promotes teeth, strong nails, thick hair, and skin that does not so easily give way to gravity as the years go by.  Brittle fingernails and receding gums are two clues to bone loss.  Aging is a risk factor for decreasing bone density as is a personal history of fracture, a history of osteoporosis or fractures in one’s mother, smoking, and low body weight.  Besides eating vegetables, grains, and maybe drinking beer--but not too much please--if you have signs or test results indicating a loss of bone, you might consider taking a Si supplement.  I personally take MMST, available via Amazon, and I splurge on a third of can of IPA at night.  

Saturday, September 16, 2017

Face a new-ish you in the a.m!

First of all, this is a really nice quality pillowcase; it is silky smooth, beautifully made, and washes wonderfully. But here is what separates this covering from all the other nicely crafted, soft-as-can-be competitors; information straight from, an online publisher of abstracts from medical journals.

Researchers from South Korea published a study in 2012 comparing outcomes in just over 60 volunteer sleepers sleeping(1), half of whom plopped their heads on pillows covered in cases made with copper-impregnated fibers, the other half just snoozing on the usual coverings. They theorized that the copper-loaded variety would reduce skin wrinkles because the mineral is known to promote the production of skin proteins and stabilize the matrix of skin as well. A stable and protein-loaded skin matrix just can't be bad when it comes to the effects of sun, gravity, and aging as the years progress.

Expert 'skin graders' were called in to check out the faces of both groups. Neither graders nor subjects knew which group got copper and which group got none. At 4 and 8 weeks into the two month study, copper sleepers had a significant reduction in 'crow's feet' wrinkles while the control group demonstrated no change at all. Furthermore, 3-D studies measuring three 'roughness parameters' (as in 'gee that's rough, you're skin's a mess?!?) also strongly favored copper bedding; notably improved roughness indicators were present only in the copper group with an average improvement of 9% per month. These results echo earlier findings by an Israeli study conducted in 2009(2). These volunteers, aged 40-60, spent a mere month on copper or no copper cases. As shown in the study above, expert graders (two of them, a dermatologist and a cosmetologist) agreed there was significant improvement in wrinkles, crow's feet, and overall appearance.

My own study group of one--me that is--concurs! I figure that boldly eyeing one's face in a magnifying mirror first thing in the morning, with reading glasses on makes one an amateur skin grader, and I'm attesting that the fine wrinkles, the crow's feet, and general roughness is notably better. Alas, too little too late for the big furrows. Nevertheless, I'm a fan.

As to hair? No scientific data on this claim (the no more bedhead thing). My hair is too fine and too thin to even think about standing up in a bedhead sort of way.
1) Baek, JH, et al. Reduction of facial wrinkles depth by sleeping on copper oxide-containing pillowcases: a double blind, placebo controlled, parallel, randomized clinical study. J Cosmet Dermatol. 2012 Sep;11(3):193-200. doi: 10.1111/j.1473-2165.2012.00624.x.
2) Borkow, G, et al. Improvement of facial skin characteristics using copper oxide containing pillowcases: a double-blind, placebo-controlled, parallel, randomized study. Int J Cosmet Sci. 2009 Dec;31(6):437-43. doi: 10.1111/j.1468-2494.2009.00515.x. Epub 2009 May 20.

p.s. Available at Amazon as of 9/16/17 for $43.92; $55.00 at Nordstrom.  AmazonCopperCase

Friday, October 14, 2016

Dancing the Bewegungschöre

I love German verbal portmanteaus.  In order to create big words for simple concepts, they just mash-up two or more words into a multi-letter string such as the noun Handschuhschneeballwerfer (a person who wears gloves to throw snowballs) or the verb Sontagspaziergangmachen (to go for a Sunday walk).  I can’t help but wonder if we had a single word for these activities, would we be more likely to grab friends or family and head for the park on a wintry Sunday afternoon for a jolly snowball fight?
But back to Bewegungschore.  I googled ‘dance’ and ‘mood’ and hit the jackpot by stumbling across information on Rudolf von Laban, a dancer and movement theorist who developed the concept of  Bewegungschore in the early 20th century.  That tongue-twister of a word translates as ‘movement choir’ where participants don’t sing but rather dance together as a shared experience in the joy of moving.  He elaborated his vision further with another mega-word, namely bedürfnislosigkeit meaning demandlessness as in having one’s time and energy free to indulge in ‘festive exaltation’.

Well now, what could be better really than to a bedürfnislosigkeit state on a Saturday a.m in order to participate in a laughing, lively Bewegungschöre, shaking those parts of your body with which you are in contact as you oscillate with a group of like-minded dancers?

In Denver? Looking forward to seeing you some Saturday soon as we dance in a movement choir with Lia Ridley at Dancing the Soul, 950 Jersey St, Denver, CO  80220.

Friday, September 23, 2016

Dancing the Soul

This Virgo girl just passed that milestone birthday that lands me on the Medicare rolls! In order to meet the event with maximum enthusiasm and joy, I spent that celebratory Labor Day weekend morning at Denver's Dancing the Soul studio doing just that, belly dancing my soul as if no one was watching.  For those of you with whom I've never had the pleasure of a face-to-face meeting, that's me in the over-the-top, so-not-me, two piece outfit front row left.

Are you live and local in the Denver area?  Consider checking this class out, 11:00 a.m. on Saturdays, The lovely lady bottom right in the above photo is our instructor Lia Ridley.  Not so sure this is your thing?  Read on!

"Belly dance is like glitter: It not only colors your life, it makes you sparkle. You find it everywhere, and in everything, and it's nearly impossible to get rid of. "
— Anonymous

"Sequins, sass, and sisterhood"

Professor Angie Moe of Western Michigan University investigated the effects of belly dancing on the perceptions that older women had about their bodies, specifically how age related changes were a source of shame and discomfort.  Interviewing aging ladies who participate in this activity, she determined that shaking whatever part of you that still moves enough to more or less shimmy is an excellent way to regain, reclaim, rebuild, and redefine that which constitutes bodily comfort and joy.  

May I add that it's a lot of laughing and a lot of fun?

Thursday, March 19, 2015

The Good Gut

Taking Control of Your Weight, Your Mood, and Your Long-Term Health
I have spent 30+ years in the practice of internal medicine attempting different strategies to change behavior when bad habits happen to good people.  Too often, lifestyle epiphanies occur after major shake-ups such as the diagnoses of diabetes or other serious conditions.  I particularly like the ‘bibliotherapy’ approach, and I’m always on the lookout for good self-help book recommendations to add to my short list of those that truly effect change.

I am pleased to report here that “The Good Gut” is just such a book, well-written in a way that makes it one of those notable non-fiction works that you’ll read cover to cover, not losing interest or comprehension somewhere between a paragraph’s start and finish (no flipping ahead to see how much longer this chapter!).  The Drs. Sonnenburg do not tediously repeat and overstate the standard health caveats to avoid sugar, lose weight, and exercise, but rather expand on their primary point, namely the importance, care, and feeding of our fellow life bacterial travelers. 

As a regular reader of the latest medical literature, much of the content herein was not news to me.  The presentation, however, in everyday layperson language, was personally compelling in ways that the New England Journal of Medicine is not.  A recent search on the NEJM web-site for ‘gut microbiota’ returned 28 articles, not one of which with a title so compelling as to change my diet for life.  Oh right, I’ve already done that, changing out breakfast foods long before the Sonnenburgs’ book and the rest of menu as a result of this read.

I will be recommending this book to my patients, and I also commend it to you.  This book will be released 4/21/15.

Saturday, November 29, 2014

Dental Probiotics: Bacterial Dental Insurance?

Our microscopic fellow travelers are all the rage today, rating their own study group known as the Human Microbiome Project.  I’ve long recommended intestinal probiotics for years to my patients as they’re treated for infections in an effort to avoid some of the intestinal upset associated with antibiotics.  I never gave a thought to probiotics for oral and dental health until I was invited to try this Pro-Dental for review.

Tuesday, November 25, 2014

How Do I Make a Medical Decision? Part II

When last I wrote about making a medical decision (Part I), I focused on the importance of identifying a trusted source to assist you in the process.  While there are inanimate sources such as Internet sites of more or less trustworthiness, printed or pixelated matter informants are one-way interactions.  You  match your situation with the closest approximation available which cannot in turn adjust its wisdom to the unique details of your past or present history.

So let's say your matter involves a consultation with a medical professional.  You've doubtless arrived with thoughts on your subject. What's going through your doc's mind as you meet face-to-face?  

From the first moment that I greet a patient, I am already forming hypotheses or educated guesses. Back in the good old days, I'd walk to the waiting room to call a patient in; we'd shake hands in greeting ( fingers dry? cold? clammy? weak?)(1), then I'd watch them walk--or limp--down the hall.   Armed with the 'reason for visit' from my day's schedule, I'm looking for pattern recognition from moment one of our visit, and 33 years into practice, I've seen a lot of patterns go by(2).  In for foot pain?  Teenaged boy limping with skateboard in hand maybe has broken his toe; older, stout man in a suit, well perhaps he's got gout.

My thoughts are forming as I call on experience (Have I seen this before?) and/or evidence (Have I read about this before?).  If I jump to a conclusion too fast, a diagnostic error called 'premature closure', I'm risking a missed diagnosis which could be inconsequential or a downright disaster.  If I narrow the diagnostic field not at all (which, unfortunately, seems to be an ER predisposition), I may be heading for an unguided work-up of unbridled costs in money and time.  What if I don't let go of my initial impression as contradictory test results come in--an 'anchoring bias'--or fall into a 'confirmation bias' in which I highlight data that supports my anchored diagnosis, ignoring the results that just don't fit in. 

No wonder patients prefer doctors with whom they have a history, seek information on the Internet, and request second opinions.  Now more than ever, get informed and ask questions. Be an advocate for yourself and your family; you're half of the diagnostic partnership.
(1) There's a serious debate now over whether or not patients and docs should shake hands.

(2) Which raises an interesting question:  Would you rather be seen by a doc out in practice for years with a lot of hands-on experience or one just out of training who's up to date on the latest medical studies, clinical tests, and procedures?

Monday, November 24, 2014

Duavee: Finally! A new approach to menopause

A decade into menopause, and I'm still hot (no, not that kind of hot, just middle-of-the-night way too warm hot).  For ten years I weighed estrogen pluses, namely good for the bones, brain, and heart, with estrogen negatives, that nagging worry regarding breast health, and I revisited that analysis annually.  Just this past year, estrogen yikes overtook estrogen yay, and I dropped my weekly dose to just a tick over negligible.  And subsequently lost two checks, a zillion pens, one notebook, my pedometer, my keys again and again, 5 pounds of muscle, and 1/2 inch of height. 

Enter a new kid on the menopausal treatment list, a so-called TSEC or tissue selective estrogen complex, also known by the not-so-catchy name of Duavee.  It was approved in October, 2013, but I only found out about it in the March issue of the journal "Menopause" which featured a long article and accompanying editorial about this drug.

Duavee is a combo drug, a pharmaceutical 'two-fer'.  It contains Premarin (no, I don't love that about it either, but more on that later) and bazedoxifene which is not approved as a stand-alone drug in the U.S. although it is available in Europe.  Each of these drugs interact with estrogen receptors in the body, but while Premarin stimulates the 'on switch' when it couples with cellular receptors, bazedoxifene turns some estrogen receptors on and some of them off depending on the specific tissue involved.  It is one of a class of drugs called selective estrogen receptor modulators (SERMs). 

Tamoxifen is also a SERM long-used to decrease risk of estrogen-receptor positive breast cancer or to prevent its recurrence. Tamoxifen, unfortunately, stimulates estrogen receptors in the uterus, thus increasing risk of uterine cancer, and some women do not like the way they feel when they're on it.  Another SERM that's been around for awhile is raloxifene or Evista which is prescribed for the prevention and treatment of osteoporosis.    Evista works well on preserving bone density, protects the breast against estrogen stimulation, but aggravates hot flashes.

The ideal treatment for the health challenges of menopause would turn on all the right estrogen receptors (bone, brain, vascular tissue, genitalia) and would turn off those better left quiescent in aging ladies (breast and uterus).  Estrogen works wonders on hot flashes also known as vasomotor symptoms; in fact, it's the very thing.  It supports bone density and has a number of favorable effects on brain and cardiovascular health.  Unfortunately for women no longer in their reproductive years, it stimulates breast and uterine tissue in an unwanted sort of proliferative way that, over many years, increases risk of cancer and fibroids.  As a result, progesterone is added to hormone regimens to offset the estrogenic stimulation to the uterus, but this addition only increases the breast cancer risk.  In addition, the effect of oral estrogen, particularly non-human oral estrogen such as Premarin, has undesirable effects on inflammation and clotting in the body.  While many women did well for many years on the combo drug known as Prempro (Premarin plus a synthetic progesterone called Provera), the results of the Women's Health Initiative released in 2002 included significant increases in incidence of stroke, heart attacks, breast cancer, and dementia in women on the Premarin/Provera combination.  Of note, however, is that women taking only Premarin did not experience an increased risk of breast cancer.  Nevertheless, this study drastically changed prevailing opinion on the benefits of post-menopausal hormone therapy, and its use has since dramatically dropped.

The combination of bazedoxifene and estrogen is just short of perfect.  The estrogen component decreases hot flashes although the dose is lower than ideal to completely beat not only the heat but also genital atrophy (as in painful intercourse).  Better yet would be bazedoxifene all by itself to be used along with an estrogen skin patch.  For now, however, as I work on my personal equation of health goals vs. personal fears, Duavee gets a tentative one to two thumbs up.

Interested in more insider scoops on good health choices for the rest of your life?  Stay tuned for September announcements on small group seminars on menopause, osteoporosis, and cardiovascular health.
Check out Duavee review and Duavee and sleep for an update on my Duavee journey.

Duavee and sleep

...or how I gave up formication and got enough sleep
I'm now entering month five of Duavee use, and updating my previous review with a bit more good news.  If you're reading this post, you must be dissatisfied with the state of your sleep.  More than one scholarly review of the downside of menopause--the upside, I suppose, being the state of maturity and wisdom to which we've arrived--states that associated poor sleep  is not just about heat.  As my night's rest improves post-Duavee, I realize that it is more, in fact, than the end of the sweats. 

Yes, hot woke me wondering what on earth I was thinking when I turned off the light and settled to sleep beneath a mountain of quilts. But what kept me awake once I'd doffed the duvets was a maddening case of formication.  Look carefully, that's an 'm' not an 'n', as in formication from the latin word formica meaning ant.  A known side effect of menopause, formication is the itchy, maddening sensation that ants or some other insects are crawling on your skin.  If you're a woman of a certain age and you know it's an illusion, it's formication.  If you are convinced there's really insects on or in your skin, it's called delusional parasitosis which is a nightmare syndrome and no laughing matter.

I still wake up in the middle of the night, but, if I do, I'm not sensing an army of ants on the march up my limbs. As a result, after a trip to the bathroom, I'm right back to sleep. One can never be sure if improvements with meds are coincidental or causative, but perhaps due to Duavee, my sleep is creep-free.

Duavee review

Since last I wrote about Duavee, I have had several e-mails from a scientist heavily involved with hormone research, specifically the development of an ideal selective estrogen receptor modulator (aka SERM) for post-menopausal use. Our communications have convinced me that this medication is the best solution currently available for those of us aging ladies unhappy with the physical effects of no estrogen on the quality of our lives yet worried about the downside of hormone therapy.

SERMs are, as I mentioned, synthetic molecules that act like estrogen insofar as they can occupy estrogen receptor sites on cell membranes.  However, unlike estrogen which activates cellular machinery in a stimulatory sort of way, these compounds can activate or turn-off estrogen effects depending on the specific tissue involved.  For instance, the SERM tamoxifen is used to prevent the development or recurrence of estrogen-receptor positive breast cancer (a tumor whose growth and spread is spurred on by its interaction with estrogen) through a blockade of estrogen receptors in the breasts. Raloxifene (brand name Evista) is prescribed for the prevention and treatment of post-menopausal bone loss because it stimulates bone in an estrogen sort of way but has tamoxifen-like effects on breast estrogen receptors.  Due to this latter property of the drug, it has the possible beneficial side effect of decreasing risk of estrogen-driven breast cancer but is not FDA approved for this purpose.

Duavee contains bazedoxifene, the newest addition to available SERMs. This compound turns on estrogen receptors in bone while turning off those in breast and uterine tissue.  When paired with a touch of conjugated estrogens (Premarin), it promotes bone health while blocking detrimental effects of its estrogen partner on breasts and uterus. Meanwhile, the estrogen squashes hot flashes and favorably affects vaginal dryness although the dose is low enough that it may not completely eliminate these problems. This is exactly what I was looking for in menopause support as my bone density is going downhill along with my height, and my sleep continues disturbed by hot flashes.

If you've been researching menopausal remedies, you are aware that the ongoing use of hormones after menopause can stimulate unwanted cell proliferation in both the breasts and the uterus and, over time, can induce a malignant transformation in either of these tissues.  For those of us who have never had a hysterectomy, hormone replacement therapy has routinely included progesterone in order to protect the uterus from estrogenic stimulation.  Progesterone, however, is fraught with side effects including breast swelling and tenderness, bleeding, drowsiness (especially from natural progesterone), and depression.  Worst of all, the estrogen/progesterone combo, whether 'natural' (molecules produced synthetically but just like those you had through your reproductive years) or 'unnatural', is the actual culprit behind the very small but real increase in breast cancer risk associated with HRT.

I'm just like you, who wants breast cancer, uterine cancer, drowsiness, underwear-ruining spotting, or just big old breasts that hurt every time you bounce downstairs?  I have loved and used transdermal estrogen patches through the years.  I have tried natural progesterone but it makes me so goofy the day after that I can't get a sentence out without fumbling word choice or pronunciation.  I have taken norethindrone rarely to counteract the estrogen, but honestly I can only say that it creeps me out when my breasts get sore.

Three months into Duavee, I feel great.  I pretty much felt great before I started Duavee but my sleep was disturbed by middle-of-the-night hot flashes which now are gone. While backaches and fretting can still plague me in the wee hours, I mostly awaken now refreshed instead of grumpy and reluctant to rise. My breasts do not feel altered in any big or sore sort of way.  I think I'm less scatter-brained, but only time--and my husband!--will tell on that one.  And finally, another time-telling sort of thing, I am hopeful based on the well-researched science of Duavee and its carefully formulated blend of estrogen and SERM (9 different combinations were tested) that my bone density, decreasing over the last two years along with my dose of estrogen, will stabilize when I check it next year.

If your 'change' is not for the better, and you're trying to make a decision about what to do about it, talk to your doc about Duavee.  I went through menopause a decade ago so I can't be sure how well it works for those just starting on journey, but I am pleased with this choice for residual flashing, bone density support, and less worry about breast cancer.

Saturday, November 15, 2014

How do I make a medical decision? Part I

Be sure to visit Medical Decision Making Part II at Medical Decision Making Part II

A weekday supplement to the Denver Post featured Bob Moore of Bob's Red Mill on its cover this past spring.  If you don't know who Bob is, you must not be into the rising nuts, seeds, and stone-ground, gluten-free flour scene.  Bob's Red Mill is an Oregon-based company which has been stone milling whole grains, seeds, and nuts for nearly 50 years.  After just one look at his picture on every Red Mill product, you'll agree with me this octogenarian not only looks a decade or more younger than he really is, but he could easily be dubbed the "Gerber Baby" equivalent for the geriatric set so round-cheeked, pink, and glowing is he.

So when Bob extols the virtues of flaxseed in this article--"One of the healthiest foods on Earth! You should have a tablespoon of that every single morning of your life. I do."--no surprise that I pulled the sack of unused flaxseed off my shelf and started doing just that, ground up a tablespoonful that very day and every day since into my morning bowl of nuts and seeds. A no-brainer decision this one; flaxseed is cheap, and a search on for 'flaxseed and health' yields 407 results, whereas 'flaxseed and dangers' returns none. Be sure to grind it before you eat it, warns Andrew Weil, or it will come out the other end unchanged and undigested.  But I digress, the health benefits of flaxseed can wait for another day, another post.

I wish all medical decisions were so simple and straight forward.  Alas, more often than not, they are complicated by emotions, belief systems, current medical evidence, conventional wisdom, Wikipedia, your doctor's latest patient, and your sister-in-law's cousin's experience last fall.  Since I semi-retired last fall, I have been particularly impressed by the power of an established partnership between patient and physician.  When I fill-in for clinics short on docs, all patients I see are as new to me as I am to them. Whether I am talking them out of an antibiotic prescription ("...but Dr. M. always gives me antibiotics, I will get terribly sick if I don't start them now") or urging them to change their usual meds ("Your blood pressure is not at goal, and has been unacceptably high for months"), when they fold their arms across their chests and regard me through lowered brows, I know we're going nowhere without that element of trust.

Fortunately, most decisions are not urgent, and most can wait for another day, another doc, an Internet search.  Those that are have an element of duress where haste trumps trust as the deciding factor. The young man doubled over in pain whom I bundled into an ambulance last week for a quick ride to the nearest hospital for an emergency appendectomy will probably neither remember my face much less my name.  Other times, finances over relationships determine decisions as in the day I told a man, thin as a rail with anemia and an enlarged spleen, that he needed evaluation for cancer. My inability to speak his language did not influence his decision-making process but a lack of insurance delayed follow-up by nearly two months.

So far, we're only talking information-gathering here--who or what is your trusted source. Are you fortunate enough to be partnered with a doc you've known for years? Perhaps it's a Santa-Claus-look-alike grist mill operator, or a vascular surgeon young enough to be your grandson who's just out of one of the nation's top fellowship programs.  Are you having trouble even defining your problem prior to researching solutions? 

What are your go-to sources for medical facts?  I'd love to hear from you.

Wednesday, August 06, 2014

Hare to hair

(...for those of you of a certain age who know exactly and personally what I mean by a 'menopause moment', please feel free to send me your best moments, and I'll post them at

I was shuffling down a leaf-covered sidewalk, enjoying the late afternoon sunshine. The lady of the house was out front raking, her mid-sized mutt clamoring at her heels for a game of fetch. Spying me, he grabbed his small toy, a saliva-soaked bunny, and dropped it at my feet. He was used to the well-aimed flick of an expert wrist, so he raced down the block anticipating the toss. I, in turn, heaved the soggy animal and hit his mistress upside her head.

Wednesday, July 23, 2014

Dr. Bryan Kramer: Vascular Institute of the Rockies

Over 30+ years of the practice of medicine, I have had the professional pleasure of working with a vast number of gifted docs, many of whom I would gladly entrust with my family's care.  Now that gravity and aging are compromising venous return in my nearest and dearest (blood gets down to N&D's feet but the return trip to his heart is increasingly hard), I'm getting a patient's perspective on Vascular Institute of the Rockies, and the view confirms the great feedback I've gotten on this office through all of these years.

From my first phone contact, through the head nurse, front desk, and medical assistants, every person has been friendly and helpful.  In particular, however, I'd like to thank Dr. Bryan Kramer for squeezing us in, then treating us as if he has all the time in the world.  He has been straight forward and clear in his explanations, addressing all concerns of my N&D as to best treatment, prognosis, and expected chain of events.  N&D is not an enthusiastic customer when it comes to medical care, and he is quick to tell me as we exit an office EXACTLY what he thinks of any particular visit and the doctor in charge.  So two thumbs up as the elevator doors slid shut behind us plus an expressed willingness to return are his five star endorsements for this competent doc!

Wednesday, March 26, 2014

Copper and wrinkles

I assume that you, like me, do not wake up looking your best.  So here's interesting news from Korea via Prevention Magazine in cooperation with Bergdorf Goodman. 

That which keeps our skin firm and fresh are two proteins--collagen and elastin--and a substance called hyaluronic acid.  Collagen gives structure to the skin and promotes the foundation in which elastin provides elasticity (e.g. the ability to spring back to smoothness after being smushed all night against the pillow) while hyaluronic acid cushions and moisturizes.  Sun exposure, smoking, dry air, pollution, facial expressions, and sleep positions along with aging hasten the loss of these three substances and the progression of lines to wrinkles to furrows and folds.

Apparently copper oxide can be absorbed by intact skin wherein it facilitates the process of making these structural proteins and stabilizes them within the sub-surface structure.  Korean dermatologists took these copper characteristics and ran with them, theorizing that sleeping on pillowcases made of copper-saturated fibers could reduce wrinkles(1).  61 volunteers were recruited to snooze perchance to lose their bags and sags. They were graded and measured by 'expert graders' as well as with an objective skin wrinkle measuring device called the 3D Image Analysis GFM PRIMOS.

A significant decrease in crow's feet as well as in 3 'roughness parameters' was both observed and measured at 4 and 8 weeks into the study in the copper-pillowcase group but not in the usual bed linen controls.  That translates into shallower wrinkles and better overall appearance! An earlier study (2) noted these same improvements after a mere 2 weeks of nighttime copper exposure.

So here's where comes in.  You can order a coppery pillowcase for $60.  I was so-so on the prospect after reading the news in Prevention and somewhat more interested now that I've read the study.  It does seem like the perfect 'milestone' birthday gift, but I'm unsure if I'm ready to buy one myself.  Let me know if you give it a try!
1) Baek, JH et al.  Reduction of facial wrinkles depth by sleeping on copper oxide containing pillowcases.
2) Borkow, G et al. Improvement of facial skin characteristics using copper oxide containing pillowcases.

Thursday, October 24, 2013

What else should I take besides calcium for my bones (Part V of "Should I take calcium")

Calcium is necessary to build and maintain strong bones, but it is not necessarily sufficient.  To focus in on calcium supplements as a top priority solution to the prevention and treatment of osteoporosis is to lose sight of the complexity of bone-building and maintenance, and to risk the unwanted consequences of too much of a single good thing.

Vitamin K, as mentioned in Part IV of this series, is essential to the modification of proteins integral to blood-clotting and the proper use of calcium.  Vitamin K1, available from plants particularly of the leafy green variety such as kale, is the K form involved with normal blood coagulation.  People are rarely deficient in K1 insofar as clotting is concerned. At times, individuals who have experienced problems such as deep vein thrombosis (clot) in leg veins or pulmonary emboli (blood clots traveling to the lungs) are put on warfarin (aka Coumadin) which partially blocks the function of K1 thus preventing future unwanted clot formation.  Unfortunately, people on long-term warfarin are known to be at greater risk for arterial calcification.

K1 can be converted to K2 by intestinal bacteria.  While there is dispute as to whether or not bacterial K2 is available for absorption into the body through the gut wall, it is known that women with high intake of K1 are less likely to sustain hip fractures, and lettuce intake--a good source of K1--was inversely proportional to future incidence of hip fractures in the Nurses Health Study(1).  Those medical professionals eating lettuce once or more daily had a nearly 50% hip fracture risk reduction compared to those downing one or less salads per week. 

It is difficult to take in enough K1, however, to meet your K2 requirements.  Researchers from The Netherlands compared the efficacy of K1 to K2 in the MK-7 form with respect to the production of proteins essential to proper bone calcification and found the K2 more effective and far more long-acting in its bone-forming functions(2).

Therefore, in order to build strong bones AND keep unwanted calcium out of your blood vessels, daily intake of K2--especially the MK-7 molecule--is absolutely the answer.  Besides the Rotterdam study cited in my previous post, multiple other clinical studies correlate K2 intake with long term vascular health. 

While calcium is good and necessary, vitamin K2 is essential.  Vitamin D, of course, is also crucial as are multiple other micro-nutrients.  In the sixth and final installment of this series, I'll give you my best advice as to "Should you take calcium" and what you should be taking as well for optimal bone and vascular health.
1) Feskanich D et al.  Vitamin K and Hip Fractures in Women, a Prospective Study.  Am J Clin Nutr vol. 69 no. 1 74-79. 
2) Schurgers LJ et al. Vitamin K–Containing Dietary Supplements: Comparison of Synthetic Vitamin K1 and Natto-derived Menaquinone-7. Blood vol. 109 no. 8 3279-3283.                                    

Wednesday, October 09, 2013

The Calcification Paradox (or Part IV of Should I Take Calcium?)

As I mentioned in Part III of this series, there is an inverse association between decreased bone calcification and increased vascular calcification, neither of which is a good thing.  In other words, those who shrink and crumble into the osteopenia/osteoporosis thing are also those most likely to deposit unwanted calcium in their aging blood vessels.  The heart of this supplemental calcium controversy (do I take it or not?) lands squarely here: how does our body calcify that which holds us upright while also preventing calcium build-up where it does not belong? What matters here is not just the necessity of incoming calcium to balance calcium loss but also an ongoing incoming supply of the known co-factors needed for proper calcium use.

Back, once again, to an evolutionary perspective.  In Part II I mentioned our Ice Age ancestors who ate a high-calcium diet of plants and insects and little or no grain--a food source both low in calcium and high in phytates (substances that bind calcium thus preventing effective absorption).  Now let's go back even further to our remote water-based relatives who spent their lives swimming about in calcium-rich seas.  Early evolutionary pressure, therefore, required the development of mechanisms to prevent widespread calcification through their soft, fishy tissues. The ability to survive and thrive depended--still depends!--on the limitation of calcium deposition solely to skeletons be they external shells or, much later, internal bones. Elaborate regulatory mechanisms developed over eons that promote calcium phosphate crystallization in the right place and prevent it elsewhere.

The central actors in strong bone production are cells that package mineral matrix--a mixture of calcium, phosphate, enzymes, and proteins--and then deposit it along collagen fibers also produced by these cells.  This can happen in the right place (in bones that are growing as in children or repairing as in adults) or the wrong place as in aging aortas or arteries.  Cells that can turn into osteoblasts (bonemakers) are not only found within the skeleton but also in the walls of blood vessels.  The most important protein responsible for bone mineralization is osteocalcin which is dependent on vitamin K2 for proper function.  The most important protein responsible for the prevention of mineralization outside of bones is matrix gamma-carboxy glutamic acid which is also dependent on vitamin K2 for proper function.  Do you see where this is going?

I am here to tell you that I had no idea why I've been taking vitamin K2 regularly for the past year except for a vague notion that it was good for bone health.  I'm certain that I learned nothing about this in medical school decades ago when the importance of vitamin K to proper blood clotting was emphasized but no one mentioned its importance to mineralization. For those of you who haven't spent hours studying the literature on vitamin K as I have while writing this series, there are two main forms of K: K1 important to normal blood clotting function, and K2 which is integral to the deposition of calcium in the body.  More on that in Part V.

Recent studies abound on the benefits of K2 with respect to cardiovascular health.  The Rotterdam Study, published in 2004, found that persons with the highest levels of K2 were less than half as likely to die of coronary heart disease or develop severe aortic calcification over a seven year period than those with the lowest levels, and almost 75% less likely to die of anything in that same time period. 

Wow, if you haven't got K2, get some!
1) Geleijnse, J et al.  Dietary Intake of Menaquinone Is Associated with a Reduced Risk of Coronary Heart Disease: The Rotterdam Study. J. Nutr. vol. 134 no. 11 3100-3105.  

Monday, September 16, 2013

Blood Vessel Calcification (or Part III of Should I take calcium?)

Here's the heart of the calcium supplement debate. Does taking extra calcium for prevention and treatment of bone loss associated with aging hasten the calcification of blood vessels, a process which is also associated with aging. That which is normal and healthy for your skeleton, namely the incorporation of calcium crystals into its structure, is neither normal nor healthy within your arteries.  Studies of aging humans and their whole body CT scans suggest that virtually all men and women have some demonstrable vascular calcium by age 70.(1)  Furthermore, the calcification was widespread in 80% of men and 60% of women by that age, and extensive calcification is known to correlate with a high degree of atherosclerosis more commonly known as 'hardening of the arteries'.(2)

This sort of dilemma--a basically good physiological process gone rogue--takes us into a lot of science on calcium, injury, hormones, aging, and inflammation.  The CT scanning study cited above not only confirmed that calcification, and therefore atherosclerosis, is definitely correlated with aging and increases as the years progress, it also, once again, found that menopause with its attendant loss of estrogen is also a time of accelerated progression of vascular disease.  Women under 50 years of age were much less likely than men to have calcium, but the prevalence of calcified vessels greatly increased between 50 and 60, and the gals were as likely as the guys to have calcifications by age 70 (just not as extensive).  Whether or not hormone therapy can slow down this vascular deterioration is another complicated story for another post.

Of note in this discussion, however, is the immune system's response to the presence of calcium crystals in developing atherosclerotic lesions in arteries.  Cells called macrophages which are first responders to bodily harm show up early in the course of blood vessel injury and set immediately to work eating foreign invaders Pac-Man style.  As they gobble up various harmful substances such as oxidized LDL cholesterol or basic calcium phosphate (BCP) crystals, they send out proinflammatory cytokines which are chemical messenger molecules that further activate an immune response.  This is a good thing with regards to incoming foreign bodies such as bacteria or dirt from the sidewalk when you've fallen and scraped your knee, but not so good when it's an ongoing assault from various environmental insults such as LDL-cholesterol, trans-fats, cigarette smoke, or...too much calcium (more on this later).  The inflammation from BCP crystals in activated macrophages "may lead to a positive feed-back loop of calcification and inflammation driving disease progression."(3)  In other words, once blood vessels are disturbed by calcification, the immune response invites the deposition of more calcium.

Here's one more puzzle to set your head reeling (mine is already so why not join me?).  There is a known clinical association between vascular calcification and osteoporosis.  In other words, those of us dealing with loss of bone mineral density are the very people that need to worry most about gaining unwanted vascular mineralization in the form of calcium in our arterial walls.  This suggests a link between bone and vascular metabolism.  Either vascular calcification promotes bone mineral loss, bone loss hastens vascular calcification, or there's a common underlying pathology to both processes.  The latter seems the most likely scenario, and the underlying normal and abnormal physiology of calcification in the body finally leads to some answers about whether or not calcium supplements are a good idea.

More on that in the next post.

1) Matthew A, et al. Patterns and Risk Factors for Systemic Calcified Atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology.                                   
2) Solberg LA, Eggen DA.  Localization and sequence of development of atherosclerotic lesions in the carotid and vertebral arteries. arteries. Circulation; 1971.
3) Nadra, I, et al. Proinflammatory Activation of Macrophages by Basic Calcium Phosphate Crystals via Protein Kinase C and MAP Kinase Pathways. Circulation Research. 96: 1248-1256.

Friday, August 30, 2013

Should I take calcium? Part II

In Part I of this series of posts, I discussed the science behind calcium intake.  In short, what goes out via intestinal loss (at least 150 mg/day or more) and kidney excretion (at least 100 mg/day or more)(1) must be replaced in order to maintain a steady level of calcium in the extracellular fluid (ECF) including blood.  If calcium out is greater than calcium in, the parathyroid glands release a hormone which facilitates breakdown of bone mineral matrix freeing calcium to enter the ECF. Thus, bone-based calcium is not only an integral part of your skeletal strength but also a readily available calcium reserve in case you're running short.

Clinical research scientists who regularly conduct studies on every sort of medical dilemma have compiled an enormous amount of data on the benefits of calcium intake. Starting from an evolutionary perspective--my personal favorite--let's first consider our ancestors from 10,000 years ago when life was quite different but the human genome was not. 

Radiologists and anthropologists from Emory University have determined that our ancestors--both human and primate--ate a lot of high-calcium insects and high-calcium plant food.(2)  These experts estimate that our Stone-Age predecessors took in at least twice as much calcium, mostly from plant based sources, along with more fiber, micronutrients, and protein than we consume with our modern diet. They ate virtually no grains which are not only a poor source of calcium but certain varieties including wheat contain phytates, a compound which binds minerals and decreases their absorption. X-rays of our foreparents' fossilized skeletons confirm that the outer layers of their bones were nearly 20% thicker than ours.  Strong Cro-Magnon structure was the result of a whole lot of outdoor hunting and gathering plus lots of calcium.  The authors of this review conclude that the best-for-modern-bone plan would include a return to the "nutritional pattern for which we have been genetically programmed by evolution."

There is an enormous amount written about the effects of calcium supplementation, with or without vitamin D, in a modern population that avoids the sun and doesn't snack on praying mantises.  The evidence is clear that calcium intake can promote a positive calcium balance--more in than out--which in turn reduces the rate of bone loss and may result in an increase in bone density.  What is not clear is whether or not this has a positive effect on fracture risk. Some experts point out that many of these studies were too short in duration to fully evaluate the long-term benefits of better bone. One study out of France(3) featuring 3,000+ old ladies with added calcium, however, demonstrated decreased fracture risk in just 18 months of follow-up! Half the subjects in this investigation received 1200 mg of calcium plus 800 units of D each day and ended up 43% less likely to have broken their hips by study's end compared with their colleagues who took look-alike placebos.

The US Preventive Services Task Force spent a lot of time reviewing this mountain of medical evidence.  They considered "meta-analyses" that pooled data from multiple studies and concluded that there was not enough evidence to support a recommendation for the use of supplements, and declared that smaller doses (less than 1,000 mg/day calcium and 400 units D) made no dent in fracture risk at all.  Because extra calcium intake can increase the incidence of kidney stones in susceptible persons, the USPSTF graded such dosing as Grade D, i.e. don't do it!, a 'living' on-line textbook for doctors, also considered the data, last updating the section on calcium supplements on August 28, 2013.  The reviewers agreed that the fracture data was variable, but were particularly impressed with the data from the Women's Health Initiative, the same trial that created headline news about negative health outcomes from the long-term use of HRT.  Over 36,000 women were assigned to take 1,000 mg/day of calcium citrate with 400 units of vitamin D or placebo pills.  Those who were most compliant with the regimen, taking at least 80% of the supplements over 7 years of follow-up, had a nearly 30% decreased risk of hip fracture.  Overall, compliant or not, the calcium/D group had a 12% decrease in fractures.

Uptodate's wrapped up their discussion after considering the latest data as of just two days ago by stating "Based upon the meta-analyses discussed above, we recommend 1200 mg of calcium (total of diet and supplement) and 800 int. units of vitamin D daily for most postmenopausal women with osteoporosis."  And, spoiler alert, they took into account the effect of supplemental calcium on the risk of cardiovascular disease.

More on that in Part III.
1) Houillier, P et al.  "What serum calcium can tell us and what it can't".  Nephrol. Dial. Transplant. 21 (1): 29-32.
(2)Eaton, SB and Nelson, DA.  "Calcium in Evolutionary Perspective." Check it out for the calcium content of grasshoppers and moths!
(3)Chapuy, MC et al.  Vitamin D3 and calcium to prevent hip fractures in the elderly women.  N Engl J Med 1992 Dec 3;327(23):1637-42.

Wednesday, August 28, 2013

Should I take calcium? Part I

I have been reading up on that which is good for blood vessels versus that which hastens their demise.  In particular, owning a set of bones increasingly fragile with age, I was curious about the effects of calcium supplementation on vascular health.  Recent headline news from the latest medical research suggests that excess intake of calcium tablets results in deposition of calcium in the walls of arteries--not something you'd wish on your hardworking vessels. I used to recommend adequate calcium intake as  an integral part of the prevention and treatment of age-related bone loss-- 1,000 mg/day total (diet plus  supplements) if on hormone replacement and 1,500 mg/day if not. Now the US Preventive Services Task Force says no. In fact they give a calcium plus D supplementation strategy a "D" grade (which is very strong language for the USPSTF) based on the increased risk of kidney stones but mentioning not at all this vascular business. widely used on-line resource for physicians says yes.
What's an old lady to decide?  Do I recommend extra calcium for myself and for others? 
After two hours of reading, I realized this was a decision so complex that it could not be answered in a single day nor a single post.  I decided to approach the problem according to the 8 components that I believe are the basis for making medical decisions.  In brief,  I think physicians bring three areas of expertise to the process--the science, the evidence from a constantly changing body of medical literature, and their personal practice experience.  Patients (and in this case I'm filling both roles) bring their current situation, their personal medical history, their family history, and their beliefs to the table.  Finally, and unfortunately, the insurance company brings its willingness to pay into the picture.  This is  not important here as calcium and D supplements are not an insurance-covered benefit.

A steady level of circulating calcium in the fluids and blood surrounding our cells is essential to the proper function of multiple organ systems, especially normal nerve conduction.  Too little can cause spasms, seizures, and abnormal heart rhythm; too much leads to confusion, coma, and abnormal heart rhythm.  As a result, a wonderfully orchestrated system controls serum calcium by balancing incoming sources from both intestinal absorption and internal release from bones with outgoing losses through the colon and the kidneys.  If your serum calcium level is normal on your lab panel, you can thank your intestines, kidneys, bones, and parathyroid glands, but you cannot assume that your calcium intake is adequate nor that your bones are holding up okay. 
In order to maintain that crucial balance, calcium in to the extracellular fluid (ECF) must equal calcium out.  Your parathyroid hormone levels rise in response to decreased ECF calcium which quickly leads to release of bone calcium.  In the short term, only superficial bone layers are involved in the release of mineralized calcium from the bone structure, and this loss is easily replenished.  On the other hand, a negative calcium balance over time, amplified perhaps by vitamin D deficiency or an age-related drop in estrogen and testosterone, can lead to a loss of bone density progressing to osteopenia and osteoporosis.  
So calcium balance is critical to bone density along with many other functions.  There are many conditions which can cause abnormal calcium levels, but what we are considering here is the situation of an otherwise healthy aging person trying to maintain bone health through calcium intake without increased risk to the cardiovascular system.  The next post will cover the evidence with regards to calcium intake and bone health.