By Dana Casciotti, PhD, Diana Zuckerman, PhD, PharmD,  and Juliana Stebbins

Updated April 2015

 

If you are taking one of Bayer’s birth control pills (Yasmin, Yaz, Beyaz, Safyral) or a generic version, you will want to know about the latest research indicating that these pills have higher risks than other types of oral contraceptives.  While all birth controls contain the hormones estrogen, progestin, or both, manufactures use different types of each in their products.  Bayer’s oral contraceptive products and their generic versions contain drospirenone, a type of progestin not found in most other oral contraceptives.

The Food and Drug Administration (FDA) held a public meeting in December 2011 to discuss the benefits and risks of oral contraceptives containing drospirenone. [1] While these products effectively prevent pregnancy, there are alarming risks that can be fatal.  Advisory Committee members discussed the growing evidence that drospirenone increases the risk of blood clots (deep vein thrombosis) more than other forms of progestin.  Blood clots are dangerous because they can detach from the vein and travel through the blood stream, blocking blood flow to the lungs or brain.  They can cause disability or death, even in young, healthy women.  Several families testified at the meeting about the death of their healthy, young daughters are a result of taking Yaz and similar pills made with drospirenone.

If you or someone you know has been harmed by a birth control pill or implant, please click here.

FDA Decision

In 2012, the FDA announced its conclusion that women taking Yaz and other drospirenone-containing oral contraceptives may be at an increased risk for developing blood clots compared to women taking pills containing other forms of progestin.  Rather than taking the drugs off the market, the FDA decided to change the labels for Yaz, Yasmin, Beyaz and Safyral to warn patients and doctors about the increased risk for developing blood clots.  The FDA is encouraging women to discuss their risk for blood clots with a healthcare professional before deciding which birth control method is best for them.  Healthcare professionals are also being encouraged to consider the possible increased risk for blood clots with drosperinone-containing oral contraceptives before prescribing these medications to their patients.  Unfortunately, the warning about drospirenone is in the 5th section of very long labels, and many patients (and doctors) are unlikely to ever notice them.

The Evidence

Although all birth control pills can cause blood clots, and all contain a warning about that risk, the FDA has reviewed six studies published over the last three years to evaluate whether these risks are higher with oral contraceptives containing drospirenone. Four of the six studies showed higher risks.  Two studies published in 2009 reported that taking oral contraceptives containing drospirenone increases the risk of blood clots by 1.5-to-2 times compared to taking pills containing the progestin levonorgestrel.[2],[3]Additionally, two articles published in 2011 in the British Medical Journal reported an increased risk of blood clots that was 2 to 3 times as high with drospirenone compared to other types of birth control pills.[4],[5]Only two published studies of drospirenone-a study led by J.D. Seeger and a study conducted by J.C. Dinger-report there is not an elevated risk with Yaz and generic versions.[6],[7]

What could account for the different findings?  The authors of the studies that found no increased risk for drospirenone had financial and professional ties to the manufacturer that makes these pills, they included women with high risk of blood clots, and the authors did not separately analyze women younger or older than 35,  which could have influenced the results.  The Seeger study investigated the safety of Yasmin, and compared “ethinylestradiol/drospirenone initiators and medically similar initiators of other oral contraceptives….”  The authors did not specify the types of “other oral contraceptives” that were compared to Yasmin, nor did they specify the dosage of estrogen and progestin taken by women in the comparison group.  That could have also influenced the findings.  The Dinger study compared drospirenone-containing oral contraceptives to pills containing levonorgestrel (a type of progestin), pills containing other progestins, and non-hormonal types of contraceptives.  There were several differences in the way that these two studies were conducted and analyzed that might explain why their results were more favorable than the studies by independent researchers.  For example, the four studies that reported higher risk of drospirenone-containing pills statistically controlled for the estrogen doses in their analyses.2-5

In addition to reviewing the six studies, the FDA funded its own enormous study to further evaluate the relative safety of drospirenone in oral contraceptives. The FDA study reviewed the medical records of 800,000 women taking birth control between 2001 and 2007 and reported that women taking birth control pills containing drospirenone were significantly more likely to have blood clots: drospirenone increases the risk of blood clots from six in 10,000 women to 10 in 10,000 women (or 1 per 1,000).[8]The study also suggests that although women below the age of 35 have a higher risk of blood clots regardless of the type of birth control pill they take, the risk of blood clots associated with Yaz, Yasmin, and other pills with drospirenone are significantly higher than other types of birth control pills only among women over 35.[9] In contrast, the FDA study also found that when they focused only on women taking birth control pills for the first time, drospirenone increased the risk of blood clots and heart attacks, especially for women under 35.

The FDA study also found that the birth control patch and vaginal ring was associated with higher risks of blood clots than pills containing levonorgestrel, but tended to be less risky than pills containing drospirenone.

Yaz, Yasmin, Beyaz, Safyral: Higher Cost and More Risk

yaz_3mg_002mgWhen new medications come on the market, they tend to cost more and be widely advertised, and this often gives the impression that they are better.  Unfortunately, newer often does not mean more effective or safer, because the FDA does not require that new drugs be an improvement over older drugs, and often the FDA doesn’t even require that they be as effective or as safe.  In addition, since FDA approval is usually based on patients taking a drug for one year or less, the risks may not be obvious at first.

Bayer has advertised Yaz and its other birth control pills in many TV commercials featuring attractive and happy young women, and this has resulted in the pills’ widespread popularity.   Bayer warns that women who smoke or have a history of blood clots, heart attacks or strokes, or particular cancers should avoid their contraceptive pills but the new research raises questions about the risks to healthy, nonsmoking women as well.

Is there more risk information that has not been made public yet?  Plaintiffs’ attorneys wanted to provide confidential documents to the FDA for the agency to consider in their review of Yaz and other birth control pills, but in November, 2011, Judge Herndon ruled that the documents should not be made available to the FDA or the public.  Several of the documents were finally made available two days before the December 8 meeting.  One was a report from former FDA Commissioner David Kessler.  It documented how Bayer had repeatedly misled the FDA when FDA officials expressed concerns about the risks of Yasmin before and after the drug was approved.

Should birth control pills containing drospirenone remain on the market?  There is no evidence that they have significant advantages compared to other contraceptive pills that would outweigh the risks of blood clots or heart attacks.  If patients and their doctors understood the latest research, why would anyone choose to take those risks?

Table of the FDA Approved Oral Contraceptives Containing Drospirenone:

Name Generic Name
Drospirenone and ethinyl Drospirenone 3 mg ethinyl estradiol 0.03 mg
Ocella Drospirenone 3 mg and ethinyl estradiol 0.03 mg
Safyral Drospirenone 3 mg, enthinyl estadiol 0.03 mg, and leyomefolate calcium 0.451 mg
Syeda Drospirenone 3 mg and ethinyl estradiol 0.03 mg
Yasmin Drospirenone 3 mg and ethinyl estradiol 0.03 mg
Zarah Drospirenone 3 mg and ethinyl estradiol 0.03 mg
Beyaz Drospirenone 3 mg, ethinyl estradiol 0.02 mg and leyomefolate calcium 0.451 mg
Drospirenone and Ethinyl Estradiol Drospirenone 3 mg and ethinyl estradiol 0.02 mg
Giavi Drospirenone 3 mg and ethinyl estradiol 0.02 mg
Loryna Drospirenone 3 mg and ethinyl estradiol 0.02 mg
Yaz Drospirenone 3 mg and ethinyl estradiol 0.02 mg

1Joint Meeting on the Reproductive Health Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee Meeting Announcement. December, 8 2011: http://www.fda.gov/AdvisoryCommittees/Calendar/ucm273236.htm

2 Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ 2009; 339:b2890.

3 Van Kylckama V, Helmerhorst Fm, Vanderbrouke Jp, Doggen CJM, Rosendale FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009; 339:b2921.

4 Parkin L, Sharples K, Hernandez RK, Jick SS. Risk of venous thromboembolism in users of oral contraceptives containing drospirenon or levonorrgestrl: nexted case-control study based on study based on UK General Practice Research Database. BMJ 2011; 342:d2139.

5 Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenon compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. BMJ 2011; 342:d2151.

6 Seeger JD, Loughlin J, Eng PM, Clifford CR, Cutone J, Walker AM. Riske of thromboembolism in women taking ethinylestradiol/drospirenone and other oral contraceptives. Obstet Gynecol 2007; 110(3):587-93.

7 Dinger JC, Heinemann LA, Kuh-Habich D. The Safety of a drospirenone-containing oral contraceptives: final results from the European Active Surveillance Study on Oral contraceptives based on 142,475 women-years of observation. Contraception 2007; 75:344-54.

8 Food and Drug Administrative. Drug Safety Communication: Safety review update on the possible increase risked of blood clots with birth control pills containing drospirenon. 26, September 2011.

9 USA. Food and Drug Administration. Office of Surveillance and Epidemiology. Combined Hormonal Contraceptives (CHCs) and the Risk of Cardiovascular Disease Endpoints. By Rita Ouellet-Hellstrom, David J. Graham, and Judy A. Staffa. Silver Spring, 2011. Print. CHC-CVD Final Report 111022v2.

Diana Zuckerman, PhD

Updated February 2014

 

Avandia was a popular drug for diabetes, but is it safe? There is research evidence that patients taking Avandia are more likely to die compared to diabetic patients taking other drugs.  The FDA defends the use of Avandia, but many concerns remain.

Since 2007, the FDA required Avandia to include a black box warning for patients and doctors that it increases the risk of heart failure, which can be fatal.  A block box around a warning about risks is the strongest warning the FDA requires, similar to the black box warning on cigarette packages, warning that smoking causes lung cancer, heart disease, and is dangerous for pregnant women.

Nearly 20 million Americans have type 2 diabetes, also known as adult-onset diabetes, a condition where a person’s body does not produce enough glucose (sugar) orrespond well to the blood sugar that the body makes naturally. Diabetes can result in many very serious health problems, including kidney disease, blindness, limb amputation and, most notably, heart disease. It is these complications caused by the disease, not the diabetes itself, which cause serious long-term effects or death. Avandia is a prescription drug manufactured by GlaxoSmithKline that lowers the sugar levels in the blood. But, does it improve the health of diabetics?

Avandia was approved by the U.S. Food and Drug Administration (FDA) in March 1999 despite concerns from FDA scientists and other experts about the safety of the drug. As a condition of FDA approval, GlaxoSmithKline was required to continue to conduct clinical trials to assess the seriousness of heart complications related to the drug’s use.

On June 28, 2010, the Journal of the American Medical Association published two research studies that concluded that patients taking Avandia were more likely to die than patients taking other diabetes medication.

Previously, Dr. Steven Nissen and Kathy Wolski, MPH, published an article on the effects of Avandia and related drugs and cardiovascularrisks in the New England Journal of Medicine based on a meta-analysis of 42 small studies. They concluded that Avandia increases the risk of heart attack by 40%, compared to placebo. The FDA and GlaxoSmithKline criticized the study, saying that the data were short-term (six months or less) and that the studies differed widely, so that combining them in a meta-analysis was questionable.

The 2010 studies are harder to criticize.  One of them is also by Steve  Nissen and Kathy Wolski, and is based on a meta analysis of 56 studies of more than 35,000 patients.  The other is a 3-year comparison of Avandia and Actos, based on more than 220,000 patients and analyzed by FDA scientist Dr. David Graham and his colleagues.

The “black box” warning labels for Avandia (also called rosiglitazone) are also required for the other drugs in its class.  Other drugs in the same class as Avandia are called thiazolidinedione drugs.  In addition to Actos (pioglitazone), they include Avandaryl (rosiglitazone and glimepiride), Avandamet (rosiglitazone and metformin), and Duetact (pioglitazone and glimepride). The warning explains that these drugs can cause or increase heart failure. If FDA takes Avandia off the market, they may need to take the combination drugs listed above that include Avandia off the market as well (Avandaryl and Avandamet).

As a result of media attention and the black box warning, many doctors and patients have decided that the risks are too high. Prescriptions for Avandia decreased dramatically, but questions remained about the safety of other diabetes drugs, some of which had not been scrutinized as carefully as Avandia.

Dr. Nissen points out that the purpose of diabetes drugs is to lessen the possible danger of diabetes, “not improvement in a laboratory measure of glycemic [blood sugar] control.” Since heart disease is the #1 cause of death among diabetics, it is reasonable to ask why a diabetes drug that possibly increases rather than decreases the risk of heart disease should remain on the market. Are warnings enough to keep patients safe? After looking at the study results, many experts are urging that patients and doctors consider whether older drugs for diabetes may be safer and more effective – as well as much less expensive. They are asking: should Avandia remain on the market?

Starting in 2010, the FDA began requiring special certification for healthcare providers who prescribed Avandia.  Only specially certified pharmacies could dispense it, and only patients who were already taking it before the restrictions or new patients who could not use any other glucose-lowering medications were eligible to take it.

However, the company insisted that Avandia was safe and challenged the studies indicating it was not.  Dr. Nissen and other critics of the company’s research pointed out the flaws in the research design.  Despite the unanswered questions and continuing concerns of many experts, in November 2013, the FDA announced its conclusion that Avandia does not pose a greaterrisk of heart disease than the most commonly used Type 2 diabetes drugs and withdrew the stronger label warnings and otherrestrictions. Rather than proceeding with caution, the FDA told GlaxoSmithKline that they no longer need to conduct a previously required study comparing Avandia to Actos and other diabetes drugs.

The FDA’s decision leaves physicians and patients with limited information about which diabetes drugs are safer, and for which patients.  However, the law suits against Avandia have continued and the safety questions still concern many physicians and patients.

In January 2014, the FDA approved a new diabetes drug, Farxiga, that seems to be less effective than Avandia, Actos, and several other diabetes drugs; increases the risk of genital fungal infections and bladder infections, and may increase the risk of bladder cancer and breast cancer. Read here for more on Farxiga.

By Dana Casciotti, PhD

Updated January 2014

Animals play an important role in many people’s lives.  In addition to seeing-eye dogs and dogs that can be trained to detect seizures, animals can also be used in occupational therapy, speech therapy, or physical rehabilitation to help patients recover.1  Aside from these designated therapeutic roles, animals are also valued as companions, which can certainly affect the quality of our lives.  Is that companionship beneficial to our health?

The better we understand the human-animal bond, the more we can use it to improve people’s lives.  This article summarizes what is known and not known about how animals help improve the health and well-being of people, and what the implications might be for helping people who don’t have pets of their own.

Over 71 million American households (62%) have a pet,2 and most people think of their pets as members of the family.3  Some research studies have found that people who have a pet have healthier hearts, stay home sick less often, make fewer visits to the doctor, get more exercise, and are less depressed.  Pets may also have a significant impact on allergies, asthma, social support, and social interactions with other people.

Impact on Physical Health

Companion animals may improve heart health by lowering blood pressure and regulating the heart rate during stressful situations.  In a 2002 study, researchers measured changes in heart rate and blood pressure among people who had a dog or cat, compared to those who did not, when participants were under stress (performing a timed math task).  People with a dog or cat had lower resting heart rates and blood pressure measures at the beginning of the experiment than non-pet owners.  People with a dog or cat were also less likely to have spikes in heart rates and blood pressure while performing the math task, and their heart rates and blood pressure returned to normal more quickly. They also made fewer errors in their math when their pet was present in the room.4  All these findings indicated that having a dog or cat lowered the risk of heart disease, as well as lowering stress so that performance improved.

A similar study found that having your dog in the room lowered blood pressure better than taking a popular type of blood pressure medication (ACE inhibitor) when you are under stress.5

Children’s exposure to companion animals may also ease anxiety.  For example, one study measured blood pressure, heart rate, and behavioral distress in healthy children aged 3 to 6 at two different doctor visits for routine physicals.  At one visit a dog (unrelated to the child) was present in the room and at the other visit the dog was absent.  When the dog was present, children had lower blood pressure measures, lower heart rates, and less behavioral distress.6  Research on the health benefits of child and animal interaction is limited.  Further research is needed on how pets influence child development and specific health outcomes.

These findings suggest that the social support a pet provides can make a person feel more relaxed and decrease stress.7  Social support from friends and family can have similar benefits, but interpersonal relationships often cause stress as well, whereas pets may be less likely to cause stress.  The social support provided by a pet might also encourage more social interactions with people, reducing feelings of isolation or loneliness.  For example, walking with a dog has been found to increase social interaction, especially with strangers, compared to walking without a dog.8

Among elderly people, pet ownership might also be an important source of social support that enhances well-being.  In one study, elderly individuals that had a dog or cat were better able to perform certain physical activities deemed “activities of daily living,” such as the ability to climb stairs; bend, kneel, or stoop; take medication; prepare meals; and bathe and dress oneself.  There were not significant differences between dog and cat owners in their abilities to perform these activities.  Neither the length of time of having a dog or cat nor the level of attachment to the animal influenced performance abilities.    Companion animals did not seem to have an impact on psychological health but researchers suggested that a care-taking role may give older individuals a sense of responsibility and purpose that contributes to their overall well-being.9

A large German study collected pet information (dog, cat, horse, fish, bird or other pet ownership) from over 9,000 people at two different times (1996 and 2001).  The survey included a number of health, economic, and labor issues, so that respondents would not realize the researchers’ interest in a link between pets and health.  Researchers found that people who said they had a pet in both 1996 and 2001 had the fewest doctor visits, followed by people who had acquired a pet by 2001; the group of people who did not have a pet at either time had the highest number of doctor visits.10

Similarly, a study of women (men were not included in the study) in China found that dog owners had fewer doctor visits, took fewer days off sick from work, and exercised more often than non-dog owners.11

Research on allergies and asthma is mixed.  Some studies show that having a cat might increase allergen sensitivity, while others show it might protect against cat allergies.  Having a dog might not influence or might protect against specific dog allergies.12 A 2013 study found that mice were protected against allergies when they were exposed to dust that came from homes with dogs.13  The researchers discovered that the protective effect was due to a certain type of gut bacteria that is often present in people with dogs.  More research is needed on the connection between allergies, asthma, and pets, but it is possible that the impact of having pets on allergies may depend on the age of the person at the time they are exposed to an animal as well as the type of pet.  For example, 6 and 7 year old children who lived with a bird during their first year of life were more likely to have respiratory symptoms like wheezing compared to children who did not have a bird in the home as an infant.14

As is true with any relationship, some human-pet relationships are likely to be more rewarding than others. Some people are more attached to their pets than others and those feelings could influence the impact of the pet on the person’s health.  Other factors such as gender and marital status may play a role. For example, one study found that dog ownership was associated with lower rates of depression among women, but not men, and among single individuals but not married people.  So, while pet ownership might have a positive impact on well-being for some people, it doesn’t affect everyone the same way.15

The Challenges of Measuring the Positive Impact of Pets

The effect of human-animal interaction on health is not fully understood because it is difficult to study.  Most evidence on the benefits of having a pet comes from surveys of current health, but that means it is impossible to know if a person is in good health because she has a pet or if he is more likely to get a pet because he is in good health.  Someone whose health is poor may decide he does not have the time or energy to care for a pet.  The German study described above suggests that having a pet for a longer period of time is more beneficial to your health; but it is also possible that people with pets have less time to spare to go to the doctor or are less concerned about their own health, especially minor ailments.

In addition, people who love their pets are likely to want to let researchers know that their pets help improve their lives.  This could bias the study results.

Another issue is how the word “pet” is defined.  Does having a goldfish confer the same health benefits as having a golden retriever?  Most pet studies were of people who had a dog or a cat, making it difficult to draw conclusions about health benefits of birds, lizards, fish, or other pets.  How much time the person spends with his or her pet could be strongly influenced by the type of pet and in turn could influence the health benefits of having a pet.16

Temporary Companions

Researchers have also used animals to temporarily provide companionship to children with health or mental health problems, or elderly people who may not have the energy or resources for a live-in pet.  While these studies do not always have consistent results, some positive findings of interacting with a therapy dog include reduced levels of pain and anxiety among hospitalized children and adults, as well as increased focus and interaction among children with autism and other developmental disorders.  In nursing home settings, interaction with visiting dogs has led to more social behaviors, more interaction among residents, and less loneliness.17

While research on animal-assisted interaction and therapy is not always consistent and is often done with small groups of participants, there is some evidence that interaction with a companion animal even for a short time might have a range of benefits

The Bottom Line

The research findings are encouraging, so it makes sense to conduct more studies on how human-animal interaction influences our health.  We don’t yet know precisely what types of animals influence what types of health issues (physical, mental, and social well-being) and what characteristics about human-animal interaction are most important.  People who have pets know that there are many benefits to having a companion animal, but we do not yet know under what circumstances those benefits are most likely.  If research shows specific health benefits under specific circumstances, that information can be used to change policies in ways that benefit even more adults and children, by influencing rules and regulations for schools, health or assisted living facilities, residential treatment centers, and other places where people’s exposure to animals is sometimes discouraged but could potentially be encouraged.

For more scientific research about human-animal interaction, see How Animals Affect Us: Examining the Influence of Human-Animal Interaction of Child Development and Human Health by Peggy McCardel, Sandra McCune, James A. Griffin, and Valerie Maholmes.  The book is based in part on a workshop sponsored by the Waltham Centre for Pet Nutrition, a division of Mars, Incorporated, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

By Diana Zuckerman, Ph.D., Padma Ravichandran, and Elly Field
Updated September 2013

 

Although the minimum drinking age is 21 years old, teenagers and young adults between the ages of 12 and 20 consume about 11% of the country’s alcohol in a given year—mostly by “binge drinking.” 18 Binge drinking is defined for men as drinking 5 or more drinks in a row (in 2 hours or less), and 4 or more drinks for women. Young adults between the ages of 18 and 24 consume the most alcohol on average when they binge drink (about 9 drinks in a two-hour period), but high school kids are also very likely to binge when they drink.19

While binge-drinking seems to be declining among teens, extreme binge-drinking (15 or more drinks in a row) is not. In 2005, 22% of high school students admitted to drinking 5 or more drinks in a row during “the last two weeks,” which was reduced to 18% in 2011.20 However, about 1 In 20 high school students drank more than 15 drinks in a row in 2011, the same as 2005.

Is this harmless fun?  Or deadly?  Every few years, there are “hazing” deaths like that of David Bogenberger, a freshman pledging to a fraternity at Northern Illinois University. He died after answering questions for two hours from upper class fraternity brothers in exchange for vodka.21 But, those individual tragedies aren’t the entire story.

Physical and Mental Health Effects

Kids that drink tend to do poorly in school, and it can harm growth,  sexual development, and brain development. 22 Whether you drink too much alcohol or not, part of being young is not thinking about how what you do now can affect you later on. Unfortunately, excessive drinking in your teens and early adulthood can have an impact on your health many years later. Research shows that binge drinking while you’re young can worsen your memory and increase you risk for obesity and heart problems.

A 2008 study by researchers in Berkeley, California, found that young adults who started drinking alcohol early and heavily in adolescence were more likely to have more abdominal fat, to be overweight, and to have lower levels of the “good cholesterol,” all of which contribute to heart disease. 23

Long-term heavy drinking, which is defined for men as consuming more than 2 drinks per day every day, and more than one drink every day for women, weakens the heart muscle 24. This prevents the heart from effectively pumping blood to other organs. Binge drinking and long-term heavy drinking can also affect heart rhythms, causing the heart to beat irregularly or too fast. These strains on the heart can affect a person’s health in a number of ways. For instance, binge drinkers are almost 40% more likely to suffer from a stroke than people who don’t binge drink.25

Heavy drinking can also affect your abilities for the rest of your life.  Long-term, heavy drinking can affect our neurons and slow the communication between neurotransmitters in the brain 8, but binge drinking when you’re a teenager may actually change the structure of the brain, damaging the tissue that messages pass through when moving from one area of the brain to another.26 These brain changes may impair a teenager’s memory and ability to learn.

A study published in 2013 that tracked college students in Brazil and Spain for two years had similar findings: the researchers found that those who binge drank had greater difficulty recalling information on memory tests—both immediately and 30 minutes later 27.

Besides the potential effects on health and memory, excessive drinking early in life is often a red flag for other problems. A study that followed almost 1,000 adolescents from high school through age 24 found that those who were problem drinkers when they were young grew into adults with drinking problems. They were also more likely to be depressed, anxious, antisocial, and have problems with other types of substance abuse.28 A study that followed college students into adulthood discovered that those who binge drank were significantly more likely to experience alcohol-related problems during college and 10 years after college.29 The researcher also found that the students who binge drank in college were less likely to continue their education and, if they did finish, were more likely to work in less prestigious and lower paying jobs.

Community Consequences

Underage drinking not only affects the teenagers who do it, but everyone around them. One in three car crash deaths involve drivers with alcohol in their blood that is above the legal limit.30 A national survey found that 8% of high school students report they had driven a car after drinking alcohol, and 24% rode in a car with a driver who had been drinking alcohol. [2]

Underage drinking and binge drinking happen because we, as a society, allow it to. Adults may choose to look the other way, and teens and young adults often egg each other on. One study found that teenagers whose parents allowed them to drink engaged in riskier behavior than teenagers whose parents didn’t allow drinking. In addition, they generally experienced more negative consequences from their drinking.31 Even if their parents forbid drinking, teens have to contend with friends who drink and pressure them to join in. Research has shown that if you’re a young adult and your peers drink, you are more likely to drink as well.32

What should family members, teachers, and other adults do to help kids?

1)     Understand the impact of peer pressure. It’s easier to talk to teenagers about the negative effects and risks of drinking when it appears you are only talking about their friends. See if he or she feels pressure to drink, and if so, discuss the possibility of finding new friends to make it easier to spend less time with peers who drink or avoid them when they are drinking. Also, help a teen practice ways of saying “no” or removing himself or herself from situations where she is expected to drink, without losing face or appearing judgmental.

2)     Never ignore teenage drinking hoping it will go away. Often it is a symptom of more serious problems that the teen is experiencing now or will develop in the coming years.11

Bottom Line: What you need to know as a teen or parent

If you are a teen, pay close attention to your friends’ drinking and talk to them about the risks.  Avoid situations where you will be under pressure to drink or ride in a car with a driver who has been drinking. If you are worried that discussing your friends’ drinking with your parents will make them dislike your friends or limit your social time with them, find another adult you trust to discuss strategies for saying “no” and avoiding risky situations. You can also visit these websites for suggestions on how to deal with peer pressure and plan ahead to minimize risky situations:

For parents: Talk with your teens about how to approach various scenarios in which they might feel pressured to drink or ride in the car with a driver who has consumed alcohol. Tell your teen that you’ll pick him up or pay for his taxi, no questions asked, if he or his ride has made the mistake of drinking. The mistake and the decision to behave differently next time can be addressed the following day.  For more information on how to keep your teenager from drinking and driving, visit: http://m.cdc.gov/en/VitalSigns/teen-drinking-and-driving .

Lastly, if you need help for your son or daughter’s drinking, there is a toll-free number you can call: 1-800-662-HELP (4357). This is a service of the Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the U.S. Department of Health and Human Services (HHS). You will get a recorded message in English or Spanish giving you the option 1) to speak to someone about treatment or request educational materials, or 2) to get a referral to a treatment place in your state. If you don’t want to call and prefer to look for help online, visit this SAMHSA site: http://findtreatment.samhsa.gov/

By Brandel France de Bravo, MPH; Sarah Miller, RN; and Jessica Becker.   Updated June 2014.

Electronic_Cigarette_SmokingElectronic cigarettes, or e-cigarettes, are being marketed as the “safe” new alternative to conventional cigarettes.  They can be used indoors, allowing smokers to get their fix wherever and whenever they want.  But are e-cigarettes safe?  What does the FDA think about them? Are e-cigarettes going to reverse the decline in smoking—giving new life to an old habit—or can they help people quit smoking?  Here is what you need to know before picking up an e-cigarette.

What are e-cigarettes?

E-cigarettes are battery-operated devices shaped like cigarettes that provide an alternative way to receive nicotine. Nicotine is an addictive drug (it stimulates and relaxes) that is naturally found in tobacco, but cigarette manufacturers have often added extra nicotine or engineered their cigarettes to maximize the amount of nicotine delivered to smokers in each puff. 33

E-cigarettes work by heating a liquid cartridge containing nicotine, flavors, and other chemicals into an inhalable vapor. Because e-cigarettes heat a liquid instead of tobacco, what is released is considered smokeless.34 However, studies show that exposure to the chemical used to create the vapor (propylene glycol mist) may cause respiratory inflammation and eye irritation.35 Propylene glycol is used in pet-friendly anti-freeze solutions (a safe alternative to ethylene glycol) and in smoke machines at dances or the theater.

Flavors, such as “gummy bear,” “cotton candy,” and “bubble gum” are not only encouraging teenagers to try e-cigarettes, they are resulting in accidental poisonings among children.  Over half of the 2,405 calls to poison centers between September 2010 and February 2014 concerned children 5 and under who had come into contact with e-cigarettes. 36 E-cigarettes are far easier for young children to smoke as they require no matches. Worse still, the liquid in the cartridges is highly concentrated so absorbing it through the skin or swallowing it is far more likely to require an emergency room visit than eating or swallowing regular cigarettes.

Are e-cigarettes safer than conventional cigarettes?

The key difference between conventional and e-cigarettes is that e-cigarettes don’t contain tobacco. But, it isn’t just the tobacco in cigarettes that causes cancer. Conventional cigarettes contain a laundry list of chemicals that are proven harmful, and e-cigarettes have some of these same chemicals.

Nicotine is one of the chemicals found in both conventional and e-cigarettes. It is highly addictive and has been shown to reduce bone health.37

An analysis of e-cigarettes by the FDA in 2009 found that they “contained detectable levels of known carcinogens and toxic chemicals to which users could be exposed.”38  For example, in e-cigarette cartridges marketed as “tobacco-free,” the FDA detected diethylene glycol (a toxic compound found in antifreeze), tobacco-specific nitrosamines which are carcinogenic to humans, and other toxic tobacco-specific impurities. The body’s reaction to many of the chemicals in conventional cigarette smoke causes chronic inflammation, which in turn leads to chronic diseases like bronchitis, emphysema, and heart disease.39 Since e-cigarettes also contain many of the same toxic chemicals, there is no reason to believe that they will significantly reduce the risks for these diseases.

You may have also heard that free radicals produced by the smoke from cigarettes can damage veins and arteries and lead to heart disease. It is possible that the vapor from e-cigarettes may contain fewer free radicals because it is not smoke. This does not mean, however, that smoking e-cigarettes is safe for your heart.

There are no long-term studies to back up claims that the vapor from e-cigarettes is less harmful than conventional smoke. Cancer takes years to develop, and e-cigarettes were only very recently introduced to the United States. It is almost impossible to determine if a product increases a person’s risk of cancer or not until the product has been around for at least 15-20 years. Despite positive reviews from e-cigarette users who enjoy being able to smoke them where regular cigarettes are prohibited, very little is known about their safety and long-term health effects.

Can e-cigarettes be used to cut down or quit smoking regular cigarettes?

If a company makes a claim that its product can be used to treat a disease or addiction, like nicotine addiction, it must present studies to the FDA showing that its product is safe and effective for that use. On the basis of those studies, the FDA approves or doesn’t approve the product. So far, there are no large, high-quality studies looking at whether e-cigarettes can be used to cut down or quit smoking long-term. Most of the studies have been either very short term (6 months or less) or the participants were not randomly assigned to different smoking cessation methods, including e-cigarettes. Many of the studies are based on self-reported use of e-cigarettes. For instance, a study done in 4 countries found that e-cigarette users were no more likely to quit than regular smokers even though 85% of them said they were using them to quit. 40. Another year-long study, this one in the U.S., had similar findings.41  People may believe they are smoking e-cigarettes to help them quit but 6-12 months after being first interviewed, nearly all of them are still smoking regular cigarettes.

The FDA has not approved e-cigarettes for use in cessation, or quitting smoking.42

In September 2010, the FDA sent a warning letter to five distributors of e-cigarettes who were marketing their product this way: E-CigaretteDirect LLC, Ruyan America INC., Gamucci America (Smokey Bayou INC.), E-Cig Technology INC. and Johnson’s Creek Enterprises LLC.  After this warning letter, four of the companies changed their position to say that their e-cigarettes are not intended to be used as a way to quit smoking. E-Cig Technology INC. hasn’t made any changes to their website in response to the warning letter.

Teenagers and e-cigarettesecigad

The percentage of teenagers who have tried e-cigarettes has more than doubled in just a year, from 4.7% in 2011 to 10% in 2012. Over 1.78 million U.S. students in middle school and high school tried e-cigarettes in 2012, according to the National Youth Tobacco Survey. And this statistic greatly underestimates use because most teens don’t even know e-cigarettes as “e-cigarettes”; they call them “e-hookas” or “hookah pens” or “vape pipes.”  Furthermore, 1 in 5 middle schoolers who said they had tried e-cigarettes also said they had never smoked conventional cigarettes. 43

Experimentation with e-cigarettes by young people is worrisome for a couple of reasons: 1) the younger people are when they begin smoking, the more likely it is they will develop the habit: nearly 9 out of 10 smokers started before they were 18;44 2) e-cigarettes may  introduce many more young people to smoking who might otherwise never have tried it, and once they are addicted to nicotine, some may decide to get their “fix” from regular cigarettes. Whether e-cigarettes end up being a “gateway” to regular cigarettes or not, young people who use them risk becoming addicted to nicotine and exposing their lungs to harmful chemicals.

The sharp rise in young e-cigarette users highlights the need to stop manufacturers from targeting teenagers with candy-like flavors and advertising campaigns such as this one that appeal to young people’s natural desire to rebel.

How are e-cigarettes regulated?

On a national level

Originally, the FDA tried to block the sale of e-cigarettes on grounds that they were an untested drug-delivery device (nicotine is a drug), but in 2010 a federal appeals court ruled that the FDA could only regulate e-cigarettes as tobacco products.45 The FDA was given the authority to regulate the manufacturing, labeling, distribution and marketing of all tobacco products in 2009 when President Obama signed into law the Family Smoking Prevention and Tobacco Control Act.  This Act also gave the FDA the authority to regulate “other tobacco products” (including products made from or derived from tobacco) by issuing a regulation “deeming” the additional products as subject to the same law.

In April 2014, the FDA issued its first proposal (a “deeming rule”) for regulating e-cigarettes. These proposed regulations are just that: a draft proposal, which the public, scientists, and e-cigarette companies have a chance to review and provide input on before it is finalized. The full text of the deeming rule can be found here but in short, the FDA is proposing:

  • To prohibit  the sale of e-cigarettes to children and teens (under 18)
  • To prohibit vending machine sales of e-cigarettes
  • People over 18 will be required to show photo i.d. to purchase e-cigarettes, including through the internet.
  • The addition of a warning label to all packaging and advertisements stating “This product contains nicotine derived from tobacco.  Nicotine is an addictive chemical”.
  • All manufacturers of e-cigarettes will have to register with the FDA, which involves providing the agency with a detailed list of all the products’ ingredients, including how much nicotine they have, and information on their manufacturing process.

Despite these positive steps, the proposed rule is not nearly as tough as the regulations governing regular cigarettes. For instance, the FDA is still not proposing to limit the marketing of e-cigarettes to children and teens—only their sale. Also, it isn’t putting any restrictions on the media e-cigarettes can be advertised in, whereas regular cigarettes can’t advertise on television or radio.  E-cigarette companies will continue to use celebrities to endorse their brands and market flavors such as “bubble gum” and “cookies and cream”.

jennylucycigB

When e-cigarette companies register their products with the FDA, they will have to apply for FDA approval of the products, but here’s the catch: they will have two years AFTER the deeming rule is finalized to apply for approval and will be able to keep selling their e-cigarettes during that time. While the FDA’s proposed rule leaves the door open for the agency to issue more regulations on the sale, advertisement and marketing of e-cigarettes down the road, issuing and finalizing additional regulations will take time. Moreover, companies have to be given time to comply. All of this means that omissions and loopholes can take years to fix. Lastly, the FDA rule proposal does not address the sale of liquid nicotine which is used to re-fill e-cigarettes and exists as an unregulated market.  Presently, there is no requirement for childproof lids or restrictions on quantity on internet and retail outlet sales of liquid nicotine. If you would like to comment on the FDA’s proposal for regulating e-cigarettes, click here. The FDA has extended the deadline for comments until August 8, 2014.

On a state level

Individual states have taken action to govern the sale and use of e-cigarettes, including restricting their use in public areas and banning their sale to minors. For example, in May 2013, the California state senate proposed a law making all e-cigarettes subject to the same regulations and restrictions as traditional cigarettes and tobacco products.46

Bottom line

E-cigarettes have not been around long enough to determine if they are harmful to users in the long run. Unfortunately, many people, including teenagers, are under the impression that e-cigarettes are safe or that they are effective in helping people quit smoking regular cigarettes. Neither of these assumptions has yet been proven. Studies by the FDA show that e-cigarettes contain some of the same toxic chemicals as regular cigarettes even though they don’t have tobacco. The big three tobacco companies—Lorillard, Reynolds American, and Altria Group—all have their own e-cigarette brands so it’s not surprising that e-cigarettes are being marketed and advertised much the way regular cigarettes used to be. Here are the 7 Ways E-Cigarette Companies Are Copying Big Tobacco’s Playbook.

Unless you want to be a guinea pig, hold off on e-cigarettes until more safety information is available. And if you want to quit smoking or reduce the number of cigarettes you are smoking, check out these Quit Smoking Resources compiled by the Centers for Disease Control (CDC).

By Elizabeth Nagelin-Anderson, MA, Isabel Platt, and Noy Birger, BS
Updated August 2013

 

WHAT IS OSTEOPOROSIS?

Osteoporosis is a silent disease that causes the bones to thin and weaken to a point where they break more easily, particularly the hip, spine and wrist. The human body is constantly destroying old bone cells and creating new ones; osteoporosis occurs when the rate of bone cell destruction is greater than bone cell production. Unfortunately, most won’t know that they have osteoporosis until they break a bone or have a bone density test.

WHY SHOULD YOU BE CONCERNED?

Osteoporosis can affect how you look, how you feel, and how long you live. People with osteoporosis often lose several inches in height, sometimes as much as 4-6 inches, because the vertebrae in the spine begin to collapse. They may also develop a hump in their back as they age. People with osteoporosis experience bone fractures more easily and live with the fear of a serious injury. A broken hip, for example, almost always requires hospitalization and major surgery, and even after it heals, many cannot walk unassisted. One in five nursing home residents that break a hip die within a year of the fracture from complications such as pneumonia, other infections, and general declining health after a hip fracture.47

WHAT CAUSES OSTEOPOROSIS?

Osteoporosis starts many years before a person suffers his or her first fracture. In a way, it is a disease of childhood that isn’t obvious until adulthood. Since 90% of bone mass is usually formed by the age of 18 in girls and age 20 in boys, the bone mass you develop as a child has a great impact on bone health later in life.48 Children should have a healthy diet rich in calcium, which they can get through fortified milk, other dairy products like cheese and yogurt, and green vegetables like broccoli and spinach. Vitamin D is essential to absorb the calcium, and children and adults can get Vitamin D through foods or from about 15 minutes of outdoor sun exposure each day.49 “Weight-bearing” exercise will strengthen the bones of children and adults, which includes walking, running, playing sports, dancing, yoga, and weight-lifting.50 An inactive childhood or a poor diet will make it almost impossible to have strong, healthy bones as an adult. To learn more about how kids can get an early start to keep their bones healthy, read Healthy Bones for Young Adults.

Although the body has almost reached maximum bone mass by age 18-20, it continues to build bone slowly until you reach your peak bone mass around age 30. After that, more bone mass is lost than formed. Women are more at risk for developing osteoporosis, because they lose bone mass during pregnancy, and in the five to seven years following menopause, falling estrogen levels can cause women to lose up to 20% of their bone mass. Bone loss continues into old age, although at a slower rate.

Hormone replacement therapy (HRT)—now called menopausal hormone therapy—is sometimes prescribed for the symptoms of menopause, including the prevention of osteoporosis. However, research by the National Institutes of Health (NIH) found that the risks of hormone therapy outweigh the benefits. Since diet and exercise have been shown to prevent and treat osteoporosis, NIH recommends that hormones be used to treat the symptoms of menopause only if the symptoms seriously disrupt daily functioning or the enjoyment of life. For more information, see Hormone Therapy and Menopause.

HOW CAN I PREVENT OSTEOPOROSIS?

There are several things you can do to prevent osteoporosis:

  • Eat a balanced diet rich in calcium and vitamin D as a child and for the rest of your life
  • Participate in weight-bearing exercise (i.e., walking, tennis, dancing, weight-training)
  • Limit use of alcohol and don’t smoke
  • Have a bone density test if you are over 65 or have risk factors (other than age, gender and postmenopausal status) for osteoporosis, and take medications when appropriate51

Calcium is important for everyone. If your mother told you to drink three glasses of milk each day, she was right. Children ages 4 to 8 need 1000 mg of calcium, and children between 9 and 18 require 1300 mg. Every adult needs about 1000 mg of calcium each day, and three 8-oz glasses of milk will provide 900 mg. According to NIH, women over the age of 50 and men over the age of 70 should get 1200 mg of calcium.52

In addition to milk products such as yogurt and cheese, other foods that are rich in calcium include broccoli, spinach, other dark green leafy vegetables, tofu, and almonds. Today, more and more foods such as orange juice, bread, and cereals are fortified with calcium and vitamin D, making it easier to consume the recommended level of calcium.

However, vegetables are not likely to provide all the calcium you need: a typical half cup serving of raw broccoli has about 25 mg of calcium, and a cup of raw spinach contains about 30 mg of calcium. Almonds have more calories than calcium: one ounce of almonds contains 70 mg of calcium and has about 160 calories; in order to get 1000 mg of calcium from almonds in one day, a woman would need to consume all of her recommended 1600 calories a day in almonds. For more information about the calcium content of various foods, you can use this osteoporosis website.

Dietary supplements can help if you don’t think you’re getting enough calcium and vitamin D from your diet and sun exposure. Results from the Women’s Health Initiative show that women who took vitamin D and calcium supplements every day suffered fewer hip fractures than women who took placebos (sugar pills). However, these benefits only occurred if the women were very conscientious about taking these daily supplements: two pills every day, each containing 500 mg of calcium and 200 IU of vitamin D. These results, together with other research, support the idea that taking calcium and vitamin D supplements every day can reduce the risk of bone fracture. For more information about calcium and vitamin D supplements, read this article.

Adult women need a total of 1000 to 1200 mg of calcium each day, but our bodies can’t absorb that much all in one dose. The best strategy is to divide the total daily amount you need into two or three smaller doses and take them with meals (to improve their absorption) throughout the day. If a meal includes calcium-rich foods like cheese, yogurt, milk, or calcium-fortified orange juice, then it is better to skip your calcium supplement or take a multi-vitamin with that meal and take one more 600 mg supplement with other meals. Remember that calcium works together with vitamin D. According to the NIH, people should consider taking more than the recommended 400-600 IUs of Vitamin D each day and can safely increase their daily dose of vitamin D to as high as 2,000 IUs.6 If your diet and sunshine exposure don’t provide enough vitamin D (and few people’s do!), then you will want to take a supplement.

Exercise is almost as important as your diet in developing and maintaining bone mass. Childhood exercise helps to develop bones, and exercise throughout adulthood helps to maintain bone density (Exercise for your Health). Throughout adulthood and especially after menopause, women also benefit from regular activity such as walking, dancing, weight-training, and low-impact aerobics, which can decrease the risk of fractures. Not only does exercise make you feel and look better, it will decrease your risk of fractures throughout your life.

Smoking is bad for your bones. Women who smoke increase their chances of developing osteoporosis. It has been shown that smokers may absorb less calcium from their diets, and low calcium intake is associated with low bone mass, rapid bone loss, and high rates of fracture. Also, women who smoke have lower levels of estrogen compared to nonsmokers, and frequently go through menopause earlier.

RISK FACTORS

Certain people are more likely to develop osteoporosis than others, and while there are many risk factors you can’t change, you do have control over others.

Factors you can’t change

  • Being female
  • Having a small frame
  • Being Caucasian or Asian (although African Americans and Hispanics are also at risk)
  • Advanced age
  • A family history of osteoporosis
  • History of fracture in an immediate relative
  • Estrogen deficiency as a result of menopause, especially early or surgically induced
  • Use of certain medications, such as corticosteroids and anticonvulsants
  • Personal history of fracture after age 50
  • Current low bone mass
  • Abnormal absence of menstrual periods

Factors you can change

  • Low lifetime calcium intake
  • Being very thin or anorexic
  • An inactive lifestyle
  • Current cigarette smoking
  • Excessive use of alcohol

DIAGNOSIS

The bone mineral density (BMD) test is a painless test that measures bone density in the spine, wrist, and/or hip (the most common sites of fractures due to osteoporosis), while other tests measure bone in the heel or hand. The results of this test can tell you how dense your bones are, whether or not you have osteoporosis, and the chances of a future fracture. This test can also be used to monitor bone loss, and the effects of any treatment you may be receiving.

The National Health Information Center (a service of the United States Department of Health and Human Services) recommends that women under 65 with risk factors and all women over the age of 65 have a BMD test.53

TREATMENT

The treatment of osteoporosis is very similar to prevention: a balanced diet rich in calcium and vitamin D, exercise, limited alcohol consumption, no smoking, and in some cases, medication.

There are different categories of medications that are used to treat and delay bone loss. However, these medications have risks as well as benefits, and it is important to understand that researchers have not studied whether these medications are better at preventing bone loss and fracture than just having enough calcium and vitamin D in the body to support bone health.54 Taking plenty of calcium and vitamin D and doing weight-bearing exercise would be a better choice than prescription medications for many women.

ANTIRESORPTIVE MEDICATIONS (BISPHOSPHONATES): RISKS AND BENEFITS

Bisphosphonates are a group of medications that slow the progress of bone loss. The brand name drugs Fosamax, Actonel, Boniva, and Reclast are all bisphosphonates.

Since bone cells are constantly being produced and destroyed, slowing the bone loss allows bone formation to happen at the same pace as bone cell destruction. However, recent research suggests that bisphosphonates are most beneficial when used for no more than 4-5 years. Using them for longer may be harmful. Why is this?  Although bisphosphonates are good at increasing the quantity of bone cells, these drugs may be causing the body to keep damaged bone cells that would normally be destroyed, as well as healthy ones.  As the damaged bone cells and minerals build up over time, it can make bones weaker.  So even if the patient is no longer losing bone mass, she may be at higher risk of a bone fracture if her bones are more brittle.55 56

A new study that has not yet been published found that postmenopausal women with osteoporosis who were taking a bisphosphonate for more than 4 years were at increased risk of an uncommon type of fracture (atypical subtrochanteric femur fracture) of the femur-the large leg bone just below the hip joint.57 Other studies have found similar results, raising concerns that that taking these drugs for extended periods of times may be harmful to bone health.8 58 59 As of October 2010, the FDA says that more research is needed to better understand the risks and benefits of these drugs.60

Bisphosphonates are generally taken as a daily or weekly pill and some patients have had damage to their gastrointestinal systems, particularly in the path from the mouth to the stomach.61 People taking bisphosphonates should be careful to follow the instructions about how to take them: with a large glass of water while standing or sitting, to remain vertical for at least 60 seconds after taking the pill, and to immediately swallow the pill rather than chewing or sucking it.13

While there are clearly risks to using bisphosphonates, new research indicates the drugs may also lower a woman’s risk of getting breast cancer.  A 2010 study published in the British Journal of Cancer found that women who took bisphosphonates were 30% less likely to develop breast cancer.62 These findings do not apply to women who are obese, because obese women taking bisphosphonates were just as likely to be diagnosed with breast cancer as obese women who were not taking these drugs.

The following information explains some of the risk and benefits of commonly used brands of bisphosphonate drugs. Since the risks and benefits of all bisphosphonates are similar, patients usually choose a brand based on how often the pill is taken (daily, weekly, or monthly) or whether their insurance covers it or not.

Fosamax (alendronate sodium)

Patients taking Fosamax were found to have a 4% increased risk of developing a condition in the jaw called osteonecrosis, in which the jaw bone does not heal after minor trauma such as tooth extraction.63 This condition leads to pain, swelling, and infection Osteonecrosis is a possible side effect of all bisphosphonates, not just Fosomax, however.64

A study conducted at the University of Washington found that women taking Fosamax have twice as high a risk of developing a chronic irregular heartbeat compared to those who took no osteoporosis medicines.65

What about the benefits?  One study showed that there was no difference in risk of fracture between women who took Fosamax for five years and then stopped and women who took the medication longer and stayed on the medication.66 This finding suggests that for most women, there is no point (and as shown in another study, possibly some harm) to taking Fosamox or a similar bisphosphonate medicine for longer than five years.

Actonel (risedronate)

This medication is nearly identical to Fosamax, just manufactured by a different company.  Fosamax came onto the market earlier than Actonel, so there have been more studies focused on Fosamax.  A study in 2001 showed that Actonel reduced hip fractures in elderly women who had been diagnosed with osteoporosis by about 40%.67

Boniva (ibandronate sodium)

Some patients taking this medicine have experienced a drop in calcium in their blood, so a patient considering this medication should talk to her doctor about also taking calcium and Vitamin D supplements.13

ANABOLIC DRUGS

Anabolic drugs work by increasing the rate of bone formation.

Forteo (teriparatide)

Teriparatide is a human parathyroid hormone that encourages the body to produce new, healthy bone cells.  It is not given to patients as frequently as bisphosphonate medicines because it must be injected daily in the lower abdomen or outer thigh, by the patient or a friend/family member.  In a study of post menopausal women, the ones taking Forteo had improved bone density within 3 months of starting treatment and had fewer fractures, compared to the women who took oral bisphosphonates, who only saw improvements after 12 months.68 with alendronate in postmenopausal women with osteoporosis. The Journal of Clinical Endocrinology & Metabolism, 87(10): 4528-4535.]

This treatment is less convenient than the oral medicines, more expensive, and there is some concern that it might be linked to a bone cancer called osteosarcoma, which has been seen in rats given the drug. For these reasons, Forteo is only recommended for people with severe osteoporosis who are at high risk of fracture.  Even people with severe osteoporosis should not take Forteo for more than 2 years.69

SELECTIVE ESTROGEN-RECEPTOR MODULATORS (SERMS)

Women don’t lose bone mass rapidly until their estrogen levels fall at menopause. SERMs are a broad group of substances that cause the body to respond more strongly to the hormone estrogen.  They can also limit the body’s response to drops in estrogen.

Evista (raloxifene HCl)

Evista is taken in the form of a daily pill.  It was approved for the treatment of osteoporosis in 1997.70 It works by preventing the body from destroying bone cells. A large study of 6,828 women who had osteoporosis or had already experienced at least one fracture, found that those who used Evista daily had a 30% reduced risk of fracture in their back bones but not their hips or other bones.71

In addition to the reduction in risk of bone fracture, Evista increases bone density in the neck, spine, hip, and throughout the body in general.25 72 SERMs may also reduce the risk of a particular type of breast cancer that targets estrogen receptors in breast tissue, known is “estrogen receptor-positive breast cancer.”  One study found that postmenopausal women who took Evista for approximately 3 years reduced their risk of estrogen receptor-positive breast cancer by 90%. But Evista did not reduced risk of breast cancer for women with estrogen receptor-negative breast cancer.73 Another possible benefit is that women taking this medication have had a significant decrease in LDL (“bad”) cholesterol in the first three months of treatment. After the drop, cholesterol levels stayed steady.26

There are serious risks, however: Evista increases a woman’s chances of getting blood clots, especially in the lungs and in leg veins, so it should not be taken by women who are pregnant or who have a history of blood clots.25 In some studies, a slightly higher proportion of the women taking this medicine than those taking a placebo (sugar pill) said that they had hot flashes, but this finding was not consistent.

FALL PREVENTION

Each year about one third of people over age 65 falls, and some will face permanent disability from the broken bones suffered. Falls are the main concern for those with osteoporosis, because that is when breaks and fractures usually occur.  To prevent broken bones, the best strategy is to avoid falling – even more than taking medication to prevent osteoporosis.

Several factors contribute to the greater likelihood of an older person falling. Many face physical factors such as poor eyesight, limited hearing, lack of strength and/or coordination, and poor balance. Others are affected by the medications they take, such as muscle relaxants, sedatives or blood pressure drugs, which can cause dizziness and/or lightheadedness. And finally, people are more likely to fall in a cluttered house, in dim lighting, or on loose carpeting or throw rugs.

Precautions you can take to avoid falls:

  • Make sure all stairways, entrances and halls are well lit. Consider using nightlights, particularly in the bathroom.
  • Install non-slip material and a grab bar in the tub/shower.
  • Secure all loose cords and throw rugs.
  • Make sure stairs are clear of clutter and treads or carpet is secure.
  • Use non-skid rubber mats in front of the sink and stove and clean up spills immediately.
  • Wear sturdy, rubber-soled shoes
  • Ask your doctor if any of the medications you’re taking could contribute to a fall.

RESOURCES

http://www.niams.nih.gov/Health_Info/Bone/
National Institutes of Health National Resource Center: Osteoporosis and Related Bone Diseases

http://www.healthfinder.gov/prevention/printtopic.aspx?topicid=12
National Health Information Center provides information about the process of bone density testing.

 

Anne Gallo, M.S., Sarah Miller, R.N., Diana Zuckerman, Ph.D., and Monica Purmalek
Updated July 2013

Can stress make you sick?  The answer is a resounding yes.  If you want to know how to handle stress, it helps to know what stress is, how it affects your body, and what you can do about it.

What is Stress?

Anything that an individual perceives as a problem can cause stress.  When we perceive a problem and don’t have the resources (or believe we don’t) to cope with it, we can experience stress.  Stressors can be physical, such as an illness or injury, or emotional, such as family, job, or financial problems.  Stress is a reaction to a situation where a person feels threatened or anxious.74  According to Dr. Esther Sternberg, director of the Integrative Neural Immune Program at the National Institute of Mental Health, our body’s response to stress is natural and adaptive.75  Even if the body has a natural way to handle stress, chronic stress may be harmful to our health, resulting in both psychological and biological changes that increase our chances of becoming ill.

 

Stress Hormones

When faced with stress (for example a physical threat), your body reacts with a “fight or flight reaction” to enable you to fight back or run away from danger.  The adrenal glands release the hormone epinephrine (adrenaline) and the neurotransmitter norepinephrine into the blood stream.  The adrenal glands also release corticosteroid hormones that release fatty acids for energy, causing digestion to stop, blood sugar levels to rise, and the heart to pump more blood to the muscles.

At the same time, the pituitary gland releases a hormone that stimulates the release of cortisol.  In the short term, cortisol helps the body divert energy to muscles and organs that are needed to avoid danger.  However, the same hormones that help defend the body in the short-term can hurt it when produced for longer periods. Because one action of cortisol is to suppress the immune system, chronic stress causes wounds to heal more slowly than normal and leaves the body prone to infections.  This is why chronic stress is also associated with gastrointestinal conditions such as ulcers and irritable bowel syndrome. Since cortisol changes blood sugar and heart rate, cortisol is also associated with diseases of the cardiovascular system, including hypertension, stroke, and heart disease.

 

Telomeres

Telomeres are caps that we all have on the end of our DNA.  As we age, we slowly lose small bits of our telomeres and they become shorter.  Therefore, measuring the length of a telomere can tell us the “real age” of a person’s cells.  Several studies have found that people who are under chronic stress tend to lose length on their telomeres more rapidly.  For example, one study found that caregivers of people with Alzheimer’s disease not only had poorer immune function, but that their telomeres were shortening more rapidly.76  In other words, the stress of caring for an Alzheimer’s patient was permanently aging their cells.

Another study found that otherwise mentally and physically healthy adults who had a history of being mistreated as children had shorter telomeres.77  This suggests that it’s not always possible to “reverse” the damage stress causes to our cells and that stress at a young age may have life-long effects.

 

Women and Stress

Studies show that women and men cope with stress differently.78  The friendships and other social support systems that are more common in women may help them cope more effectively with stress, enhancing their immune response and resistance to diseases.79  Studies have shown that women with breast cancer who have strong social supports have significantly longer life spans than women who do not.80  Interestingly, researchers found that social support provided by women is more effective at lowering blood pressure responses to stress in both males and females than support from men.

On the negative side, scientists find that women are two times more likely to develop depression in reaction to the stress in their lives.81  Working women are often under considerable stress as they try to balance work, marriage, and children. Some experts have found that chronic stress can cause a chemical imbalance that can lead to depression.82  In addition, those who care for sick and elderly family members are usually women. Studies indicate that these caregivers have high cortisol levels and therefore weakened immune systems.83

 

What Causes Stress?

It is unclear how much of the stress response is determined genetically and how much can be controlled by the individual. Genetics play a part in determining someone’s stress response, as does an individual’s experience with stress and their learned perceptions of specific events or situations as stressful. So, the way we see ourselves and others, our methods of handling stress, and our genetic makeup all affect the immune system and therefore our health.Not everyone is the best judge of what reduces his or her own level of stress. For example, smokers depend on cigarettes to relax, but the nicotine in cigarettes does exactly the opposite. Watching TV may feel relaxing, but depending on the program and on how TV interferes with sleeping or other responsibilities, it may sometimes increase stress and decrease the ability to cope with stress.  Here are some tips you can try to help you deal with stress.

 

Tips to Reduce Stress

Experts indicate that there are many different ways to manage our levels of stress.  It is important to keep in mind that different strategies work for different people. You can try to manage stress levels by meditation, exercise, and doing things that you find relaxing.  The most effective stress-reduction measure for many people, however, is exercise. Physical exertion causes your body to release endorphins which can make you feel better while also boosting your immune system.

If you need something to help you reduce stress in the moment, try taking slow and deep breaths. Slow breathing has been shown to have a calming effect that can lower blood pressure, reduce muscle tension, and decrease heart rate.

Our eating habits can affect our immune systems’ response to stress. A balanced diet emphasizing fresh fruits, vegetables, legumes, raw nuts and seeds, and whole grains can help the body respond better to stress. Reducing caffeine can also help. Studies have found that blood pressure during stress is higher if caffeine has been consumed.84   This suggests that people who have a high intake of caffeine might experience more stress and produce more stress hormones.

Getting enough sleep is also important.  (To find out why you should get enough sleep, read here).  Many Americans get only 7 hours of sleep a night, but research indicates that most adults and children do better with 8-9 hours; in fact, most teens in a sleep lab sleep more than 9 hours each night if given the opportunity.  It can be a vicious cycle: lack of sleep can make an individual more susceptible to stress, and stress often interferes with the ability to sleep.

Researchers have also linked the inability to identify and express emotions to a number of health conditions.85  Expressing emotions to members of a support system or even writing down feelings can help.  Try talking to others, whether friends, family, a counselor, or a professional, if you are having trouble managing your stress.

 

Bottom Line

It’s worth making the effort to think through how stress affects your life.  If you’re aware of how physical and emotional stresses affect your body, you will be better prepared to cope with stressful situations, modify the way you react to them, feel better, and live longer. It is important to remember that often we can’t do it all on our own – in that case, try seeking help from a professional.

If you or someone you know needs immediate help, please contact the one of the following crisis hotlines:
-Disaster Distress Helpline: 1-800-985-5990
-National Suicide Prevention Lifeline: 1-800-273-TALK
-Youth Mental Health Line: 1-888-568-1112

For more information, we recommend Dr. Esther Sternberg’s book, The Balance Within: The Science Connecting Health and Emotions (Holt, Times Imprint).

Also, check out our Survival Guides for Working Moms for more tips and research based information about coping with stress.

Kids in Danger · Consumer Federation of America
Consumers Union · National Research Center for Women & Families

For Immediate Release
Friday, November 16, 2012

Chicago, IL — A coalition of consumer groups praised the Maryland Department of Health and Mental Hygiene and its Director Joshua Sharfstein for announcing a ban on the sale of crib bumper pads, effective June 21, 2013.

The decision followed a more than year-long investigation by the Maryland Department examining the safety of crib bumper pads. The department conducted its own review of evidence, convened a panel of health experts, held two public meetings, and reviewed public comment. The department concluded that the risks crib bumper pads pose towards infants far outweigh any potential benefits.

Maryland becomes the first state in the nation to ban the sale of crib bumper pads. Chicago, Illinois adopted a ban that became effective in April 2012. In addition, most states already prohibit the use of the product in licensed child care facilities.
The groups — Consumer Federation of America, Consumers Union, National Research Center for Women & Families and Kids in Danger — hailed the act as a major step forward in protecting infants.

“Our organization has been working with families whose children suffocated on this unnecessary crib decoration,” stated Nancy Cowles executive director of Kids In Danger. “We applaud Director Sharfstein and his department for their thorough study of the issue and courage in taking the lead on this safety issue.”

Consumer, safety and health care organizations all agree that a baby sleeps safest alone, on their back in a bare crib that meets current safety standards. Adding soft padding to that environment in the form of pillow, bumper pads or comforters increases the risk of suffocation or entrapment. The American Academy of Pediatrics recently updated their safe sleep guidelines to warn against the use of bumper pads.

“While standards might be appropriate to address the safety of many products, for this unnecessary decorative item which poses danger to infants, Maryland’s action to ban the product will be more effective,” stated Rachel Weintraub, Legislative Director and Senior Counsel of the Consumer Federation of America. “The regulation gives the department the ability to move to a standard if one is developed that is as protective of safety as the ban.”

The regulation defines baby bumper pads as “a pad or pads of non-mesh material resting directly above the mattress in a crib, running the circumference of the crib or along any of the interior sides of the crib, and intended to be used until the age that an infant pulls to stand.” The ban does not apply to vertical bumpers that wrap tightly around each individual crib rail or to mesh crib liners. The Department nonetheless does not recommend the use of these or other novel products.

“This ban will save lives and serve as a model for other states,” added Diana Zuckerman, President of the National Research Center for Women & Families. “As a Maryland resident, mother, and president of a nonprofit group that is dedicated to improving the health and safety of kids and adults, this decision makes me very happy.”

“Action on the state level has historically been effective in addressing emerging hazards and bringing them to the general public’s attention,” concluded Ami Gadhia, Senior Policy Counsel of Consumers Union, the policy arm of Consumer Reports. “We urge CPSC to consider national action against this suffocation hazard.”

Dr. Diana Zuckerman

November 14, 2012

The FDA law is supposed to make sure that all medical products sold in the U.S. are safe and effective.  Unfortunately, it doesn’t.

There are several giant loopholes in the law, including loopholes for compounding pharmacies, as well as companies that call themselves compounding pharmacies but aren’t.  That loophole is enormous, and that’s why hundreds of people are now sick with fungal meningitis and so many have died.

And that’s just the tip of the iceberg, because thousands of people got medications that are not proven safe and not proven effective.   And I’m not just talking about the injections that harmed Jerry, which we heard about today.  There have been many other examples of unsafe medical drugs sold through compounding pharmacies, including cancer drugs that were either weaker or stronger than they should have been.

There’s enough blame to go around, but I don’t want to play the blame game today.  Obviously, a major part of the blame is on the compounding pharmacies that didn’t care enough about patients to make sure the products they were making were safe.  This includes the specific pharmacies in Massachusetts that have been identified, but also includes many other compounding pharmacies.  We also have to wonder about the state and FDA inspectors and officials who knew that there were serious, life-threatening problems but didn’t do enough to fix them, and the doctors who ordered products from compounding pharmacies without considering safety issues.

The innocent victims are the patients who trusted their doctors and the FDA to make sure their medications are safe.  The costs to them are enormous, but the human costs and the financial costs.

This VALID Compounding Act is designed to close the loopholes that are so harmful to patients.  It is a well thought out, comprehensive, and balanced bill, and I congratulate Rep. Markey and his staff on the bill and on their excellent report.

The FDA will do a much better job of enforcement if the law is improved.  The FDA’s hands have been tied — they haven’t been able to get the information they needed to fully investigate.  FDA’s resources are very limited, so the agency tends to focus on the slam dunks, not the efforts that are less likely to be successful.

This law will save lives.  It will save a lot of lives if it isn’t watered down by those who care more about protecting companies than protecting people.  We heard a lot of opposition to safety regulations this past year in the House of Representatives, based on claims that safety regulations kill jobs.  Let’s remember that having more inspectors and requiring research evidence of safety will create jobs.  Personally, I’d rather make new jobs for inspectors and researchers, than jobs for people making unsafe medical products.  This law will make new jobs and it will save lives and healthcare dollars, a great combination.

In closing, I want to point out that the history of the FDA is a history of disasters followed by improvements in the law.  The Food, Drug, and Cosmetic Act passed in 1938 after 107 people died, mostly women and children, from taking an elixir made with an antifreeze that was added to improve the color.  That law was greatly strengthened in 1962, after the Thalidomide tragedy caused thousands of babies to be born without terribly deformed arms, legs, fingers, and toes, and in some cases no arms or legs. And, medical devices – even implanted ones – were not regulated until 1976, after many women died or became infertile from the Dalkon Shield IUD.

This is the latest tragedy, and it is an important opportunity to prevent similar tragedies in the future.  That’s why it is essential to act now.  It is not a partisan issue, and we look forward to working with Congress to act quickly.

By Morgan Wharton and Jessica COte, BS

Updated January 2015

 

latte-249102_640Most Americans drink coffee every day.86 The most widely known benefits and risks have to do with caffeine, which helps us stay alert but also may cause jitteriness and interfere with sleeping. A few studies have suggested that decaffeinated coffee also has a positive impact on health, perhaps because of other ingredients in the coffee bean such as natural antioxidants (which fight cellular damage) and acids.87

What are the health benefits of drinking coffee?

For years medical experts advised people to drink less coffee, mostly because of research suggesting coffee might increase the risk of heart disease. However, numerous studies conducted recently have discovered coffee’s unexpected health benefits. Like all well-designed research, most of these studies took into account factors that could affect the results such as age, sex, body mass index (BMI), physical activity, smoking status, and family cancer history. By controlling for those factors, researchers made sure they could separate coffee’s impact on health from the effects of people’s lifestyle and previous health problems.

Colorectal Cancer

Meta-analyses combine data from several comparable studies to make one very large study. These results are usually more accurate than any one study can be. Taken together, three meta-analyses suggest that drinking about four or more cups of coffee per day may reduce the chances of getting colorectal cancer by 11-24%.888990

Endometrial (Uterine) Cancer

Using data from 67,470 women who participated in the Nurses’ Health Study, researchers found that women who drank four or more cups of coffee per day had a 25% lower risk of endometrial cancer than women who drank only one cup of coffee per day. Compared to women who did not drink any coffee, those who drank four cups or more per day were 30% less likely to develop endometrial cancer. Decaffeinated coffee was just as effective as caffeinated coffee, but caffeinated tea did not lower the risk of endometrial cancer.91

Liver Cancer And Cirrhosis (Scarring of the Liver/Chronic Liver Disease)

One study found that the risk of the most common type of liver cancer was reduced by drinking coffee. People who drank only one or two cups of coffee per day had a slightly lower risk of getting the disease compared to non-drinkers, but people who drank three or four cups of coffee were about half as likely as non-drinkers to get this kind of liver cancer. Meanwhile, people who drank five or more cups per day had an even lower risk than that (about one-third the risk of non-drinkers).92

Similarly, a study in Japan found a 76% decrease in the risk of that type of liver cancer in people who drank at least five cups of coffee per day compared to those who did not drink coffee. The strongest benefit was seen in individuals with hepatitis C, a disease which increases a person’s risk of developing liver cancer, although the researchers were not sure why.93

A study of 120,000 Americans over an 8-year period found a 22% reduction in the risk of cirrhosis per cup of coffee per day. In Norway, a 17-year study of 51,000 citizens found that those who drank two or more cups of coffee per day were 40% less likely to develop cirrhosis compared to those who did not consume coffee.94

Skin Cancer

Using data from two enormous studies, the Nurses’ Health Study and the Health Professionals Follow-up Study, researchers found that men and women who drank more than three cups of caffeinated coffee per month had a 17% lower risk of getting basal cell carcinoma compared to people who drank less than one cup per month. Basal cell carcinoma is the most common and least dangerous type of skin cancer. Decaffeinated coffee was not associated with higher or lower basal cell carcinoma.95

A 2014 study in the Journal of the National Cancer Institute found that the more coffee participants drank, the less likely they were to develop malignant melanoma over a 10 year period. Close to 450,000 non-Hispanic whites, aged 50-71, participated in the study. Researchers found that drinking four or more cups of coffee per day was linked to a 20% lower risk of getting malignant melanoma. Once again, drinkers of decaffeinated coffee lost out. Their risk of getting melanoma was no different from that of non-coffee drinkers. Coffee drinking, however, had no influence  on risk of melanoma in situ (the least dangerous form of melanoma). Remember that no matter how much coffee with caffeine you drink, the best way to prevent skin cancer is still to limit your time exposed to the sun and ultraviolet light! 96

Type 2 Diabetes Mellitus

People in Finland consume more coffee than almost any other nation, and a study of 14,000 people over 12 years  found that men who drank 10 or more cups of coffee daily had a 55% lower risk of developing type 2 diabetes mellitus than men who drank 2 cups of coffee a day or fewer.  Even more dramatic, women who drank 10 or more cups per day had a 79% lower risk of developing type 2 diabetes than those who drank fewer than 2 cups daily.97

A different Finnish study of 5,000 sets of identical twins found that individuals who drank more than seven cups of coffee per day had a 35% lower risk of type 2 diabetes than their twins who drank two cups or fewer per day.98 Because identical twins are so biologically similar, the difference in disease risk can more confidently be attributed to coffee consumption levels. Studies of fewer people in other countries have found less dramatic but similarly positive results.

Parkinson’s Disease

A study of more than 8,000 Japanese-American men found that men who did not drink coffee at all were three to five times more likely to develop Parkinson’s disease within 30 years than men who drank four and a half cups or more of coffee per day.99

Suicide

Because suicide may be related to alcohol intake, medications, and stress levels, suicide studies took those factors into account.  A 10-year study of 128,000 people in California found that the risk of suicide decreased by 13% for every additional cup of coffee consumed per day. Even one cup of coffee per day seemed to reduce the risk of suicide. A different 10-year study of 86,000 women found a 50% lower risk of suicide for those who drank two or more cups of coffee per day compared to women who did not drink coffee.100

Brain Power and Aging

A study of 676 healthy men born between 1900 and 1920 suggested that coffee helped with information processing and slowed the cognitive decline associated with aging. Cognitive functioning was measured by the Mini-Mental State Examination, a 30 point scale. Men who regularly consumed coffee experienced an average decline of 1.2 points over 10 years, whereas men who did not drink coffee saw a decline of 2.6 points over 10 years. The greatest benefit occurred in men who drank three cups of coffee per day-their cognitive decline was only 0.6 points over 10 years.101

Even old mice are sharper with caffeine: a study using a mouse model of Alzheimer’s disease showed that coffee actually reversed the cognitive decline and slow-down in processing that occurred with age. Mice given caffeine in their water showed signs of recovering their memory during testing.102

 

What about the Risks?

 

Childbearing

Two separate studies found that 300 mg of caffeine (two to three cups of coffee) decreased a woman’s chances of getting pregnant by more than a third. This same amount of coffee also increased the risk of women having low birth-weight babies by 50%. These studies took into account additional factors such as contraception used in the past and infertility history.103

Hip Fracture

According to data from the Nurses’ Health Study, women aged 65 and over who drank more than four cups of coffee per day experienced an increased risk of hip fracture over the next six years-approximately three times the risk of women who did not drink coffee. Researchers took important factors into consideration such as calcium intake.104

Parkinson’s Disease Among Post-Menopausal Women Taking Estrogen-Only Hormone Therapy

Other researchers used data from the Nurses’ Health Study to evaluate the risk of Parkinson’s disease among women who drank coffee while using estrogen after menopause. For women who were NOT using estrogen therapy, those who drank four or more cups of coffee per day were about half as likely to develop Parkinson’s disease as women who did not drink coffee. For women who DID use post-menopausal estrogen, however, those who drank four or more cups of coffee were about twice as likely as those who didn’t drink coffee to develop Parkinson’s.105

Heart Disease

Two different meta-analyses found that people who drank five or more cups of coffee per day had a 40-60% increased risk of developing heart disease compared to those who did not drink coffee at all. Other studies have also shown that high coffee use (five to ten cups per day) increases the risk of heart disease, while moderate consumption (three to four cups daily) was not associated with a higher risk. Only coffee drinkers who consumed more than nine cups a day had a greater risk of dying from heart disease.106 It is important to consider that  people drinking close to 10 cups of coffee a day are likely to have other health problems, such as stress or sleep deprivation, and this could contribute to higher risk of heart disease and death regardless of coffee use.

 

 

The Bottom Line

For most people, drinking coffee seems to improve health more than harm it. Many of coffee’s health benefits increase with the number of cups per day, but even one cup a day lowers the risk of several diseases. However, women who want to get pregnant or already are pregnant and women over 65 should probably limit their coffee intake because, in their case, the risks may outweigh the health benefits.

Even though numerous studies show coffee to be beneficial, it’s still not clear why. How can one popular beverage help metabolism (for example, lowering the risk of type 2 diabetes) and also protect against a range of cancers? Until further research can solve that puzzle, most adults should continue to enjoy their cup (or two, or three) of Joe. Finally, remember that nearly all studies on coffee and health have been done on adults. Coffee may affect children and teens differently.