Women

Stress

The Effects of Stress on Your Body

Stress is the body's reaction to any change that requires an adjustment or response. The body reacts to these changes with physical, mental, and emotional responses.
Stress is a normal part of life. Many events that happen to you and around you -- and many things that you do yourself -- put stress on your body. You can experience stress from your environment, your body, and your thoughts.

How does stress affect health?

The human body is designed to experience stress and react to it. Stress can be positive, keeping us alert and ready to avoid danger. Stress becomes negative when a person faces continuous challenges without relief or relaxation between challenges. As a result, the person becomes overworked, and stress-related tension builds.

Stress that continues without relief can lead to a condition called distress -- a negative stress reaction. Distress can disturb the body's internal balance or equilibrium -- leading to physical symptoms including headaches, upset stomach, elevated blood pressure, chest pain, and problems sleeping. Research suggests that stress also can bring on or worsen certain symptoms or diseases.

Stress also becomes harmful when people use alcohol, tobacco, or drugs to try to relieve their stress. Unfortunately, instead of relieving the stress and returning the body to a relaxed state, these substances tend to keep the body in a stressed state and cause more problems. Consider the following facts:

Forty-three percent of all adults suffer adverse health effects from stress.
Seventy-five to 90% of all doctor's office visits are for stress-related ailments and complaints.
Stress is linked to six of the leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide.

The Occupational Safety and Health Administration (OSHA) declared stress a hazard of the workplace. In terms of lost hours due to absenteeism, reduced productivity and workers' compensation benefits, stress costs American industry more than $300 billion annually.
The lifetime prevalence of an emotional disorder is more than 50%, often due to chronic, untreated stress reactions.

Physical Warning Signs

Chronic stress can wear down the body's natural defenses, leading to a variety of physical symptoms, including the following:
Dizziness or a general feeling of "being out of it"
General aches and pains
Grinding teeth, clenched jaw
Headaches
Indigestion
Increase in or loss of appetite
Muscle tension in neck, face or shoulders
Problems sleeping
Racing heart
Cold and sweaty palms
Tiredness, exhaustion
Trembling/shaking
Weight gain or loss
Upset stomach
Sexual difficulties

Tips for Reducing Stress

If you are one of the millions of stressed-out Americans, there's good news. People can learn to manage stress. Start with these tips:
Keep a positive attitude.
Accept that there are events that you cannot control.
Be assertive instead of aggressive. "Assert" your feelings, opinions, or beliefs instead of becoming angry, defensive, or passive.
Learn and practice relaxation techniques..
Exercise regularly. Your body can fight stress better when it is fit.
Eat healthy, well-balanced meals.
Get enough rest and sleep. Your body needs time to recover from stressful events.
Don't rely on alcohol or drugs to reduce stress.
Seek out social support.
Learn to manage your time more effectively.

By Laura Lane
WebMD Feature

Reviewed By Louise Chang, MD

SOURCES: Institute of Medicine Dietary Reference Intakes Tables. Jeffrey Blumberg, PhD, professor of nutrition, Tufts University School of Nutrition, Science and Policy. Lisa Scott, clinical nutritionist, UCSF Mount Zion Medical Center.

Published Feb. 19, 2003.

Medically updated Dec. 13, 2005.

Supplements to Boost Your Health

Many older adults benefit from these five nutritional supplements.

Doctors instruct people 65 years and older to get flu shots, eat a high-fiber diet and do strengthening exercises to stay healthy.

But of all the things older people can do, taking nutritional supplements ranks as one of the easiest, says Jeffrey Blumberg, PhD, professor of nutrition at Tufts University School of Nutrition, Science and Policy.

"It's one thing you can do that's not too hard to do," he says.

That's important, since seniors need to do what they can to protect themselves from heart disease and cancer, the two leading causes of death among people 65 years and older, according to the National Center for Health Statistics.

Nutritional supplements not only help decrease the risk of certain diseases, but they also fill up what's missing in a typical elderly person's diet. It usually doesn't have a sufficient number of calories to cover the essential nutrients, says Blumberg. Older people tend to have a smaller appetite and usually eat only about 1,200 calories of food. Compare that with the 2,000 calories required to follow the food pyramid -- a recommended diet that includes a healthful balance of foods -- and the need for supplements is clear.

Vitamin B-12

The supplement that nutritionists have been promoting most recently is vitamin B-12, which in food depends on stomach acid to be absorbed. However, recent studies have shown that 10% to 30% of people 51 years and older have lower amounts of stomach acid and therefore can't absorb much of the vitamin.

But in supplement form, the vitamin doesn't rely on stomach acid, making supplements a good way to make up for the lack. Otherwise, people who don't get enough of the vitamin can suffer from anemia, other blood-cell disorders, and neurological disorders including memory loss and changes in gait.

Nutritionists recommend that all adults get at least 2.4 micrograms per day of vitamin B-12, which is found mostly in meats. People 51 years of age or older should get most of the vitamin from supplements or fortified cereals.

Folate

The B vitamin folate reduces levels of homocysteine, a molecule that is a risk factor for cardiovascular disease and stroke. Blumberg recommends that elderly people take 400 micrograms per day to supplement the amount of folate they may get from their diet.

Folate is found in dark green, yellow and orange fruits and vegetables, beans, nuts, seeds and fortified grain products such as pasta and flour. Foods with a high concentration of folate include spinach, orange juice, and lentils.

Vitamin E

Research studies show conflicting evidence that vitamin E reduces the risk of heart disease, cancer, and other conditions. Vitamin E is found in fatty foods such as nuts and oils.

People 14 years and older should take 15 mg per day, according to the Food and Nutrition Board, the organization that determines "RDAs."

Calcium and Vitamin D

Finally, elderly people need to keep their bones strong by supplementing their diet with calcium and vitamin D. The pair work hand in hand to prevent bones from thinning, which can lead to devastating fractures.

Many older people lack enough calcium in their diets because they can't digest dairy foods, the primary source for calcium, says Lisa Scott, a clinical nutritionist at UCSF Mount Zion Medical Center who works with elderly patients. And meeting the daily requirement of 1,200 milligrams of calcium through other foods, such as broccoli, simply doesn't happen.

For patients who don't eat any dairy products or calcium-fortified orange juice, she recommends they get the full 1,200 milligrams from supplements. Supplements made from calcium carbonate or calcium citrate are best.

With the sun's help, the skin produces the body's main source of vitamin D. But as skin ages, its ability to produce vitamin D decreases. At the same time, elderly people tend to stay out of the sun, making a deficiency all the more probable. The Food and Nutrition Board recommends that people 51 years or older receive 10 to 15 micrograms of vitamin D each day. Taking supplements is a good way to meet the daily requirement.

Still, however convenient supplements may be, they shouldn't take the place of eating a well-balanced diet, Blumberg says.

"It's important to recognize that dietary supplements are not dietary substitutes," he says. Taking supplements is "just another healthy thing you can do for yourself."

Osteoporosis

What Increases Your Risk

The risk of osteoporosis increases with age as bones naturally become thinner. After age 30, the rate at which your bone dissolves and is absorbed by the body slowly increases, while the rate of bone building decreases. Both men and women lose a small amount (approximately 0.4%) of bone each year after age 30.1

In women, more rapid bone loss usually begins after monthly menstrual periods stop, when a woman's production of the hormone estrogen slows down (usually between the ages of 45 and 55). A man's bone thinning starts to develop gradually when production of the hormone testosterone slows down, at about 45 to 50 years of age. Women typically have smaller and lighter bones than men. As a result, women develop osteoporosis almost 4 times more often than men.2 Osteoporosis usually does not have an effect on people until they are 60 or older.

Whether a person develops osteoporosis depends on the thickness of the bones (bone density) in early life, as well as health, diet, and physical activity later in life. Factors that increase the risk of osteoporosis in both men and women include:

Having a family history of osteoporosis. If your mother, father, or a sibling has been diagnosed with osteoporosis or has experienced broken bones from a minor injury, you are more likely to develop osteoporosis.
Lifestyle factors. These include:
- Smoking. People who smoke lose bone thickness faster than nonsmokers.
- Alcohol use. Heavy alcohol use can decrease bone growth and increase the risk of falling. However, moderate alcohol use is linked to higher bone thickness. Most doctors recommend limiting, but not eliminating, alcohol use.
- Getting little or no exercise. Weight-bearing exercises—such as walking, jogging, stair climbing, dancing, or lifting weights—keep bones strong and healthy by working the muscles and bones against gravity. Exercise may improve your balance and decrease your risk of falling.
- Being small-framed or thin. People with small frames are more likely to develop osteoporosis because they have smaller bones and less bone mass. Thin people are more likely to develop osteoporosis because they have less body fat. Fat cells make estrogen, which may protect women from bone loss after menopause.
- However, being overweight puts a woman at risk for other serious medical conditions, including type 2 diabetes, high blood pressure, and coronary artery disease (CAD).
- A diet low in foods containing calcium, phosphorus, and vitamin D.
- Cola soft drinks. A recent study showed a link between women's low bone thickness and drinking 3 or more servings of cola per day. A typical can of cola contains 44 to 62 mg of phosphoric acid, which can interfere with bone absorption of calcium.
Having certain medical conditions, such as hyperthyroidism or rheumatoid arthritis, that put you at greater risk for osteoporosis.
Taking certain medications. Several medications cause bone thinning, such as:
- Corticosteroids, used to treat conditions such as asthma and chronic obstructive pulmonary disease (COPD). If used for a period of 6 months or longer, corticosteroids can lead to steroid-induced osteoporosis.8
- Medications used to treat endometriosis.
- Aromatase inhibitors, used to treat breast cancer.
- Thyroid replacement medication, if the dose is more than the body needs. This should be monitored by checking the level of thyroid stimulating hormone (TSH) every year.
- Depo-Provera, a birth control medication given by injection. Longtime use may thin bones.
- Antacids that contain aluminum, if they are overused. Aluminum-containing antacids remove phosphorus and calcium from your body.

Other risk factors for osteoporosis may include:

Being of European and Asian ancestry, the people most likely to have osteoporosis.
People of African ancestry are least likely.
Being inactive or bedridden for long periods of time.
Dieting excessively or having an eating disorder, such as anorexia nervosa.
Being a female athlete, if you have few or irregular menstrual cycles due to low body fat.

Women who have completed menopause have the greatest risk of osteoporosis, because their levels of the estrogen hormone drop. Estrogen protects women from bone loss. Likewise, women who no longer have menstrual periods—either because their ovaries are not working properly, or because their ovaries have been surgically removed—also can have decreased estrogen levels.

Some studies report that excessive vitamin A may be linked to low bone mass and increased hip fractures, although the evidence is not conclusive. The recommended daily allowance of vitamin A is 700 ug (2330 IU) for adult women or 900 ug (3000) IU) for adult men.

When To Call a Doctor

Call your health professional immediately if you:

Think you have a broken bone, notice a deformity after a fall, or cannot move a part of your body.
Have sudden, severe pain when bearing weight.

Call your health professional for an appointment if you:

Want to discuss your risk of developing osteoporosis.
Have symptoms of menopause or have completed menopause and want to discuss whether you should take medication to prevent osteoporosis.
Have been treated for a fracture caused by a minor injury, such as a simple fall, and want to discuss your risk of developing osteoporosis.
If you are nearing age 65, have osteopenia, or think that you are at high risk for osteoporosis, talk with your health professional about your concerns.

Watchful Waiting

If you do not have any risk factors for osteoporosis and you are already taking preventive measures, such as taking adequate calcium and vitamin D, you may only need routine screening.

Who To See

Health professionals who can evaluate your symptoms and risk of osteoporosis include:

Nurse practitioners.
Physician assistants.
Family medicine doctors.
Internists.
Rheumatologists.
Endocrinologists.
Gynecologists.

Exams and Tests

A diagnosis of osteoporosis is based on your medical history, physical examination, and a test to measure your bone thickness (density). During a physical exam, your health professional will:

Measure your height and compare the results with past measurements.
Examine your body for evidence of previous broken bones, such as changes in the shape of your long bones and spine.

A bone mineral density test measures the mineral density (such as calcium) in your bones using a special X-ray, computed tomography (CT) scan, or ultrasound. From this information, your health professional can estimate the strength of your bones. See an illustration of a bone mineral density test.

Routine urine and blood tests can rule out other medical conditions, such as hyperthyroidism or Cushing's syndrome, that can cause bone loss. In men, blood tests to measure testosterone levels can see whether low levels are causing bone loss.

If you have been diagnosed with osteoporosis, you may need to follow up regularly with your health professional to monitor your condition.

Early Detection

If you or your health professional thinks you may be at risk for developing osteoporosis, you may have a screening test to check your bone thickness. A screening test may be advisable if you have:

A fracture in a minor injury that may have been caused by osteoporosis.
Another medical condition that is known to cause bone thinning.
Risk factors for or symptoms that suggest osteoporosis.

The United States Preventive Services Task Force recommends that all women age 65 and older routinely have a bone mineral density test to screen for osteoporosis. If you are at increased risk for fractures caused by osteoporosis, routine screening should begin at age 60.

Most experts recommend that the decision to screen women age 60 and younger be made on an individual basis, depending on the risk of developing osteoporosis and whether the test results will help with treatment decisions.

Treatment Overview

The process of bone thinning (osteoporosis) is a natural part of aging. However, if you receive treatment early, you may be able to stop or slow the progress of bone loss. Treatment is important to:

Prevent broken bones.
Maintain or increase your bone thickness.
Relieve pain caused by fractures and changes to bones.
Maintain your ability to function physically.

Treatment for osteoporosis includes eating a diet rich in calcium and vitamin D, getting regular exercise, and taking medication to reduce bone loss and increase bone thickness. It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. Even small changes in diet, exercise, and medication can help prevent spine and hip fractures. Adults who adopt healthy habits can slow the progress of osteoporosis.

Initial treatment

If you have been diagnosed with osteoporosis, your health professional probably will recommend lifestyle and diet changes. Eat foods rich in calcium, vitamin D, and phosphorus, all necessary for maintaining healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day.

The recommended minimum intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%.

Research shows that taking calcium plus vitamin D significantly reduces the incidence of hip and other fractures in postmenopausal women.

Exercises, including weight-bearing exercise (walking, jogging, stair climbing, dancing, or lifting weights), aerobics, and resistance exercises are all effective in increasing bone mineral density and strength of the spine in postmenopausal women. Start out at an exercise level that you are comfortable with and work up gradually. To be most effective, weight-bearing exercises should be done for 45 to 60 minutes at least 4 days a week. If you stop exercising, your bones weaken and may be more likely to break. Walking also increases bone mineral density of the hip.

Along with exercise and diet, your health professional will recommend that you not smoke and limit alcohol to one drink per day.

In some cases, medications are prescribed to protect against bone loss. These medications include bisphosphonates, such as risedronate (Actonel), alendronate (Fosamax), or raloxifene (Evista). It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis.

If you take corticosteroids longer than 6 months for asthma or other conditions, you may be at greater risk for developing steroid-induced osteoporosis. If you begin to have bone loss, you may need to take osteoporosis medications, such as bisphosphonates, while you are taking steroids.

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.14, 15 Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.

Ongoing treatment

Once you have been diagnosed with bone loss, whether it is mild or severe, you will need to have regular follow-up tests to monitor the disease. Osteoporosis is a progressive disease; both men and women lose approximately 0.4% of bone each year after age 30.1 It is never too late to develop and then maintain healthy habits that can slow progression of the disease.

Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%.
Get regular exercise. Weight-bearing exercises such as walking, jogging, stair climbing, dancing, or lifting weights keep bones healthy by working the muscles and bones against gravity.

When you have osteoporosis, it is especially important to protect yourself from falling. When bones lose mass and become more porous, they lose strength and break more easily. Women of European and Asian ancestry are more likely to have osteoporosis than those with African ancestry.1 An estimated 17% of white women will break a hip sometime after age 50, as will 6% of white men.4 To reduce your chances of breaking bones, take steps to prevent falls, such as having your vision and hearing checked regularly and wearing slippers or shoes with a nonskid sole. Exercises that improve balance and coordination, such as Tai Chi, can also reduce your risk of falling.

If your tests indicate continuing bone loss, your health professional probably will recommend that you take medication to increase bone density and decrease your risk of spine and hip fractures. These medications include bisphosphonates, such as risedronate (Actonel) or alendronate (Fosamax). It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis.

Calcitonin may be prescribed for women who are more than 5 years beyond menopause and who cannot take bisphosphonate medications, or for men who are not receiving testosterone treatment. Calcitonin has the added advantage of helping reduce pain from spinal fractures. However, studies show that calcitonin is less effective than bisphosphonate medications at stopping bone loss.

Raloxifene (Evista) may be prescribed for women, especially if you are 55 to 65 years old. Raloxifene has been proven to reduce the risk of spinal fractures, but not hip fractures.18 Raloxifene may also reduce the risk of breast cancer, although it is not approved for this purpose. Raloxifene can cause hot flashes, so it is not often used in early menopause (45 to 55 years) when hot flashes are frequent.

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.14, 15 Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.

Treatment if the condition gets worse

It is never too late to develop and then maintain healthy habits that can slow bone thinning.

Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%.
Get regular exercise. Weight-bearing exercises, such as walking, jogging, stair climbing, dancing, or lifting weights, keep bones healthy by working the muscles and bones against gravity.

Medications called bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel), may be used to slow the rate of bone loss and increase bone thickness and strength. This will reduce the risk of broken bones.

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.14, 15 Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.16, 17

If your osteoporosis is severe or you continue to have bone loss while taking a bisphosphonate:

You may need to take both a bisphosphonate medication and hormone therapy. Studies show that taking both medications results in increased bone mass when compared to taking either alone.19, 20
Your health professional may prescribe teriparatide (Forteo). Forteo has been shown to slow bone loss and increase the rate of new bone growth.21 However, Forteo is expensive and requires daily self-injectio

It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis.

Compression fractures resulting from osteoporosis can cause significant back pain that lasts for several months. Treatments available to relieve your pain include:

Nonprescription nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin.
Nonprescription acetaminophen (such as Tylenol, Panadol, or Tempra).
A pain reliever such as a narcotic, which may be prescribed on a short-term basis.
Other medicines such as calcitonin (Calcimar or Miacalcin) to help decrease pain from spinal fractures.
A back brace or corset to slow curvature of the spine.

One of two surgical treatments, vertebroplasty or kyphoplasty, may relieve persistent pain from spinal compression fractures. In these procedures, a surgeon injects bone cement into the crushed spinal bones (vertebrae) through a needle. Both treatments are considered experimental.

If you experience a fractured bone related to osteoporosis, treatment to slow your bone thinning becomes very important. A recent study reports that many people older than 65 who have had fractures do not receive treatment to strengthen their bones and do not have follow-up bone density tests.3 Men and women who experience a spinal fracture have twice the risk of having subsequent spinal fractures as do people of the same age who have not had a fracture.

What to think about

Although HRT and ERT have been used to prevent or slow bone loss, currently they are not recommended for women as the first choice for prevention or treatment of osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.14, 15 Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.16, 17 To learn more about the study, see WHI: Risks and benefits of taking HRT or ERT.

Because taking estrogen alone increases the risk of developing cancer of the lining of the uterus (endometrial cancer), ERT is only used if a woman has had her uterus removed.

Researchers are studying the effects of low-dose estrogen on women 65 and older. An early small study indicates that a low estrogen dose (one-quarter that of conventional ERT) may provide the same benefit—increased bone density and decreased fractures—as the higher dose. In the same study, about one-third of the women were given the low estrogen dose and progesterone (because these women had not had hysterectomies). This group of women also experienced increased bone density. However, the long-term risks of taking low-dose estrogen (and progesterone in one-third of the cases) were not studied and are unclear.22

It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis.

Prevention

After the age of about 30, bone thinning is a natural process and cannot be stopped completely. Whether you develop osteoporosis depends on the thickness of your bones early in life, as well as your health, diet, and physical activity later in life. The thicker your bones, the less likely the bones are to become thin enough to break. Young women in particular need to be aware of their risk for developing osteoporosis and take steps early to slow its progress and prevent complications. Plentiful physical activity during the preteen and teen years increases bone mass and greatly reduces the risk of osteoporosis in adulthood. If you eat a diet adequate in calcium and vitamin D and exercise regularly early in life and then continue with these healthy habits, you may be able to delay or avoid osteoporosis.

Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. The best source of vitamin D is exposure to sunlight. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%.11 If you are not getting enough calcium and vitamin D in your diet, take supplements.
Get regular exercise. Weight-bearing exercises, such as walking, jogging, stair climbing, dancing, or lifting weights, keep bones healthy by working the muscles and bones against gravity.
Don't drink more than one alcoholic drink per day. Drinking more than this puts you at higher risk for osteoporosis.

Don't smoke. Smoking puts you at a higher risk for developing osteoporosis and increases the rate of boneOnce osteoporosis develops, getting enough calcium and vitamin D, along with other healthy habits, can slow the process and reduce the chances of bones breaking. It's common for a person's diet to supply only half the calcium the bones need, so you probably need to take supplements. Studies show that taking calcium plus vitamin D significantly reduces hip fractures and other fractures in women who have gone through menopause.1Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%. thinning once it starts.

Home Treatment

Most adults with osteoporosis need to take medication to slow bone loss. In addition to medication, there is much you can do to help slow the process and prevent broken bones:10

Get enough calcium. This is one of the first and then ongoing steps in trying to prevent and treat osteoporosis. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day. Calcium is found in many foods, including dairy products such as milk or yogurt. If you think you may not be getting enough calcium in your diet, take calcium supplements.23 Most Americans get only half the calcium they need from their diet. Studies have shown that taking calcium plus vitamin D significantly reduces the incidence of hip fractures and other fractures in women who have gone through menopause. Vitamin D helps your body absorb calcium; taking calcium without vitamin D is probably not beneficial.
Get enough vitamin D. Getting enough vitamin D, along with sufficient calcium, is one of the first steps toward preventing or reducing the effects of osteoporosis. Vitamin D helps your body absorb calcium. The recommended daily intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. One glass of milk [8 fl oz(0.2 L)] has about 100 IU. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk of falling by 22%.11 Usually 10 to 15 minutes' sun exposure a day is enough to satisfy the body's vitamin D requirement, although as you age, your ability to make vitamin D through the skin decreases. People who stay indoors, older adults, and people who live in areas where the winters are long may not get enough vitamin D and probably should take vitamin D supplements. Many calcium supplements also include vitamin D.
If you are taking medications to treat osteoporosis, also take calcium and vitamin D supplements.
Exercise. Recent studies show that weight-bearing exercises (walking, jogging, stair climbing, dancing, or lifting weights), aerobics, and resistance exercises (using weights or elastic bands to help improve muscle strength) are all effective in increasing the bone mineral density and strength of the spine in postmenopausal women. Walking also increases bone mineral density of the hip.13 Regular exercise throughout life halves the numbers of hip fractures experienced by older people.24 Develop an exercise program that fits your lifestyle and is easy to follow. For more information, see the topic Fitness.
Eat a nutritional diet to keep your body healthy. For more information, see the topic Healthy Eating.
Take steps to prevent falls that might result in broken bones. Have your vision and hearing checked regularly, and wear slippers or shoes with a nonskid sole. Exercises that improve balance and coordination, such as Tai Chi, can also reduce your risk of falling.
Limit alcohol use. Heavy alcohol use can decrease bone formation, and it clearly increases the risk of falling. However, some studies show moderate alcohol use is linked to higher bone density. At this point, most health professionals recommend limiting, but not eliminating, alcohol use as part of treatment for osteoporosis.5
Stop smoking. Smoking reduces your bone density and speeds up the rate of bone loss. For information on how to stop, see the topic Quitting Tobacco Use.

Experts recommend that you choose calcium supplements that are known brand names with proven reliability. Most brand-name calcium products are absorbed easily by the body. The U.S. Food and Drug Administration (FDA) has recently taken action against companies that tout the benefits of coral calcium as a superior source of calcium and a cure for disease. There is no scientific evidence to support these claims.

Author Kerry V. Cooke
Editor Kathleen M. Ariss, MS
Associate Editor Michele Cronen
Primary Medical Reviewer Joy Melnikow, MD, MPH
- Family Medicine
Specialist Medical Reviewer Carla J. Herman, MD, MPH
- Internal Medicine
Last Updated January 27, 2005

Calcium

Bone thinning occurs as part of the natural process of aging. If the thinning continues to the point that your bones become fragile and in danger of breaking, you have osteoporosis. However, osteoporosis is considered a preventable disease.

Key points

After age 30, men and women naturally begin to lose bone mass. You can slow bone loss and possibly prevent osteoporosis by eating a diet rich in calcium and vitamin D.
Getting enough calcium and vitamin D is especially critical for women in the first few years after menopause, when bone mass is lost more rapidly.
Most Americans get only half the calcium they need from their diet. If you do not get enough calcium from the foods you eat, take calcium and vitamin D supplements. The body needs vitamin D to absorb calcium.
If you are diagnosed with osteoporosis, you should take calcium and vitamin D supplements in addition to any other medication prescribed by your doctor.
Calcium is found in many foods, including dairy products such as milk or yogurt, fortified orange juice, and many vegetables.

Talk with your health professional

If you have questions about this information, take the packet with you when you visit your health professional. You may want to use a highlighting pen to mark areas or make notes in the margins of the pages where you have questions.

What is the recommended daily amount of calcium?

Calcium should always be taken with vitamin D, because vitamin D is necessary for the body to absorb calcium. The recommended daily calcium intake is:

Age of Life	Recomended Calcium Intake (in mg/day)
1 - 3	500
4 - 8	800
9 - 18	1,300
19 - 50	1,000
Older then 50	1,200
Pregnent / Nursing	1,000 - 1,200

Most people do not get enough calcium through diet alone. You need to eat 3 to 4 servings per day of foods high in calcium to get the recommended daily amount.

Why is calcium used to treat or prevent osteoporosis?

Calcium, combined with vitamin D and phosphorus, maintains or helps reduce the rate of bone loss that occurs with osteoporosis.

Vitamin D is vital for calcium absorption in bones and to improve muscle strength. It may reduce an older person's risk for falling by 22%.1 You need 200 IU of vitamin D per day if you are an adult age 19 to 50. If you are age 51 to 70, you need 400 IU per day of vitamin D, and if you are age 71 or older, you need 600 IU of vitamin D a day. If you live in a sunny climate, you can get enough vitamin D through 10 to 15 minutes per day of sun exposure a few days a week; however, older people may not get enough this way. You can also get vitamin D in foods such as egg yolks, liver, saltwater fish, and vitamin D–fortified dairy products. Taking a vitamin D supplement along with your calcium can help strengthen your bones.

Many foods contain high amounts of calcium. It is important that you also get enough vitamin D and phosphorus along with calcium to help your body absorb the calcium. The following table shows foods that are rich in calcium.

Food	Serving size	Calcium (mg) per serving
Sardines in oil	3 oz	324
Milk (whole, 2%, 1%, and skim)	1 cup	291–302
Cheddar cheese	1 1/2 oz	306
Yogurt (plain)	8 oz	415
Yogurt (low-fat)	8 oz	245–384
Canned salmon (with bones)	3 oz	181
Broccoli (raw)	1 cup	42
Turnip greens (boiled)	1/2 cup	99
Ice cream	1/2 cup	85
Cottage cheese	1 cup	138
Tofu (if made with calcium sulfate)	1/2 cup	138–204

How can I get enough calcium in my daily diet?

The best source of calcium is milk fortified with vitamin D. Four glasses a day provide 1,200 mg of calcium. Other good sources of calcium include shrimp, blackstrap molasses, calcium-fortified tofu, and almonds. You can also buy foods that have been calcium-fortified, such as cereals and orange juice, although the amount of calcium in each varies.

Because most Americans get only half the calcium they need from their diet, many people need to take a calcium supplement. Everyone who has been diagnosed with osteoporosis should take calcium and vitamin D supplements in addition to eating a diet rich in these nutrients.

Types of calcium supplements include:

Calcium carbonate, which is 40% elemental calcium.
Calcium citrate, which is 21% elemental calcium. While lower in elemental calcium than calcium carbonate, calcium citrate is easier to digest and does not cause constipation as much as do other types of calcium supplements.
Calcium gluconate and calcium lactate, which contain a low amount of elemental calcium.

The following table shows examples of calcium supplements. Some of these products include vitamin D. Be sure to take vitamin D with calcium, either in combination or separately, to help your body absorb the calcium into your bones.

Product name	Calcium in each tablet
Healthy Woman Bone Health Supplement plus vitamin D	600 mg calcium carbonate
Caltrate (tablets or chewables)	600 mg calcium carbonate
Citracal Calcium Citrate Plus D, Coated Caplets	315 mg calcium citrate
Calci-Chew Wafers	500 mg calcium carbonate
Viactiv Soft Calcium Chews plus D	500 mg calcium carbonate
Vitaline	250 mg calcium citrate

Take the number of tablets per day that satisfies your daily recommended amount of calcium based on your age and health condition. You should not get more than 2,500 mg per day of calcium, whether it is from supplements or food.

Where to go from here

Now that you have read this information, you can feel confident that you know how to get enough calcium daily to prevent or treat osteoporosis and reduce your risk for bone loss.

Breast Cancer

Overview

Cells in the body normally divide (reproduce) only when new cells are needed. Sometimes, cells in a part of the body grow and divide out of control, which creates a mass of tissue called a tumor. If the cells that are growing out of control are normal cells, the tumor is called benign (not cancerous.) If however, the cells that are growing out of control are abnormal and don't function like the body's normal cells, the tumor is called malignant (cancerous).

Cancers are named after the part of the body from which they originate. Breast cancer originates in the breast tissue. Like other cancers, breast cancer can invade and grow into the tissue surrounding the breast. It can also travel to other parts of the body and form new tumors, a process called metastasis.

Causes
We do not know what causes breast cancer, although we do know that certain risk factors may put you at higher risk of developing it. A person's age, genetic factors, personal health history and diet all contribute to breast cancer risk.

Who Gets Breast Cancer?

Breast cancer is the most common cancer among American women, after nonmelanoma skin cancer. Over the past 50 years, the number of women diagnosed with the disease has increased each year. Today, approximately 1 in almost every 8 women (13.4%) will develop breast cancer in her lifetime. Breast cancer is the second-leading cause of cancer death in women after lung cancer -- and is the leading cause of cancer death among women ages 35 to 54. The American Cancer Society estimates that in 2005, approximately 211,240 women will be diagnosed with invasive breast cancer and approximately 40,410 will die. Although these numbers may sound frightening, research reveals that the mortality rate could decrease by 30% if all women age 50 and older who need a mammogram had one.
Only 5-10% of breast cancers occur in women with a clearly defined genetic predisposition for the disease. The majority of breast cancer cases are "sporadic," meaning there is no direct family history of the disease. The risk for developing breast cancer increases as a woman ages.

Warning Signs

The warning signs of breast cancer include:

Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle.
A mass or lump, which may feel as small as a pea.
A change in the size, shape or contour of the breast.
A blood-stained or clear fluid discharge from the nipple.
A change in the feel or appearance of the skin on the breast or nipple (dimpled, puckered, scaly or inflamed).
Redness of the skin on the breast or nipple.
An area that is distinctly different from any other area on either breast.
A marble-like hardened area under the skin.

These changes may be found when performing monthly breast self-exams. By performing breast self-exams, you can become familiar with the normal monthly changes in your breasts.

Breast self-examination should be performed at the same time each month, three to five days after your menstrual period ends. If you have stopped menstruating, perform the exam on the same day of each month.

Types

The most common types of breast cancer are:

Invasive ductal carcinoma. This cancer starts in the milk ducts of the breast. Then it breaks through the wall of the duct and invades the fatty tissue of the breast. This is the most common form of breast cancer, accounting for 80% of invasive cases.
Ductal carcinoma in situ (DCIS) is ductal carcinoma in its earliest stage (stage 0). In situ refers to the fact that the cancer hasn't spread beyond its point of origin. In this case, the disease is confined to the milk ducts and has not invaded nearby breast tissue. If untreated, ductal carcinoma in situ may become invasive cancer. It is almost always curable.
Infiltrating (invasive) lobular carcinoma. This cancer begins in the lobules of the breast where breast milk is produced, but has spread to surrounding tissues or the rest of the body. It accounts for about 10% of invasive breast cancers.
Lobular carcinoma in situ (LCIS) is cancer that is only in the lobules of the breast. It isn't a true cancer, but serves as a marker for the increased risk of developing breast cancer later, possibly in both breasts. Thus, it is important for women with lobular carcinoma in situ to have regular clinical breast exams and mammograms.

In addition, there are several other less common types of breast cancer.

Stages of Breast Cancer

Early stage or stage 0 breast cancer is when the disease is localized to the breast with no evidence of spread to the lymph nodes (carcinoma in situ).
Stage 1 breast cancer: The cancer is two centimeters or less in size and it hasn't spread anywhere.
Stage 2A breast cancer is a tumor smaller than two centimeters across with lymph node involvement or a tumor that is larger than two but less than five centimeters across without underarm lymph node involvement.
Stage 2B is a tumor that is greater than five centimeters across without underarm lymph nodes testing positive for cancer or a tumor that is larger than two but less than five centimeters across with lymph node involvement.
Advanced breast cancer (metastatic) results after cancer cells spread to the lymph nodes and to other parts of the body.
Stage 3A breast cancer is also called locally advanced breast cancer. The tumor is larger than five centimeters and has spread to the lymph nodes under the arm, or a tumor that is any size with cancerous lymph nodes that adhere to one another or surrounding tissue.
Stage 3B breast cancer is a tumor of any size that has spread to the skin, chest wall or internal mammary lymph nodes (located beneath the breast and inside the chest).
Stage 3C breast cancer is a tumor of any size that has spread more extensively and involves more lymph node invasion.
Stage 4 breast cancer is defined as a tumor, regardless of size, that has spread to places far away from the breast, such as bones, lungs, liver, brain or distant lymph nodes.

Diagnosis

During your regular physical examination, your doctor will take a careful personal and family history and perform a breast examination and possibly one or more other tests:

Mammography
Ultrasonography

Based on the results of these tests, your doctor may or may not request a biopsy to get a sample of the breast mass cells or tissue.

After the sample is removed, it is sent to a lab for testing. A pathologist -- a doctor who specializes in diagnosing abnormal tissue changes -- views the sample under a microscope and looks for abnormal cell shapes or growth patterns. When cancer is present, the pathologist can tell what kind of cancer it is (ductal or lobular carcinoma) and whether it has spread beyond the ducts or lobules (invasive).

Laboratory tests such as hormone receptor tests (estrogen and progesterone) can show whether the hormones help the cancer to grow. If the test results show that hormones help the cancer grow (a positive test), the cancer is likely to respond to hormonal treatment. This therapy deprives the cancer of the estrogen hormone.

Breast cancer diagnosis and treatment are best accomplished by a team of experts working together with the patient. Each patient needs to evaluate the advantages and limitations of each type of treatment, and work with her team of physicians to develop the best approach.

Treatment

If the tests find cancer, you and your doctor will develop a treatment plan to eradicate the breast cancer, to reduce the chance of cancer returning in the breast, as well as to reduce the chance of the cancer traveling to a location outside of the breast. Treatment generally follows within a few weeks after the diagnosis.

The type of treatment recommended will depend on the size and location of the tumor in the breast, the results of lab tests done on the cancer cells and the stage or extent of the disease. Your doctor usually considers your age and general health as well as your feelings about the treatment options.

Breast cancer treatments are local or systemic.

Local treatments are used to remove, destroy or control the cancer cells in a specific area, such as the breast. Surgery and radiation treatment are local treatments.
Systemic treatments are used to destroy or control cancer cells all over the body. Chemotherapy and hormone therapy such as tamoxifen, and biologic therapies like Herceptin, are systemic treatments. A patient may have just one form of treatment or a combination, depending on her needs.

What Happens After Treatment?

Following local breast cancer treatment, the treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with the surgeon, may advise the use of tamoxifen or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

How Can I Protect Myself From Breast Cancer?

Follow these three steps for early detection:

1. Get a mammogram. The American Cancer Society recommends having a baseline mammogram at age 35, and a screening mammogram every year after age 40. Mammograms are an important part of your health history. If you go to another healthcare provider, or move, take the film (mammogram) with you.
2. Examine your breasts each month after age 20. You will become familiar with the contours and feel of your breasts and will be more alert to changes.
3. Have your breast examined by a healthcare provider at least once every three years after age 20, and every year after age 40. Clinical breast exams can detect lumps that may not be detected by mammogram.

Reviewed by the doctors at The Cleveland Clinic Taussig Cancer Center.

Edited by Tracy Shuman, MD, WebMD, August 2005.

SOURCE: The American Cancer Society

Heart Disease

Coronary Artery Disease

Coronary artery disease, also called coronary heart disease, or simply, heart disease, is the No. 1 killer in America, affecting more than 12 million Americans.

What Is Coronary Artery Disease?

Coronary artery disease is atherosclerosis of the coronary arteries. Atherosclerosis is when the arteries become clogged and narrowed, restricting blood flow to the heart. Without adequate blood, the heart becomes starved of oxygen and vital nutrients it needs to work properly.

How Does Coronary Artery Disease Develop?

Your coronary arteries are hollow tubes. Inside, they are smooth and elastic, allowing blood to flow freely.

Before your teen years, fat starts to deposit in the blood vessel walls. As you get older, the fat builds up. This causes injury to your blood vessel walls. In an attempt to heal itself, the cells release chemicals that make the walls sticky.

Then, other substances such as inflammatory cells, proteins and calcium that travel in your bloodstream start sticking to the vessel walls. The fat and other substances combine to form a material called plaque. The plaque builds up and narrows the artery (atherosclerosis).

Many of the plaque deposits are hard on the outside and soft and mushy on the inside. The hard surface can crack or tear, exposing the soft, fatty inside. When this happens, platelets (disc-shaped particles in the blood that aid clotting) come to the area, and blood clots form around the plaque. This causes the artery to narrow even more.

Over time a narrowed coronary artery may develop new blood vessels that go around the blockage to get blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle.

In other cases, the blood clot may totally block the blood supply to the heart muscle, causing what is called an acute coronary syndrome. This is actually a name given to three serious conditions: unstable angina (an impending heart attack) and two types of heart attacks called non-Q-wave myocardial infarction and Q-wave myocardial infarction.

The length of time that blood flow is blocked and the amount of damage that occurs determines the type of acute coronary syndrome. Some people have symptoms that tell them that they may soon develop an acute coronary syndrome, others may have no symptoms until something happens, and still others have no symptoms of the acute coronary syndrome at all.

What Is Ischemia?

When plaque and fatty matter narrow the inside of an artery to a point where it cannot supply enough oxygen-rich blood to meet your organ's needs, cramping of the muscle occurs. This is called ischemia.

Ischemia of the heart can be compared to a cramp in the leg. When someone exercises for a very long time, the muscles in the legs cramp up because they're starved for oxygen and nutrients. Your heart, also a muscle, needs oxygen and nutrients to keep working. If its blood supply is inadequate to meet the heart muscle's needs, ischemia occurs, and you may feel chest pain or other symptoms.

Ischemia is most likely to occur when the heart demands extra oxygen. This is most common during:

Exertion (activity)
Eating
Excitement
Exposure to cold

When ischemia lasts less than 10 minutes, there is no permanent damage to your heart. You may be told you have "stable coronary artery disease."

Symptoms

The most common symptom is angina or "angina pectoris." Angina can be described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing or painful feeling. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, throat, jaw or back.

Other symptoms that can occur with coronary artery disease include:

Shortness of breath
Palpitations (irregular heart beats, skipped beats or a "flip-flop" feeling in your chest)
A faster heartbeat
Weakness or dizziness
Nausea
Sweating

Learn to recognize your symptoms and the situations that cause them. Call your doctor if you begin to have new symptoms or if they become more frequent or severe.

Ischemia, and even a heart attack, can occur without any warning symptoms. This is called silent ischemia. It can occur among all people with heart disease, though it is more common among people with diabetes.

Diagnosis

Your doctor can tell if you have coronary artery disease by:

Talking to you about your symptoms, medical history, and risk factors.
Performing a physical exam.
Performing diagnostic tests, including an electrocardiogram (ECG or EKG), exercise stress tests, cardiac catheterization and others. These tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart, and the best form of treatment for you.

Treatment

Treatment for coronary artery disease involves reducing your risk factors, taking medications, and possibly undergoing invasive and/or surgical procedures.

Reduce your risk factors. This involves making lifestyle changes. If you smoke, you should quit. Your diet will likely need modifying to reduce your cholesterol, keep your blood pressure in check, and keep blood sugar in control if you have diabetes. Low fat, low sodium, low cholesterol foods are recommended. You should also get more exercise to help maintain a healthy weight and reduce stress. But, check with your doctor before starting an exercise program.
Medications. If making lifestyle changes isn't enough to control your heart disease, medications may be needed to help your heart work more efficiently and receive more oxygen-rich blood. The medications you are on depend on you and your specific heart problem.
Surgery and other procedures. Procedures to treat coronary artery disease include balloon angioplasty (PTCA), stent placement, rotoblation, atherectomy, and coronary artery bypass surgery. All of these procedures increase blood supply to your heart, but they do not cure coronary heart disease. You will still need to decrease your risk factors to prevent future disease.

Doctors are also studying several innovative ways to treat heart disease. Here are a couple of the more promising ones:

Transmyocardial laser revascularization, or TMR. This procedure improves blood flow to the heart muscle for people with advanced coronary artery disease. Laser beams are used to make channels through the heart muscle to increase blood flow to dying, but not dead, heart tissue. This technique is used for people with intractable angina who are not candidates for traditional open-heart surgery or transplantation.
Angiogenesis. This involves giving substances through the vein or directly into the heart that trigger the heart to grow new blood vessels to bypass the clogged ones.
EECP. There are an increasing number of patients who have persistent angina symptoms, who have exhausted the standard treatments without successful results. Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. EECP is a non-invasive treatment for people who have chronic, stable angina; who are not receiving adequate relief from angina by taking nitrate medications; and who do not qualify for an invasive procedure such as bypass surgery, angioplasty or stenting.

Reviewed by the doctors at The Cleveland Clinic Heart Center.

Edited by Charlotte E. Grayson, MD, June 2004, WebMD.