Bone Health: Beyond sticks and stones…

As the month of May is upon us, it seems fitting to write this blog about a condition May is dedicated to. May is National Osteoporosis awareness and prevention month. According to the US Surgeon General’s 2004 report Bone Health and Osteoporosis: A Report of the Surgeon General, the number of hip fractures in the US may double or the numbers may be much worse by 2020. This seems to be due not only to the increase in longevity of the population, but also the lack of emphasis on bone health in the past.

The Numbers

About 10 million of Americans have osteoporosis and 44 million are at risk of osteoporosis due to low bone density. An estimated 2 million broken bones per year are due to osteoporosis with 1 in 2 women over 50 having fractures due to osteoporosis. Yet about 80% of elderly Americans suffering from bone fractures are not tested for osteoporosis.

Why should we care about osteoporosis?

Well a risk of fracture in a woman is equal to the risk of breast, uterine and ovarian cancer combined!! The risk of breast cancer alone is 1 in 8 or 12.5%.

What is the severity of these fractures?

About a quarter of patients over 50 who have hip fractures end up dying within the following year. Of nearly 300,000 hip fracture patients that survive hip fractures, a quarter end up in nursing homes, and half never regain their previous abilities and function

Defining osteoporosis.

Osteoporosis is a systemic disease involving the skeleton characterized by low bone mass, weakening of the composites of bone tissue causing the bone to become fragile and susceptible to fractures.

Osteoporosis is defined as a bone mineral density that is 2.5 standard deviations or more below the young woman (t-score -2.5 or below)

 

Bones are part of the skeleton which is an active organ. Bones have 2 functions: storage of certain minerals such as calcium and provide structure for the body. Whenever the body runs low in these minerals (mainly calcium), bone is broken down to release calcium into the blood stream. If calcium is too low and too much of the stored calcium is released, bone can become brittle and break.

Risks and causes of osteoporosis.

Risk factors that can’t be changed

• Older age, female gender, menopause, family history, small/thin body type, broken bones/height loss
  

Risk factors that are controllable

• Diet: calcium and vitamin D intake
  • Recommended daily intake of calcium and vitamin D.
    
• Diet: fruits and vegetables
• Lack of exercise
• High alcohol consumption- more than 2 beverages a day is considered heavy consumption. Moderate consumption may improve bone strength in postmenopausal women.
• Diet: rapid weight reduction causes bone loss
• Smoking

Causes of osteoporosis

• Many conditions also cause bone loss including
  • Inflammatory bowel disease
  • Pancreatic disease
  • Celiac disease
  • Bariatric (weight loss) surgery)
  • Blood diseases such as sickle cell anemia
  • Lupus and others
  • Epilepsy
  • Stroke
  • HIV
• Lifestyle
  • Vitamin D insufficiency
  • Smoking
  • Low calcium intake
  • Low physical activity
  • High phosphate intake
  • High salt intake
  • Excess vitamin A
  • Excess protein intake
  • Alcohol abuse
• Medications that can decrease bone density
  • Androgen blockers (Lupron)
  • Anticonvulsants (Dilantin, phenobarbital)
  • Anticoagulants (heparin)
  • Cancer chemotherapy (Cyclosporine A, Tacrolimus, Methotrexate)
  • Estrogen blockers (Tamoxifen)
  • Steroids (cortisone, prednisone)
  • Contraceptives (Depo-Provera)
  • Thyroid replacement hormones (excess)

Let’s break the barrier to bone health by increasing awareness and preventing osteoporosis!

The US preventive Services Task Force in 2011 recommended all women age 65 and older to be screened with a type of X-ray called DEXA (dual energy X-ray absorptiometry) scan to prevent osteoporotic fractures. In 2011, women younger than 65 were not mandated to be screened. But the North American Menopause Society 2014 meeting revealed that the USPSTF guidelines caused many missed 75% of women aged between 50-64 with osteoporosis. However, in December of 2017, the USPTF reviewed these recommendations and added that postmenopausal women younger than 65 who are at risk of osteoporosis, determined by formal clinical risk assessment should also be screened for osteoporosis. The new recommendations are still under review and are being updated.

The National Osteoporosis Foundation recommends 5 steps. Focus on these steps even if you are young!

Focus on strengthening your bones, because after all it turns out sticks and stones are not the only threat to their health!!

Christel Francois

DUCOM 2018

References

Chapurlat R D et al: Osteporosis. In : Jameson JL et al, eds: Endocrinology: Adult and Pediatric. 7^th ed. Philadelphia, PA: Saunders; 2016: 1184-1213, e6.

Cosman, F., de Beur, S.J., LeBoff, M.S. et al. Osteoporos Int (2014) 25: 2359. https://doi.org/10.1007/s00198-014-2794-2

National Osteoporosis Foundation. https://cdn.nof.org/wp-content/uploads/2017/04/Who-Gets-Osteoporosis-BONE-BASICS.pdf

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryDraft/osteoporosis-screening1

https://www.nof.org/news/nof-response-uspstf-recommendation-calcium-vitamin-d/

http://www.who.int/chp/topics/Osteoporosis.pdf

https://www.medscape.org/viewarticle/461563

 

 

 

 

The Politicization of Motherhood

 

This article* presents the viewpoint of one Erica Komisar, a psychoanalyst living in the Upper West Side of Manhattan, who published a book earlier this year titled “Being there: Why Prioritizing Motherhood in the First Three Years Matters.” She had also talked about her work on multiple Christian radio stations and Fox news but mentions that “I couldn’t get on NPR.” After reading the article and skimming through sections of her book, I’m not surprised.

I agree with several of Ms. Komisar’s claims. In one instance, she calls for a more “child-centric society” and promotes paid maternity leave, although her explanation of how to attain a child-centric society is more heavily geared towards maternal responsibility than mine. She also states that mothers are extremely important to their infants and toddlers and that mothers should prioritize their family in the early years and try to be as present as possible during the first 3 years of their child’s life. All these things I agree with; however, that is where Ms. Komisar’s viewpoints and mine heavily diverge.

 First of all, she claims that her book is informed by her years of research, which is misleading. Her research is not evidence-based research but rather a book of opinions and “years of experience as a psychoanalyst,” meaning it is purely anecdotal. Her calling her own experience “research” in and of itself decreases her credibility. That being said, the studies that she does reference in her work are valid, such as research involving attachment theory and differing levels of oxytocin and vasopressin in women and men. The problem is, neither the research that she references nor her anecdotal experiences conclude what she concludes:

1) mothers are to blame for rise in mental illness in children and                                                                                      

2) mothers alone should primarily and preferentially shoulder the responsibility of providing nurturing, loving care to their children.

Although she adds that society as a whole should be more child-centric, it is clear that mothers, particularly mothers’ parental transgressions, are at the center of her argument.

Ms. Komisar’s most striking and controversial claim is that of a direct correlation between a myriad of illnesses (including ADHD, depression, anxiety, violence, and bullying) to mothers’ disinterest in their children’s lives. More specifically, she blames the rise in mental illness in young children and teens on their mothers for “placing their own self interest over their child’s well-being.” It is an incredibly judgmental stance, one that I am not surprised Fox news is sympathetic to. Firstly, let us address the phenomenon of the rise in mental illness. This alone is controversial, whether there is truly a significant increase in mental illness. Studies have shown that there has been increased utilization of mental health care services, increased number of diagnoses of mental disorders and increased prescriptions of psychotropic medications. However, this increase could be due to a historic underutilization of mental health care services, poor metrics for mental health data collection prior to the 1960’s, an increased physician and community awareness of mental disorders, or reduced stigma of seeking treatment. In fact, an article by Olfson et al 2015 in the New England Journal of Medicine did find that youths with less severe or no impairment accounted for most of the absolute increases in service use, supporting the claim that perhaps, the prevalence of mental illness has not changed but the number of patients seeking services and appropriately being diagnosed has. Ms. Komisar does not mention any of these reasons but rather jumps to conclusions. The research simply does not conclude what Ms. Komisar concludes: that mothers going back to work before the age of three correlates with increased mental disorders in children.

 

Furthermore, I would like to remind the reader of the striking similarity of this argument to a long-debunked refrigerator mother theory, in which a lack of motherly love was thought to induce autism or autism-like symptoms. Autism is now known to be primarily due to a combination of genetic factors, but in the 1950s and 1960s much undue blame and guilt were layered upon the mothers. Ms. Komisar is therefore using a reiteration of the refrigerator mother theory to shame and guilt mothers for functioning as anything other than a full-time 100% present mother, including – going to work full time, utilizing their other spousal support.

 

In her book, Ms. Komisar names a hierarchy of preferential primary caregivers for the baby. In her view, the mother is paramount. Next comes the spouse/husband, then a blood relative like a grandmother or grandfather, and down at the very bottom is daycare. She calls the mother the central nervous system of the baby in the first three years. She references studies on higher levels of vasopressin in men and higher levels of oxytocin in women in order to explain how in her view, men’s love influenced by vasopressin is more “aggressive and protective instinct” and women’s love influenced by oxytocin is more a “loving and nurturing instinct.” She goes on to state that mothers and fathers have equal but different physiological roles as parents. However, there is an internal contradiction when she names the mother as the central nervous system of the baby, because if that is true, there is no possible way that the father can be of equal role in the child’s life. The central nervous system is comprised of the brain and spinal cord and there is nothing more important than the brain and spinal cord. Therefore, by her definition, mothers must be more important than fathers. And this concept is insulting to a myriad of caretakers: fathers, gay parents, adoptive mothers, grandparents, single fathers, or various other non-traditional family arrangements because it assumes that the loving, nurturing care that they provide their child is inferior to that of a biological mother. There is no single source of learning caring love, just as there is no single source of learning protective love from the world, and it is not as black and white (vasopressin versus oxytocin) as Ms. Komisar describes. The stereotyped gender roles that she prescribes to are inflexible and unhelpful: fathers can kiss their sons’ skinned knees and mothers can teach their daughters resilience. Love is not gendered and thus, the “CNS of the baby” can be extended to not just the mother but rather the nuclear family, if not society, for allowing loving nurturing care to take place.

 

If anything, our society should be the centerpiece of this argument and share the burden of guilt, rather than piling it onto our poor mothers. Our society creates an environment that is unsupportive of raising children, of which entire families (including mother, father, and children) are victims. All in all, I felt that Ms. Komisar shoveled undue burden on already overwhelmed mothers, who are trying very, very hard to juggle managing a household, loving and caring for their children and partner, and managing a job or career. I agree with Ms. Komisar’s call for paid maternal leave, although I call for both paid maternal and paternal leave. I also agree with Ms. Komisar that daycare sometimes is not a wonderful option, particularly if those workers are underpaid, undervalued and underqualified. But Ms. Komisar’s emphasis on maternal responsibility is excessive, unnecessary, inflammatory, and unhelpful, particularly since mothers are often not in a position to change their circumstances. Let’s talk about a more child-centric society. But let’s make it more about societal change and less about individuals. Let’s give more support and less blame.

Katherine Mai

DUCOM 2018

                                                                                                                                                                                         

*The Politicization of Motherhood

Conservatives cheer and liberals jeer New York psychoanalyst Erica Komisar’s book on the science of early childhood development.                                                                                                                                                                                                James Taranto                                                                                                                                                                                                        The Wall Street Journal    Oct. 27, 2017

Strides in Treatment for Depression

Being sad is a normal and human reaction to certain factors in life. This emotion is something nearly all of us go through, and what many of us don't know is that sadness is completely different than depression. Depression is a serious medical condition that alters the way an individual feels, thinks, and handles daily activities. It is not something an individual can snap out of or try and be happier, and usually requires treatment and medication.

Unfortunately, depression has been found to impact women more than men because of social, biological and hormonal differences between the two genders. Specifically, life events like pregnancy, postpartum, perimenopause and menstrual cycles may all trigger depressive onset.

Major Depressive Disorder (MDD) particularly impacts women twice as likely as men and four times as likely to have recurring episodes. Women are also subjected to anxiety and atypical presentation of depression, with hypersomnia and weight gain.

A recent study has show that through observing brain autopsies from 50 MDD patients and 50 control patients differences in gene expressions. Within the eight brain regions, researchers found that very few genes similar in both men and women. The remaining genetic changes indicated that men had increased inflammation in their brain regions, and were protected because of testosterone. This study helps treat patients on a more personal level which will certainly help with the overall care.

With these recent strides in care, it is important to help your loved ones find the right physician for them. If you or someone in your life is depressed, lend a compassionate ear. Ask them how you can be there to help them and learn about the resources and treatments available for them.

 https://www.helpguide.org/articles/depression/helping-someone-with-depression.htm

https://www.sciencedirect.com/science/article/pii/S0006322318300659

Meghana Pisupati

IHS 2018