CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!!








NO MORE PADS,

NO MORE DRIPS -  

TIPS TO ADDRESS AND HELP PREVENT

URINARY INCONTINENCE

Urinary incontinence (UI) in older women is an under addressed problem by patients and clinicians. In general, women's rates of UI are twice that of men and are a problem for 80% of institutionalized elder (e.g. living in nursing homes.) Because women don't bring it up (less than half in some studies) and clinicians don't screen, clinicians miss the more than one out of three women with this condition. A woman's lifetime risk is 30-60% This 'miss' is incredibly expensive. It is expensive in terms of quality of life (women have greater isolation, depression, anxiety, falls/fractures as well as bedsores and admission to long term care facilities) - but it is expensive in care delivery. Excluding cost of long term care facilities, some estimates are up to $20 billion dollars (about 1/3 are for absorbant products alone)

More than one in five young women have IU, for middle aged women the range is about 42-56 percent and in elderly the number is about 75%. With boomers, booming, we will see more and more of IU. Clinicians and patients alike need to be more aware and discuss this.

So, the breakdown of types of IU and urine leakage include functional (mobility or access reasons); stress (pressure overcomes pelvic muscles); urgency (bladder signals urination is needed and releases urine); mixed reasons and overflow (this occurs more in men than women but is often seen in neurological conditions or as a result of medications). Overactive bladders refers to bladder wall hyperreactivity that creates urgency (but leakage does not occur) It is also important to recognize that the urinary incontinence can be associated with rectal or fecal incontinence, so even if not identified by the patient, elements of rectal tone should be included in the evaluation.

Women at higher risk include - ethnicity being Caucasian, being postmenopausal; having multiparity; having a higher BMI, using hormonal therapy; having Diabetes/Sleep Apnea/CHF; having neurologic diseases (Parkinsons, MS) An interesting point I came upon is that women with two or more of the following (DM, HTN, Back Pain, Arthritis, COPD;  hearing/visual deficits; cognitive deficits; parkinsons) are also a higher risk.

The pelvic muscles are an amazing grouping of muscles. It is extremely rare in a human body to have a muscle group simultaneous contract and relax in a coordinated fashion. That's what the pelvic floor does. That is why you can void without deficating and deficate without voiding. It is also why the coordination can get confused - post hysterectomy or birth or trauma.

In older women - more than 50% have mixed UI. So it is important to assess if it is stress or urgency predominant in order to treat.  One item jumps out when reviewing contributing factors of incontinence and that is the functional status and the ability to void.

We have no practice standard to assess functional strength of pelvic muscles (and maybe we should!!) So if pelvic floor muscles are weak, women will have IU. How we hydrate and when we void are another important element.

Many people only urinate when they feel they can't hold any more urine and are very uncomfortable. The 'waiting until your eyes turn yellow' approach is NOT bladder healthy. 

Retraining on intake and urination is important in addressing incontinence and bladder diaries are used to guide this. Some women have to schedule getting up and voiding in their daily calendar to remind them and that is one strategy that can work. Another important piece of information about hydration is that is you are dehydrated, concentrated urine is an irritant and can contribute to the sense of urgency!

A reversible element a clinician must screen for is urinary infection (taking into consideration that asymptomatic bactiuria should not be treated.) Functional status is also important. If gait is unsteady or arthritis is severe and transfers take a long time, incontinence can results. If there are sensory deficits (vision, hearing) o if it takes far longer to get to the toilet than is planned, women can have leakage. Sometimes, soft cognitive deficits (which can be hidden) are the reason why strategies to address incontinence don't work.

Medications also play a role - these include caffeine and alcohol as well as diuretics.
As seen in the chart, multiple medications can have a urinary effect. It is reasonable to consider that if a patient has polypharmacy, she should be screened for incontinence.

CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!! Info for clinicians and consumers here: 



http://www.effectivehealthcare.ahrq.gov/ehc/products/169/1030/ui_cons_fin_to_post.pdf





Active Lifestyle May Help Counter Obesity Genes

TUESDAY, Aug. 31 (HealthDay News) -- Exercise can reduce a person's genetic predisposition to obesity by 40 percent, finds a new English study.

Researchers looked at 20,430 people in Norwich and focused on genetic variants known to increase the risk of obesity. Most people had inherited 10 to 13 of these variants from their parents, but some had more than 17 while others had fewer than six.

The participants also provided information about their levels of physical activity.
Overall, each additional obesity-related genetic variant was associated with an increase in body mass index (BMI) equivalent to 445 grams (0.98 pounds) for a person 1.70 meters (5 feet, 6 inches) tall. BMI is a measurement that takes into account a person's height and weight.

However, this effect was greater in sedentary people than in active people, the researchers found. For those with a physically active lifestyle the increase was 379 grams (0.84 pounds) per genetic variant. That's 36 percent less than the increase of 592 grams (1.3 pounds) per genetic variant for inactive people.

The researchers also found that each additional obesity susceptibility variant increased the odds of obesity by 1.1-fold. But this risk was 40 percent lower for active people compared to inactive people, the findings revealed.

The study shows that adopting a healthy lifestyle can benefit people at increased genetic risk of obesity, the authors explained.

"Our findings further emphasize the importance of physical activity in the prevention of obesity," “Our research proves that even those who have the highest risk of obesity from their genes can improve their health by taking some form of daily physical activity. People don’t have to run marathons to make a difference either - walking the dog or working in the garden all counts. It goes to show we’re not complete slaves to our genetic make-up and really can make a big difference to our future health by changing our behaviour." Dr. Ruth Loos, of the Medical Research Council's epidemiology unit in Cambridge and colleagues wrote in the August 31st 2010 article published online in PLoS Medicine.

CHECK OUT:

The U.S. National Heart, Lung, and Blood Institute offers a Guide to Physical Activity.

Download  BMI calculator here

Women and overweight obesity data info here and resources here

                  Women lag in time spent in leisure activity (weights, calisthenics) as compared to men,  2008 data

Obesity as a Risk Factor for Early Sexual Debut in Young Adolescent Girls?

The topic of obesity in relation to adolescent girls and sexual activity first arose during a patient encounter of an obese 13-year-old girl, who was asking for birth control pills.  The family physician I was following, mentioned that recently, in the past few years, she has noticed that her overweight and obese adolescent female patients are having sex much more than her normal weight patients.  She prompted me to read an interesting article on the topic on Medscape Medical News, which is summarized below:

“In a recent study presented at the 58^th Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists by Villers, et al, showed that overweight and obese adolescent girls are more likely to engage in risky sexual behavior than their normal-weight peers.  The researchers evaluated data from the CDC’s Youth and Behavior Survey from 2003-2007 of 21,773 girls in grades 9-12.  The BMI was calculated using self-reported height and weight.  The study analyzed 6 different risky sexual behaviors such as whether or not the teens had sexual intercourse age at first sexual intercourse, number of sexual partners, condom use, and alcohol/drug use during their last sexual intercourse.  The results revealed that obese and overweight girls were more likely to have an earlier age of sexual debut, more sex partners, and were less likely to use condoms than their normal weight counterparts.”

During the women health discussion of the topic at DUCOM, it was noted that the study did not account for history of abuse, socioeconomic factors, and other factors such as self-esteem and depression.  Another interesting point is that obese and overweight girls reach puberty earlier than their normal weight counterparts.  More research needs to be done on why overweight and obese adolescent girls are more likely to engage in sexually risky behaviors than those are normal weight.  Childhood and adolescent obesity is a risk factor for many things from health related ailments to psychosocial limitations, and this recent survey adds to the list of the harmful effects of obesity.

-- Mimi Mak MS IV, adapted from Obesity a Factor in High-Risk Sexual Behavior in Adolescent Girls 
Medscape Medical News , 2010-05-28

Additional Resources Role and Consequences of childhood obesity

AAP Consensus report Prevention of Pediatric Overweight and Obesity Committee on Nutrition

CDC Resources