Is the Clock Ticking?

It’s common wisdom that it’s harder for a woman to get pregnant as she gets older. Women are most likely to easily get pregnant between the ages of 19 and 26 and the rate of conception steadily ebbs thereafter. There is a significant decline starting at age 31 and there is a big drop off in fertility at age 37. The subfertility in older (!) women is due to the poor quality of aging eggs, fewer eggs in reserve and changing hormones. Additionally, as time passes women have more opportunity to acquire medical and surgical conditions.

Now it appears that what’s sauce for the goose is sauce for the gander. Multiple studies haves shown that advancing age is a serious reproductive factor for men as well as for women. Animal studies show that older sperm contributors have lower fertilization rates, poorer embryo quality, increased miscarriages and smaller fetuses. Since sperm cells undergo many more replications there is more chance for mistakes to occur. Older fathers pass along many more genetic mutations than do younger men.

Observational data indicate that increasing weight in men leads to decreased fertility; observing a crowd of 35 year old men would indicate that they weigh more than when they were college seniors.

Men face the same time pressures as women. In the world of reproductive medicine, delayed childbearing is defined as older than age 30 for both men and women. Women have long heard the tick of their biologic clocks – perhaps it’s time for men to listen as well. 

School Lunch

Lunch is an important part of the school day – almost as important as recess! Many children brown bag their lunches, but many more depend on the school lunch (and breakfast) for a substantial portion of their daily nutrition.

In the past, school lunch programs have depended upon contributions of excess food from USDA programs – the idea was that farmers would have a ready market for their wares and that school children would benefit eating farm-fresh products. Well, we all know how that turned out! For the first time in fifteen years the USDA has raised the standards of the school lunch program. This will have a direct impact on the thirty-two million children who participate in the school meals program every day.

The final standards make the same kinds of practical changes that many parents are already encouraging at home, including offering students both fruits and vegetables every day of the week, substantially increasing offerings of whole grain-rich foods, offering only fat-free or low-fat milk varieties, and increasing the focus on reducing the amounts of saturated fat, trans fats and sodium.

For the first time, calories are limited based on the age of the children. Under the old plan, the regulations stated a minimum number of calories; faced with increasing obesity we need to reeducate ourselves about proper portion size. It’s challenging for adults to regulate intake. It’s unreasonable for beginning readers to scan a nutrition label to see that a granola bar is actually two portions or for a thirsty adolescent to know that a bottle of juice drink is four servings.

Parents play an important role in supporting the school lunch program. Don’t sabotage the healthy meal initiatives by criticizing the food. If you are not satisfied, contact the school and offer help. Don’t allow children to have additional sweets or beverages other than water. Contact the school if your child is truly hungry after finishing the school breakfast or lunch.

Bon appetit.

 Nutrition Standards for School Meals

The Nocebo Effect

Just knowing that a drug can have side effects may increase your risk of suffering them. This is the nocebo effect: the patient’s expectation that a drug will do harm. An excellent summary of this appears in the New York Times review pages.

Side effects from medications are real and can be harmful. Even so, the benefits may still outweigh the potential risks. A recent study confirmed that certain cholesterol medications might lead to diabetes in susceptible patients. However, the reduction in cardiovascular disease with lowering the blood cholesterol is real – and even more important in patients with diabetes. Certain patients (and we have a good idea who they might be) can have terrible effects from osteoporosis medications. This doesn’t mean that other patients at high risk for hip and vertebral fractures shouldn’t take them.

I believe that direct to consumer pharmaceutical advertisements do greater harm than good. Mind you, only expensive medications have the budgets needed to buy television commercials. The ads rarely get down and dirty to discuss the actual disease but show idyllic vacations scenes or silly cartoons, ending with a sonorous litany of terrible outcomes (rash, headache, liver failure, depression and/or death).

Starting a medication should be a shared decision. Usually the physician is more knowledgeable party but the patient is the one that actually decides whether to take the medicine. No decision is written in stone – treatment plans can be (and often are) revised. These discussions are best done face to face; the discussions are of a higher quality when the patient is prepared with questions and concerns. 

Dementia

As people age, there is some decline is short-term memory. However, when memory becomes so poor that there is an impact on the activities of daily living, it is no longer simple forgetfulness but may be dementia. The most common causes of dementia are cerebrovascular disease and Alzheimer’s disease. In Alzheimer disease, build-up of abnormal proteins damages brain cells. In cerebrovascular disease, low blood flow to the brain damages brain cells. While there is no cure for dementia, there are several medications that may be helpful in slowing the progression of disease.

The medications that are currently approved for dementia have shown small improvements in measurements of memory and thinking, but there is no data that show important improvement in behavior and quality of life.

Patients with dementia are less able to make clinical decisions and are less able to cooperate with treatment plans; caregivers play a large role in determining plans of care. Behavioral disturbances (delusions, aggression, depression) can have a profound effect on those around the patient. Inadequate nutrition is common. Exercise program and occupational therapy have been shown to improve everyday life without the side effects seen with many medications.

Caregivers of patients with dementia can suffer significant stress, particularly as cognitive function declines. Respite care and support groups are available in most areas, often through the local agency on aging.

For more information:

Alzheimer's Association at 1-800-272-3900 or on-line.  

One Little Thing

I was chatting with my patient, an architect known for her sensitive adaptations that bring old structures to modern expectations. She tells her clients, who spend a great deal of time obsessing over every detail, that they will be surprised by what will give them the most joy. It will always be one little thing: the sunlight coming through a new window, the feel of a doorknob or the delight in a well-placed bookshelf.

How true! One little thing, seemingly trivial to the big picture, will be the most important. One of my patients decided to give up mayonnaise – and lost 10 pounds. Another person decided that there would be no cigarette smoke in his new car – the first step in eliminating cigarettes from his life. No ‘screens’ (computer, telephone, television) after 9 pm could mean a new reading habit and a better night’s sleep.

On newspaper writer vowed not to buy objects made in China and eliminated much of the junk in her life. She has fewer possessions, nicer things and better karma. A small decision with a big impact.

Having good health is a big goal. Instead of worrying about the big picture, try to change one little thing.

This Week in the Office

From the office this week:

1.     I barely recognized my patient when he came in asking to have his cholesterol checked. He had lost 55 lb! The secret to his success: he joined AA. He didn’t know what to do in the evenings since he wouldn’t be polishing off a couple of six-packs while watching the game. His sponsor suggested that he go to the gym and watch the game while working out. The result: new friends, a new body and a 35% reduction in his cholesterol.

2.     Another patient really didn’t want to tell me his concern. Since a picture is worth a thousand words, he took out his phone and showed me a picture of his hemorrhoid! Great photo – I didn’t ask him how he accomplished it. I hope that his phone is not confiscated for any reason before he has a chance to edit his photos.

3.     I recalled a middle-aged lady to review her blood tests. Since she was a two-pack a day smoker, I was very concerned about her elevated cholesterol and future risk of heart disease and stroke. She agreed to start some medication, but objected to my suggestion that she repeat the blood test in 6 weeks and then return so that we could evaluate the treatment. She stated that she could not afford the $30 co-pay for the visit.

4.     It’s been hot and patients are getting dehydrated. Don’t rely on thirst. A better guideline is passing light yellow urine every two hours while awake. 

Tips

From the American College of Physicians:

The following tips can be shared with patients to help them remember to take their medications:

•   Take at the same time each day.

•   Take when you do other routine activities (e.g., eat meals, get ready for bed).

•   Store in a pill container with days of the week.

•   Keep a dose in a purse, briefcase, or pocket.

Create a reminder system for doses that are especially hard to remember—for example, a watch with an alarm clock, an electronic reminder through your computer at work, or a sticky note where you will be sure to see it at the appropriate time.