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2 Gazette Health | Fall 2012 A GAZETTE PUBLICATION

A publication of The Gazette | Fall 2012

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Content is for informational purposes only and should not be construed as medicaladvice, nor as a substitute for seeing your own medical professional(s).

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Karen Finucan ClarksonMary Wade BurnsideArchana Pyati

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GAZETTE.NET Fall 2012 | Gazette Health 3

Giving small daily doses of egg powder tochildren with an egg allergy could pave theway to letting them eat the food safely.After 10 months, more than half of the aller-gic children in a new study who had beeneating egg powder daily showedno allergic reaction, or onlyminor symptoms. A yearlater, 30 of the 55 kidsin the study passed achallenge with evenhigher doses of eggpowder. The 30 thenavoided all egg productsfor four to six weeks, after whichthey were given egg powder, plus a wholecooked egg. Over a third of those childrendid not react and were cleared to eat eggsas part of their diet. A year later, they werestill showing no signs of allergic reaction.Researchers said the therapy is still in theearly experimental stages. And they stronglycaution that this type of oral immunotherapyshould never be tried at home due to the riskof severe allergic reaction.

-NIH

Beating eggallergy in kids

Silent heart attacks—in which there are notypical symptoms like chest pain andshortness of breath—are not only morecommon than previously thought, but more

common than heart attacks withrecognized symptoms, accord-ing to a recent study of olderadults. Researchers from theNational Institutes of Health

found the prevalenceof these heart attacks

was especially high inseniors with diabetes,

and that magnetic resonanceimaging (MRI) was more effective than anelectrocardiogram (EKG) in identifyingthem. Those who suffer a silent heartattack may mistake it for something else,such as muscle pain, indigestion or the flu,according to the Mayo Clinic.

Is it safe toRinse Your Sinuses? A silent killer

Taking vitamin D supplements may lower children’s risk of respiratory infections. Because the body naturallyproduces the vitamin in response to sunlight, this may be especially true in winter when that light is limited.

ittle teapots with long spouts havebecome a fixture in many homes forreasons that have nothing to do withtea. Called neti pots, they are used torinse the nasal passages with a saline

solution, and have become popular as a treat-ment for congested sinuses, colds and allergies,and for moistening nasal passages exposed to dryindoor air.

However, the U.S. Food and Drug Administra-tion (FDA) warned about the risk of infectiontied to improper use, issuing a statement inAugust about safe practices for neti pots andother nasal rinsing devices.

The source of water used with neti pots is thelargest concern, the FDA said. Unfiltered tapwater that is not treated in specific ways isunsafe to use for nasal rinsing. Tap water cancontain low levels of organisms, like bacteria

and protozoa, including amoebas that, while safeto swallow because stomach acid kills them, canlive in nasal passages and cause potentially seri-ous infections, according to the Centers forDisease Control and Prevention.

These devices are generally safe and helpfulwhen used and cleaned properly, said StevenOsborne, M.D., a medical officer with the FDA.

Improper use of neti pots may have causedtwo deaths in 2011 in Louisiana from a very rarebrain infection that the state health departmentlinked to tap water contaminated with an amoebacalled Naegleria fowleri.

Talk to your doctor to determine if nasal rins-ing will be safe and effective for your condition.If symptoms are not relieved or worsen after therinse, then return to your health care provider,especially if you have a fever, nosebleed orheadaches while using the rinse.

L


Brain abnormalitiesseen in hoarders

Until recently, hoarding disorderhas been considered a type of obses-sive-compulsive disorder (OCD).Now, many experts consider it aunique diagnosis.

People with hoarding disorderhave trouble making decisionsabout when to throw things away.Possessions pile up, resulting indebilitating clutter.

Results from a new study fund-ed by the National Institute ofMental Health suggest that hoard-ers’ decisions about possessions arehampered by abnormal activity inbrain regions used to identify theemotional significance of things.

Scientists believe that theseabnormalities are specific to hoard-ing and separate the disorder fromOCD. In addition to furtherexploring the unique traits ofhoarders, researchers are now usingthis information to help assesspotential treatments.

Previous studies of brain func-tion in hoarders implicated regions

associated with decision-making,attachment, reward processing,impulse control and emotionalregulation. But the patient popula-tions and research methods variedamong the studies, making clearconclusions difficult.

In the new study, researchersanalyzed brain images of 43 hoard-ers, 31 people with OCD and 33healthy controls. Participants weregiven six seconds to make a deci-sion about whether to keep or dis-card junk mail that either belongedto them or to someone else.Participants later watched as theitems they chose to discard wereplaced in a paper shredder.

The hoarders chose to keepmore mail that belonged to themthan those in the OCD or healthycontrol groups. Hoarders alsotook longer to make decisions andreported greater anxiety, indeci-siveness and sadness than the othergroups. -NIHIS

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BY ARCHANA PYATI

Fear of the dentist is serious and has far-reaching consequences for a person’s overallhealth. According to the Centers for DiseaseControl and Prevention, only 61 percent ofU.S. adults in 2010 had visited the dentistwithin the previous year. However, 81.6 per-cent of adults in the “Bethesda, Gaithersburgand Frederick” region seen had a dentist atleast once that year.

Many patients still avoid the dentist for avariety of reasons, including a lack of

insurance and basic paranoia. “If youhave fear, go and have a consult

first,” said Michele Dozier, D.D.S.,a pediatric dentist at nusmiles inTakoma Park. “A conversa-tion—that’s where we start.”

1 Prevention of gumdiseaseGum disease is the No.1 cause of tooth lossin the United States,according to TamiPantano, D.M.D., who

recently opened AudubonDental Center of Clinton. Itbegins with gingivitis, where

bacteria in the mouth causeplaque and tartar—a hardenedform of plaque—to build upalong the bottoms of the teeth.

If left untreated, gingivitiscan progress to periodontaldisease, when plaque seepsbelow the gumline, causingthe gums to recede and boneto deteriorate. “When thathappens, that’s irre-versible,” she said, addingthat it takes six monthsfor plaque to slip downbeyond a toothbrush’s

reach. Those scraping instruments a dentistuses, called scalers, are sharp and preciseenough to remove the buildup. “Even thehealthiest mouths need cleaning every sixmonths,” said Pantano.

2 Spotting cavities before they lead toinfection or tooth loss

Like plaque, cavities are also caused bybacteria, which eat away the tooth’s enamel,creating holes. If caught when they’re smallenough, they can be filled, said Danny Dinh,D.D.S., a dentist with the Family SmileCenter in Frederick. If left to grow, cavitiescause tooth decay, which may lead to anextraction or an infection of the nerves andtissues around the tooth.

“By the time [the patient is] in pain, thecavity is huge. That’s when they need a rootcanal,” where damaged nerves and tissue areremoved and what remains of the tooth issealed and protected with a crown, said Dinh.

3 Learning the proper way to brush“I didn’t know how to brush my teeth

until I went to dental school,” said Pantano.Proper brushing, she added, is not exactly aninstinctual skill, but something that must belearned. She recommends brushing in a circu-lar motion with the brush held at a 30- to 35-degree angle.

“Many patients don’t know what theproper technique is, and they never removethe plaque effectively,” said Rimple Singh-Crawford, D.D.S., of Fenton Family Dental’sClinton office. Patients target the front teeth,she said, but aren’t always diligent aboutcleaning molars in the back of the mouth.

The insides of the bottom front teeth areanother tricky area where plaque canbecome a problem, according to Pantano.The Philips Sonicare, she said, creates the cir-cular motion needed for proper cleaning.Many electric toothbrushes also have timersto make sure brushing lasts long enough.

ISTOCKPHOTO/M

OCKER_BAT

8 to stop avoiding your dentistREASONS

DENTAL HEALTH


4 Rule out oral cancer andother diseases that startin the mouth

Dentists check more than yourgums and teeth. They consideroverall oral health and perform anoral cancer screening on newpatients. “We examine the gums,the tooth structure…underneaththe tongue where they can’t see,”said Singh-Crawford.

“A lot of systemic diseases haveoral dimensions,” said Pantano,citing HIV as an example of a dis-ease that appears in its early stagesin the mouth. “Most of the time,it’s a fungal infection, and if we seea fungal infection, that shows thepatient is immunocompromised.”

5 Fix functional orcosmetic problems

Even if you diligently brush andfloss every day, you can’t fix struc-tural problems without the help ofa dentist and, probably, an ortho-dontist. “Sometimes teeth need tobe straightened out for functionalreasons,” said Dinh, such as theinability to clean in between theteeth due to overcrowding.

Braces or retainers may be need-ed for adults if structural problemswere not corrected when they wereyounger. Under bites and overbitescould indicate a problem with thejaw and other temporomandibulardisorders, said Pantano.

6 Control halitosis, knownas bad breath

One telltale sign of periodontaldisease, said Dozier, is a distinctive,foul odor. Halitosis is caused bybacterial buildup in the mouth.Infrequent and ineffective brushingand flossing can be the culprit, ascan a failure to clean the tongue,said Dinh, who recommends atongue scraper for this purpose.Getting timely cleanings helps keepthe buildup of plaque at bay, whichwill mean fresher breath.

7 Oral hygiene and healthis critical when managingdiabetes.

Pantano recently attended a dia-betes fair in Washington, D.C.,where she reminded attendees howimportant it is to care for theirmouths and get regular checkups.

“Gum disease is more severe indiabetic patients…and one of thebiggest reasons is that the elevatedblood sugar provides extra nutri-tion for the bacteria,” she said.

Due to weaker immunity, dia-betic patients tend to be prone toinfections in all areas of their body,including the mouth. Diabetes alsomanifests itself with oral symp-toms like dry mouth, said Pantano,which a dentist can help treat.

“Health starts with yourmouth,” said Singh-Crawford. “Ifyou lose your teeth, you can’t eathealthy foods like fruits and vegeta-bles,” which are essential for dia-betic patients. “It’s very importantfor these patients to have healthymouths so they can chew anddigest properly.”

8 It’s better to take apreventative, rather thanreactive, approach tooral health.

In the old days, dentistry tendedto be more reactive than proactive,said Pantano. The thought “used tobe if ‘it’s broken, fix it,’” saidPantano. “Now, we’ve figured outways to prevent it from being bro-ken in the first place.”

Not all of her patients, though,have changed their mindset aboutthe importance of catching prob-lems early. She still gets calls fromemergency room doctors when oneof her patients shows up at the hos-pital in excruciating pain with anabscessed tooth. “I really push pre-vention,” she said. “I have happierpatients and a happier me whenthey don’t have problems.”

1867929


BY KAREN FINUCAN CLARKSON

f you think you’re immune to whoop-ing cough, think again. “Sometimespeople think, ‘I got vaccinated as a kidso I’m protected,’” said CynthiaRoldan, M.D., a pediatric hospitalistat Carroll Hospital Center inWestminster. With whooping cough—known as pertussis—staging a come-

back nationwide, Maryland public health offi-cials and physicians are encouraging vaccinationof adults as well as children.

Whooping cough can be fatal, especially ininfants. “Pertussis can bring on seizures or makeit difficult to breathe properly, resulting in braindamage or death,” said Avni Jain, M.D., aprimary care physician with AdventistMedical Group in Germantown andprivileges at Shady GroveAdventist Hospital in Rockville.“Two-thirds of children less than1 year of age with pertussis arehospitalized.” Of the 111 pertus-sis deaths in the U.S. from 2004 to2008, 83 percent were in infantsunder 3 months old, according tothe Centers for Disease Control andPrevention (CDC).

WHOOPING COUGH CASES ARE ON THERISE. The CDC reported 21,401 cases ofpertussis this year, through Aug. 4. That ismore than double what was reported for eachof the last three years at the end of the 31st weekand is on track to become the highest numberrecorded in more than 50 years.

Maryland has seen an increase in pertussis,though it is not on par with Washington state,where 3,202 cases have triggered an epidemic.As of August, there had been 141 cases ofwhooping cough in Maryland this year, com-pared with 56 in 2011 and 64 in 2010. InMontgomery County, Registered Nurse CindyEdwards has noticed “a significant upswing ofpertussis.” Last July there was one case, whereas

this July there were 14. In April through June oflast year, two cases were reported, comparedwith 36 in the same quarter this year. “That’s notan epidemic, but still significant,” said Edwards,the manager of the Disease Control Programwith the county’s Department of Health andHuman Services.

THERE AREMULTIPLE REASONS FOR THE INCREASE,according to Vivek Sinha, M.D., a family medi-cine physician with Southern Maryland HospitalCenter’s Fort Washington Family MedicalCenter. “Some people, worried about sideeffects, are not vaccinating anymore. We’re test-ing more, so we’re finding it more. And, after awhile, the immunity of those who were vaccinat-ed wanes,” he said.

As a result, “we don’t have as high of a herdimmunity,” said Edwards. Couple that with thecyclical nature of pertussis—“every three to fouryears there’s a resurgence in cases,” she said—and there’s the potential for a perfect storm.

The clouds of that storm began to form inthe 1990s when a new whooping cough

vaccine was developed. In response toconcerns about potential side effects—fever, swelling at the injection siteand, rarely, seizures—associatedwith the original 1940 vaccine,which used small amounts of inac-tivated whole bacteria, an acellularversion, containing only fragmentsof bacterial cells, was substituted.“There is concern that the acellu-lar pertussis vaccine doesn’tprovide immunity as long as theolder pertussis vaccine,”Edwards said.

Vaccination, which is about85 percent effective, remainsthe best way to prevent pertus-sis or minimize the severity of

the disease, most medical pro-fessionals agree. Two vac-cines—DTaP and Tdap—helpprotect against diphtheria,tetanus and pertussis. DTaP is a

pediatric formulation, while Tdap, considered abooster, is primarily for adolescents and adults.

Current “guidelines recommend that DTaP begiven five times—at 2, 4 and 6 months, then at15 to 18 months and 4 to 6 years of age,” saidSinha. “In adolescence, about the time they’regoing into seventh grade, they

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I

Vaccination is still the best way toprevent whooping cough.

[continued on 20]

CHILDRENS’ HEALTH

WHOOPING COUGHcases on the rise in Maryland


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CHILDREN’S HEALTHISTOCKPHOTO/001ABACUS

CHILDRENS’ HEALTH


According to study published in May in PEDI-ATRICS, the official journal of the AmericanAcademy of Pediatrics, researchers from theCenters for Disease Control and Preventionnoted the prevalence of prediabetes or diabetesjumped from 9 percent in 1999 through 2000 to23 percent in 2007 through 2008.

Prediabetes is a precursor to type 2 diabetes,where the body gradually develops resistance toinsulin. Insulin is the hormone needed to regulateblood sugar, moving it from the bloodstream tocells to be stored and later used for energy.

Historically, children were more likely to bediagnosed with type 1 diabetes. Also known asjuvenile diabetes, type 1 occurs when the bodyproduces little or no insulin, and researchers sayits origin is a faulty immune system. Type 2 dia-betes, on the other hand, had been found mostlyin adults, whose bodies stopped responding toinsulin due to weight gain and other factors.

Now, that generational divide seems a littleless clear as more overweight and obese teenagersqualify as prediabetic. As more patients fit thisprofile, doctors urge parents to take a moreaggressive role in ensuring their children stayphysically active and maintain a low-carb, high-protein diet to facilitate weight loss and maintainhealthy blood sugar levels. While not fully under-stood, the link between obesity and insulinresistance, a hallmark of prediabetes, has beenmade by scientists in recent years, which doctorssee on the front lines of their practices.

“Definitely, we’re seeing more kids withoverweight and obesity, and soon, I will seemore patients with prediabetes and type 2 dia-betes,” said Cong Ning, M.D., a pediatricendocrinologist at Shady Grove AdventistHospital in Rockville.

Prediabetes: Why Diagnose?Prediabetes occurs when a person’s fasting

blood sugar is in an abnormal range—between100 and 125 mg/dL—and they have one ormore of the following: a high body massindex; dark, velvety patches of skin behind theneck and underarms, known as acanthosisnigricans; a family history of diabetes; or highblood pressure. Once a person’s fasting bloodsugar reaches 126 mg/dL or higher, she’s con-sidered diabetic.

While it’s not a new term, prediabetes amongboth adults and teens is being discussed withgreater frequency now because we’re learningmore about how diabetes and other chronic dis-ease work, and the definition of what’s “normal”keeps changing, said Vivek Sinha, M.D., a fami-ly physician at Fort Washington Family MedicalCenter, affiliated with Southern MarylandHospital Center. “Research has shown that evenpatients that are at 118 [mg/dL] show signs ofinsulin resistance…,” he said.

Identifying teens who are prediabetic opens upthe possibility of reversing course on a diagnosisthat once seemed inevitable. “I’ve had patientswho are prediabetic and not become diabetic

exclusively through losing weight,” said Sinha.“The name of the game is prevention rather thantreatment in pediatrics.”

Disparities in DiagnosesBelonging to certain ethnic groups amplifies

the risk of prediabetes. African-Americans,Alaska Natives, American Indians, Hispanics,Asian Americans and Pacific Islanders are at agreater risk for developing prediabetes and type2 diabetes, according to the National Institute ofDiabetes and Digestive and Kidney Diseases.

Researchers in a study published in BioMedCentral Research Notes in January wrote that“nearly one out of every six overweight youthhas prediabetes,” and that “the burden ofdiabetes falls disproportionately on ethnicminority youth, particularly Native Americans,Hispanic/Latino Americans, and African-Americans.”

In its most recent National Diabetes FactSheet, the CDC noted that from 2002 to 2005,new cases of type 2 diabetes were either similarto or greater than new cases of type 1 diabetesdiagnosed among black, Hispanic, Asian/PacificIslander and American Indian 10- to 19-year-olds. Only non-Hispanic whites of this same agegroup had a larger percentage diagnosed withtype 1 diabetes.

While scientists are still mapping out the genet-ic underpinnings of why certain ethnicities are atgreater risk for developing type 2 diabetes, otherfactors such as household

BY ARCHANA PYATI

ver a nine-year period, prediabetes or diabetes inAmerican teenagers nearly tripled. This troublingnews comes as pediatricians are treating a specificgroup of patients with greater frequency: youngpeople who have developed symptoms of a chronicdisease more commonly found in adults.O

[continued on 21]


BY KAREN FINUCAN CLARKSON

e’re all destined to godeaf if we live longenough. If you make itto 100, you will be hardof hearing, guaranteed.

Everyone loses hearing to one degree oranother as they age,” said Bryan C. Ego-Osuala, M.D., an otolaryngologist with TheCenter for Ear, Nose & Throat at DoctorsCommunity Hospital in Lanham.

The first signs of age-related hearing loss,known as presbycusis, begin to appear inone’s late 50s or early 60s, according to Ego-Osuala. High-frequency sounds—such asthe chirping of a bird, the ringing of aphone, or consonants and blends such as“s” and “th”—generally are the first to go.

“I was stunned when my husband andchildren said I had a hearing problem. Ithought people weren’t speaking loudlyenough or were mumbling,” said LeanoreCalem, 79. “I kept turning the TV up loud-er and louder to the point when my kidswould visit they’d tell me to turn it down.”

The Kensington resident is in good com-pany. As many as half of all people 75 andolder have hearing loss, as do about a thirdof adults from 65 to 75, according to theNational Institute on Deafness and OtherCommunication Disorders (NIDCD).

Presbycusis is progressive. “We’re allborn with a finite number of hair cells inour ears—in the cochlea or inner ear—thathelp transmit sound to the hearing nerve,which then takes the sound to the brain,”said Ego-Osuala. “During our lives, as thehairs grow and are exposed to sound, theydie. They do not regenerate. So, most hear-ing loss is permanent.”

“What we’re finding is that, for the vastmajority of people, hearing loss doesn’thappen in isolation,” said Kate Scully, aclinical audiologist with Hearing CenterSilver Spring. There are a number of phys-iological changes and age-related ailmentsthat cause it.

“IT USED TO BE THAT AGING ALONE was theNo. 1 cause of hearing loss—and noise sec-ond. Now it’s [the] reverse,” said Scully.“Noise has a compound effect and, overtime, takes a toll.”

Many baby boomers who frequented rockconcerts, cranked up the stereos and blasted

Noise may be the No. 1 culprit of hearing loss“W

ISTOCKPHOTO/SJLOCKE;OPPOSITE

PAGE,EMRE

ELDEMIR

SENIORS’ HEALTH


personal CD players are discoveringthat for themselves. Among Americans46 to 64, about 15 percent alreadyhave hearing problems, according to asurvey by the Better Hearing Institute(BHI).

While there are conflicting studiesas to whether the baby boomergeneration’s hearing loss is any moresignificant than that of previous gen-erations, the large number of agingboomers means that by 2030 theremay be 44 million Americans withsome degree of hearing loss, accord-ing to BHI. That would be an approx-imately 19 percent increase overtoday’s number.

CARDIOVASCULAR DISEASE CANbring about hearing loss. “The innerear is highly dependent on a richblood supply, so vessel health canaffect hearing,” said Scully. “Smokingalso can result in vascular issues andlimit blood flow to the cochlea.”

More than 70 percent of those 60to 79 live with cardiovascular dis-ease and, as a result, are at increasedrisk for hearing loss. Cardiovasculardisease, which includes high bloodpressure, “is associated more withlow-frequency hearing loss,” saidScully. That might mean someone isless likely to hear the rumbling of atruck or of thunder.

Both heart and cancer patients maysuffer hearing loss as certain medica-tions can damage the ear, according tothe American Speech-Language-Hearing Association. More than 200drugs—some prescription, others overthe counter—are considered ototoxic.

Diabetics are twice as likely as thegeneral population to suffer hearingloss, according to Scully, and risk ofthe disease increases with age. “It’sone of the first questions I ask on theintake form, as there are about 20million diabetics in this country and54 million with prediabetes, and thenumber is rising,” she said.

Kidney issues have a direct correla-tion with hearing loss. “Over 50percent of people with chronic kidneydisease have some degree of hearingloss,” said Scully.

Age-related hearing loss tends torun in families, according to Ego-Osuala. “If your mother became hardof hearing at age 38, there’s a highchance you will too. If hearing lossbegan at 65, we don’t consider thatunusual,” he said.

Because age-related hearing loss isincremental, many people don’t noticeit at first or don’t think the problem issignificant enough to warrant treat-ment, said Ego-Osuala.

Such was the case with Calem, whorecently began wearing a hearing aid.“I must have had serious problems adecade before, which I either wasn’taware of or didn’t acknowledge. Ithink I was probably in denial.”

AFTER AN APPOINTMENT WITH ANotolaryngologist, Calem learned thather ears were structurally sound. Thenext stop was the audiologist’s office,where Scully “explained that I hadsome rather drastic losses in certainregisters. I knew she was right, but itwas an uncomfortable admission thatI didn’t like to make,” said Calem.

Putting her vanity aside, Calemopted to purchase hearing aids. “Mostpeople, if I didn’t say anything, would-n’t notice. The only thing not coveredby my hair is a tiny wire that goes fromwhat’s in my ear to the battery, whichis hooked behind my ear.”

Her hearing improved dramatically.“The first moment was a stunner. Italmost sounded artificial because foryears I hadn’t been hearing thesesounds—paper rustling, birds sing-ing,” she said.

While nearly three-quarters ofthose who use hearing aids reportmuch better or somewhat better hear-ing, according to a 2011 AARP study,only about a fifth of those who wouldbenefit from a hearing aid actuallyuse one, noted NIDCD.

Hearing aids are not 100 percenteffective and in some cases may notbe effective at all. It’s not unusual,according to Ego-Osuala, for peoplewho wear hearing aids to continue tohave trouble hearing in places, likerestaurants, where there is a lot ofbackground noise.

And, if hearing loss has more to dowith the way a person’s brain process-es the information, a hearing aid isn’tthe answer. “Making something loud-er won’t help if the sounds are jum-bled in the brain,” said Ego-Osuala.

“Hearing aids have come a longway since the first digital ones wereintroduced in 1996,” said Scully.“Today, there are devices other thanhearing aids that can help in morechallenging environments.” She points

to mini microphones that the wearercan use to transmit sounds wirelesslyto a hearing aid and to hearing aidsthat use Bluetooth technology so thatphone calls and television shows canbe run through them.

Getting medical help as soon as aloss of hearing “is noticed by you orsomeone else is essential,” said Scully.“On average, people wait seven yearsto do something about it. Some waitdecades. By the time they come in, it’sharder to deal with because they maybe trying to cope with other issues.”

Only about afifth of thosewhowouldbenefit from ahearing aidactually use

one.

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BY ARCHANA PYATI

magine eating a healthydiet and exercising regular-ly, yet gaining weight andfeeling a debilitating fatiguefor no explicable reason.

Now imagine going to your doctor,taking a blood test and being told youare absolutely fine.

This is precisely what happened toAbbey Black, 32, a medical assistantwho lives on the outskirts ofHagerstown in Falling Waters, W. Va.Seeking a specialist’s opinion can beimportant for women who sufferfrom hypothyroidism, a type of thy-roid disease.

It took Black a year from the“everything’s fine” conversation

with her general practitioner toreceiving a diagnosis from anendocrinologist that made sense toher: Hashimoto’s thyroiditis. Theautoimmune disease occurs whenantibodies attack the thyroid gland,impairing its ability to secrete hor-mones that control every majorbodily function—from metabolismto heartbeat to hair growth tobowel movements.

“It’s a frustrating disease,” saidBlack, whose mother and sisters alsohave Hashimoto’s. “You have towork a lot harder at things whenyou have thyroid disease.”

The American Thyroid Associa-tion (ATA) estimates that 20 millionAmericans have some form of thy-roid disease, and it disproportionate-

ly affects women. Women are five toeight times more likely to developthyroid problems, and up to 60 per-cent of those with a thyroid diseaseare not aware they have a disorder.

“There’s a lot of misdiagnoses,”said Majd Hakim, M.D., theFrederick-based endocrinologist whotreated Black. “Many patients havesymptoms for many years beforethey get diagnosed.”

Hakim said the underdiagnosesstem, in part, from a less-than-pre-cise blood test doctors administer tofind out if a patient’s thyroid isworking properly. The test measuresthe amount of thyroid-stimulatinghormone—or TSH—in the blood.Secreted by the pituitary gland, TSHtriggers the thyroid to produce

Sometimes a woman

can experience both

hyper- and

hypothyroidism, as was

the case with media

queen Oprah Winfrey,

who went public with her

struggles with thyroid

disease in 2009. After

putting back on the

pounds she had lost in

the mid-2000s, she

was diagnosed with

hyperthyroidism, which

then morphed into

hypothyroidism, a culprit

behind her weight gain.

“Who knew this tiny

butterfly gland at the

base of the throat had so

much power? When it’s

off, the whole body feels

the effects,” she wrote in

her essay “How Did I Let

This Happen Again?”

published in O,

The Oprah Magazine.

THYROID DISEASEWhy It May Go Undetected

I

WOMEN’S HEALTH


essential hormones T3 (triiodothy-ronine) and T4 (thyroxine).

The test range for what’s nor-mal is fairly broad, which causesmany patients’ thyroid disorderto remain undetected. Symptoms,like fatigue, weight gain, insom-nia and depression, persist andmay even be attributed to a mooddisorder. “We need to look atpatient family history, symp-toms…a lot of times [patients] getmisdiagnosed because their hor-mone level falls within the normalrange,” said Hakim.

In Black’s case, her conditionresulted in hypothyroidism, wherethe thyroid doesn’t secrete enoughT3 and T4; the sluggishness andweight gain without an increasedappetite are a result of the metabo-lism slowing down. Hyperthy-roidism, a condition caused by thethyroid producing too much T3and T4, usually creates the oppo-site effect—loss of weight whilefeeling hungrier and eating more,anxiety and a rapid heartbeat.

Not only can the TSH test some-times fail to identify an overactiveor underactive thyroid, but in thosewho have been diagnosed withhypothyroidism, it may not be pre-cise enough to ensure a patientreceives the correct amounts ofhormone replacement therapy, saidHakim. Getting the level of the T4hormone, known commercially asSynthroid, just right is especiallycritical since T4 eventually convertsinto T3.

“The bottom line is the prob-lems occur when they’re not takingthe right amount of T4 to beginwith,” Hakim said. “It’s a very,very common scenario.”

Hyperthyroidism can be theresult of another underlying

autoimmune disorder like Graves’disease when antibodies areunleashed on the thyroid, causingit to go into overdrive. Studieshave shown that stress, pregnancyor a viral infection can lead to anoveractive thyroid, said MadhuriDevdhar, M.D., an endocrinologistwith Adventist Medical Group inMontgomery Village.

While antithyroid medicationsare prescribed for Graves’, they’renot meant for long-term use due todamaging side effects, including theloss of white blood cells, saidHakim. An iodine pill that hasbeen radiated is frequently used asa one-time treatment for Graves’,and is generally considered safe,while surgery is the less commonand riskier solution. Both oftenlead to hypothyroidism since thethyroid becomes disabled due tothe powerful radioactive iodinedosage or surgical removal.Hormone replacement therapy,which is usually prescribed for theremainder of the patient’s life, “isvery benign,” and causes “very lit-tle problem as far as side effects,”said Hakim.

Black, the medical assistant,whose second child was due lastmonth, has successfully navigatedher thyroid disease along with herpregnancy. A woman’s thyroidrequirements increase by 30 to 50percent during pregnancy since afetus can’t produce its own thyroidhormone in the first trimester,according to Hakim.

Black has had to increase herdosage of Synthroid a few times.After her delivery, she imagines lifewill go back to the way it was,where weight management is theperennial issue.

Up to 60 percent of those with athyroid disease are not aware

they have it.

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MEN’S HEALTH

ISTOCKPHOTO/FLUBYDUST

Misnomer alert:It’s usually notcaused by beer.

BY KAREN FINUCAN CLARKSON16 Gazette Health | Fall 2012 A GAZETTE PUBLICATION

f a keg now sits where yoursix-pack used to be, youcould end up paying a heftyprice—your health or yourlife. “Excess weight in themidsection can lead to prob-lems with cardiovascular dis-

ease, hypertension, metabolic syn-drome—which can lead to dia-betes—and some cancers, the mostcommon for men being prostate can-cer,” said Patricia Guay-Berry, clini-cal nutrition manager at SuburbanHospital in Bethesda.

With nearly 75 percent of the menin Maryland considered overweightor obese, according to The Henry J.Kaiser Family Foundation, there aremore than 1.5 million men whosespare tires could use some deflating.And the sooner the better, as belly fatis potentially lethal, according to theMayo Clinic.

What makes abdominal fat sodangerous is that it includes visceralfat, which lies deep inside theabdomen and surrounds the internal

organs, said Heather Boyd, lead die-titian at the FMH Wellness Center inFrederick.

“Visceral fat is more likely to getbroken down and go into the blood-stream, increasing lipid and triglyc-eride levels,” she said. Unhealthyblood fat levels cause plaque to formon artery walls, eventually restrictingblood flow and leading to heartattack and stroke.

Despite the label, beer does notmake a belly. “The beer belly got itsname because people who drink a lotof beer take in extra calories,” saidReed M. Shnider, a cardiologist withCardiology Associates LLC and priv-ileges at MedStar MontgomeryMedical Center in Olney, “and whenyou take in more calories than youburn, you get fat.”

In men, that fat ends up in the gut;in women, it most often plants itselfin the hips and thighs. “Men areapples and women are pears,” saidShnider. Gender plays a major role inhow fat is distributed.

Hormones seem to influencewhere fat goes in the body, accordingto Boyd. Both estrogen and testos-terone hold in check an enzymeknown as lipoprotein lipase (LPL),which promotes fat storage. In awoman’s body, the highest LPL levelsare usually found in the breasts, hipsand thighs, and in a man’s body, LPLlevels are highest in the abdomen. Ashormone levels decline with age, LPLin those areas becomes more activeand fat deposits grow.

A waist circumference of 40 inchesor more for men and 35 inches ormore for women is cause for concern,according to Boyd. It indicates anunhealthy concentration of belly fat.

“The good news [for men] is thatabdominal weight is easier to losethan weight from the hips andthighs,” said Guay-Berry. Althoughvisceral fat is buried in theabdomen, it tends to respond wellto diet and exercise.

The prevailing theory is that vis-ceral fat is more

I

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YFLIPPO

NAIL FUNGUS:Easy to get. Hard to treat.Nail fungus is an unsightly but relatively benign condition, and accounts forabout half of all nail disorders, according to the American Academy ofDermatology (AAD). “The fungus is everywhere,” said Farid Quraishi, D.P.M.,a podiatrist at Oxon Hill Orthopaedics in Oxon Hill. “It’s in your house, in yoursoil, all over the place.” BY MARY WADE BURNSIDE

GENERAL HEALTH


hile fingernails alsocan become infected,toenails are moresusceptible to fungalinfections because of

their proximity to the floor and thesoil, said Quraishi. Toes are alsooften confined to a warm, moist,weight-bearing environment inshoes, according to the AAD.

Wearing shoes and socks—oneway to help prevent nail fungus—does not always do the trick.

“Even if you wear socks, somepeople don’t change their socksevery day,” said Quraishi, who hasprivileges at Southern MarylandHospital Center in Clinton andFort Washington Medical Centerin Fort Washington.

Those who have athlete’s foot—an infection of the foot caused byfungus—can become reinfectedfrom not washing their socks ornot spraying their shoes with anantifungal spray. The same canhold true for those with nail fun-gus. In fact, Quraishi said, many ofhis patients who have nail fungushave previously had athlete’s foot.

If left untreated, a nail fungusinfection can lead to more prob-lems, especially for those withweakened immune systems, suchas patients with leukemia or AIDS,according the Mayo Clinic. Also,someone with diabetes who con-tracts a nail fungal infection mayhave more complications.

“People who are immunocom-promised, people who have circu-lation problems in the leg, peoplewho have diabetes, they are moresusceptible to getting fungus in thenail,” Quraishi said.

Some people are genetically pre-disposed to the condition, accord-ing to Lawrence Green, M.D., adermatologist who practices atShady Grove Adventist Hospital inRockville. Plus, the older we get,the more easily we seem to contractnail fungus, he noted.

“There must be some sort of adecrease in your natural immunefunction so you can’t fight it off likewhen you are 25, so you get it eas-ier,” said Green.

As many as 30 percent of sen-iors have had nail fungal infections,known as Onychomycosis, accord-ing to the AAD.

With Onychomycosis, the nailcan become thick and crumbly.

“Your nail gets thicker, whiterand the debris builds up under thenail,” Green said. “That’s themost common form of toenailfungus. There are other kinds inwhich you don’t get the thick andcrumbly nail.”

Another type, white superficialOnychomycosis, is similar, but hasless severe symptoms. In bothcases, patients might not notice anychange in their nails for some timeafter being infected. “It comes onslowly,” Green said. “Some peopledon’t look at their nails. It takes awhile to develop.”

Since the infection is underneaththe nail plate in the nail bed, treat-ment is difficult, according to theAAD. The slow growth rate of nailscan explain why it can take time forsomeone to notice the infection, aswell as why it can take so long tocure. It can take a year or longer togrow a toenail, Quraishi said.“And for everybody it’s different.”

While the condition is not neces-sarily painful, said Quraishi, it canbe if one stubs a toe or tries to wearpointy shoes or other footwear thatpresses against the nail.

Both Quraishi and Green saidoral medications are more effec-tive than topical ones in treatingnail fungus. Quraishi prescribesthe oral medication terbinafine,commonly known as Lamisil,which he said has been found tobe 85 percent effective. He com-pared this to a rate of 35 percentfor a topical medication, whichgenerally must be applied twice aday for several months.

Before prescribing Lamisil,Quraishi takes a culture of the nailto determine whether a patient hasa nail fungus. If that comes backpositive, blood work is done to testthe patient’s liver function.

“With Lamisil, it can have sys-temic results and 1 percent of thepatients can get

W

[continued on 20]

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hepatitis,” he said. If a patient beginsto have systemic symptoms, such asnausea or vomiting, he should stoptaking it. According to Green, apatient taking Lamisil has “virtually”no chance of having liver problems.

The medication itraconazole, mar-keted under the brand nameSporanox, requires that the liverfunction be monitored, and in rarecases may cause congestive heart fail-ure, according to the U.S. NationalLibrary of Medicine.

Laser treatments on nail fungus areused by some doctors, but neitherQuraishi nor Green use this form oftreatment. “It’s not covered by insur-ance, so using it is out-of-pocket,”said Quraishi. “The problem with

that is that the anecdotal evidence isgood, but there are no long-termstudies because it’s a new treatment. Itdoes treat the fungal nail, but nobodyknows what the reinfection rate is. ”

Prevention is the best way to battlenail fungus. However, “By the timemost people come to see me, theyhave fungal nails, so there is very lit-tle I can tell them in terms of avoid-ing it,” Quraishi said.

Some tips to protect your nailsinclude: wear clean socks and shoes,and spray them with an antibacterialspray once or twice a month; keepyour feet clean and dry, as well as drybetween the toes; and if you showerat a gym, wear flip-flops, Quraishisaid. “Once you get it, it’s hard to getrid of it.”

should get Tdap. Adults between theages of 19 and 64 should get a singleTdap vaccine.”

IN FEBRUARY, THE CDC’S ADVISORYCommittee on Immunization Prac-tices recommended Tdap for all adults65 and older. Given whooping cough’sresurgence, the committee is reviewingthe need for additional doses of Tdapand the timing of revaccination ofthose who have received Tdap.

Because more than 30 percent ofwhooping cough cases in infants canbe traced to the mother, it is impera-tive that pregnant women be vacci-nated, said Roldan. A dose of Tdapmay be given to underimmunizedwomen during the late-second orthird trimester, or in the immediatepostpartum period before dischargefrom hospital.

Pertussis is highly contagious and,once brought into a home, infects 80percent of susceptible members of thehousehold. “The only way to protectyour infant is to protect everyonearound the infant,” Roldan said.

Jain concurred: “If you have a smallinfant in the house, get everyone immu-nized who may come in contact—par-ents, grandparents, siblings, nanny.”

Because pertussis initially mimics acommon cold, many cases, particular-ly mild ones in adults, go undiagnosed,according to Robin Madden, M.D., a

pediatrician with Discovery Pediatricsin Silver Spring and secretary/treasurerof the medical staff at Holy CrossHospital. While the adult may not beterribly ill, he is contagious.

Keeping those who cough or sneezeaway from an infant is sensible,though not always practical. “Ifyou’re a mom or dad taking care of ababy, you’re probably not going to leta cough or cold keep you from doingso,” said Sinha.

Even more problematic is thatsomeone in the early stages of whoop-ing cough may not know he has it.“The incubation period lasts up tothree weeks and during that time theremay not be any symptoms, or just mildones. You may not feel your best orhave a bit of a runny nose.”

ONCE SYMPTOMS APPEAR, IT TAKES“about a week for the cough to turnmore severe,” said Roldan. “It’s arapid, deep cough followed, at the endof the episode, by a high-pitchedwhoop…Older kids may not have thewhoop, but may cough so forcefullythat they vomit. Like other upper res-piratory infections, whooping cough

may worsen at night.”Pertussis often presents differently

in infants. Cold symptoms may belacking. “Half of them have apnea,meaning they stop breathing,” saidMadden. “About 20 percent get pneu-monia, 1 percent have seizures and 1percent die. In about 0.3 percent thereis brain swelling, which could be dueto a lack of oxygen or from toxinsthat the bacteria produce.”

Whooping cough is most common-ly treated with an antibiotic. “Afterfive days on an antibiotic, [a person is]no longer considered contagious,”said Edwards. Still, it can take weeksto fully convalesce.

In the meantime, Edwards worksto identify anyone with whom awhooping cough patient may have

had close contact during the incuba-tion period and when symptomswere present. “Our investigationinvolves a fairly large group of con-tacts,” she said, “and we recommendto every single one that they receive aprophylactic antibiotic. We coordi-nate with physicians and, if a minoris involved, the parents.”

While natural infection may sub-sequently boost immunity to pertus-sis for a period—between four and20 years, according to CDC esti-mates—routine vaccinations shouldbe continued.

“We need to be vigilant about vac-cinations,” said Roldan. “No delaysor withholding. That’s how to protectthe unprotected.”

More than 30 percentof whooping coughcases in infantscan be tracedto the mother.

ISTOCKPHOTO/D

EREJEB.MODELS

MAY

NOTACTUALLY

HAVE

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WHOPPIN

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COUGH, continued from 8

metabolically active than subcuta-neous fat, which is found under theskin, said Boyd. In other words, bel-lies tend to shrink faster than hips orthighs. And, after just a 10-poundreduction in visceral fat, “lipid levelsstart dropping. Ten pounds can makea difference,” she said.

In addition to diet, exercise is crit-ical to reducing the size of one’spaunch. “But don’t think you canspot reduce. It doesn’t work,” saidBoyd. While sit-ups and crunchesmay strengthen abdominal muscles,those muscles will be hidden under alayer of fat. “It’s a combination ofaerobics and strength training thatwill help reduce that beer belly.”

While it’s important “to becomemore mindful of what you are put-ting in your mouth,” said Guay-Berry, it’s not necessary to depriveyourself of the libation that gave yourgut its name. “Beer and other bever-ages can be continued, but make sureto have them in moderation.

“For men, that means two beersor two 1-ounce servings of liquor orspirits or two 6-ounce glasses ofwine maximum per day.”

“People with beer bellies can ben-efit tremendously from lifestylemodification,” said Shnider. “Alter-ing the collection of fat in theabdomen is one of the most sensiblethings you can do to improve youroverall health.”

BELLY, continued from 17 NAILS, continued from 19


income, low levels of physical fitnessand poor dietary choices play a role,said Sinha and Ning.

Less than 10 percent of childhoodobesity is caused by genetics or anendocrine disorder, while diet andexercise are the main determinants,according to Ning.

Role of ParentsDoctors say parental involvement

is the game changer when it comes tolowering risk. “If a child is prediabet-ic, then parents have to become dia-betes experts,” said Sinha. “I haveseen patients who have come out ofthe prediabetes zone, but that doesn’tmean they won’t go back in.”

For parents who may not knowwhere to start, Sinha arrangesappointments with a nutritionist tohelp them devise a sensible diet fortheir child. Food diaries, in whichpatients write down everything theyconsume, sometimes work, althoughcompliance is minimal, he said.

To avoid setting a bad example,parents must also confront their own

weight problem if they have one. “Alot of kids who are overweight, theirparents are overweight as well,” saidSinha.

Parental perceptions about theirchild’s weight and health status aresometimes at odds with reality.“Parents perceive that a child’s diet ishealthy,” said Ning. “They don’t haveany idea what a normal diet is.” Foradolescent patients who are trying to

lose weight, Ning prescribes a 1,500-calorie-a day diet.

Cultural norms and attitudesabout weight and body image canalso influence behavior. The BioMedCentral Research Notes study foundthat compared with parents of otherraces, African-American parents“were more likely to report theiroverweight child’s weight as under-weight or normal and less likely toreport they felt their child’s weightwas unhealthy.”

The study also found that African-American girls “tolerated heavier bodyweight and perceived less social pres-sure to lose weight, resulting in infre-quent pursuit of lifestyle changes.”

Emotional CostWhen talking to a prediabetic

patient, Ning prefers not to use theword “obese,” especially when theparents are overweight themselves.She places a teenager’s weight in con-text, saying instead, “You seem to beoverweight for your height.”

Among the teenagers she treats forprediabetes, Ning said, “girls tend to

have a problem with depression”and, at times, eating disorders.Infrequent menstrual periods are alsoa hallmark of prediabetic girls, sug-gesting they might have polycysticovary syndrome, an endocrine disor-der that may lead to infertility.

Sinha advises boys at risk for devel-oping prediabetes to “treat their bod-ies like a temple.” Yet these pep talkscan’t always lift a teenager’s self-esteemand create motivation to change.

“They’re tired,” said Sinha. “They’reexhausted by being different. They’reexhausted by…being told what todo....I see many patients who are veryfrustrated and who have given up.”

Patients who are already motivatedacademically tend to do better withtreatment plans, he said. They tend toapproach their own weight loss like achallenging assignment and get excit-ed about setting goals and completingtasks. Strong parenting and lots ofpositive reinforcement aid the process:“You want to empower the child, andget them to take responsibility fortheir own health.”

PREDIABETES, continued from 11 “If a child is prediabetic,then parents have tobecomediabetesexperts. I have seenpatients who have comeout of the prediabeteszone,but that doesn’tmean they won’t go

back in.”-Vivek Sinha, M.D.

WE TAKE CARE OF VETERANS!

Compassionate Care.Quality Care.Veteran-centered Care.

Call the Patient Service Center at 1-877-DCVAMC1or visit www.washingtondc.va.gov


VEGETARIANS MISS OUT ON A LOT OF FOODS, BUT THEY ALSO TEND TOmiss out on a lot of major health problems that plague manyAmericans. They generally live longer than the rest of us, and they’remore likely to bypass heart-related and other ailments.

Most people think of vegetarian diets as simply eating plant foods andnot eating meat, poultry and fish, but there are many variations.

Strict vegetarians, or vegans, eat plant foods and reject all animal prod-ucts—meat, poultry, fish, eggs, dairy and sometimes honey. Those whoalso eat dairy products are called lacto-vegetarians. Vegetarians who eatboth dairy and eggs are called lacto-ovo vegetarians. Some vegetarians eatfish but not meat or poultry. They’re called pescatarians (pesce is Italianfor fish).

“Then there are the so-called flexitari-ans, or semivegetarians. These are peoplewho eat a mostly vegetarian diet, but theyoccasionally eat meat,” said Jody Engel, anutritionist and registered dietitian at theNational Institutes of Health (NIH). “Theymight say ‘I’m a vegetarian, but I need toeat my burgers every Sunday.’ People tendto follow their own rules, which is one rea-son why it’s hard for researchers to studyvegetarians. There’s so much variance.”

Despite the different definitions, “there’stremendous agreement among nutritionexperts and health organizations that amore plant-based diet is beneficial, whetheryou’re a true vegetarian or not,” said NIHnutritionist Dr. Susan Krebs-Smith, whomonitors trends in cancer risk factors.

Vegetarian diets tend to ingest fewercalories, and have lower levels of saturatedfat and cholesterol, and more fiber, potassium and vitamin C than thosewith other eating patterns. They tend to weigh less than meat eaters, andto have lower cancer rates. “Evidence also suggests that a vegetarian dietis associated with a lower risk of death from certain heart diseases, andthat those who follow a vegetarian diet tend to have lower LDL [‘bad’]cholesterol levels,” said Engel.

IN SOME CASES, THOUGH, IT’S UNCLEAR IF CERTAIN HEALTH BENEFITScome from plant-based eating or from the healthy lifestyle of most veg-etarians. “Vegetarians are generally more physically active and havehealthier habits than nonvegetarians…,” said Krebs-Smith.

To tease out the effects of diet, scientists have to conduct large, careful-ly controlled studies that account for other factors. One of the world’slargest studies of plant-based diets is now under way at Loma LindaUniversity in California. Cardiologist Gary Fraser is leading an NIH-funded team of scientists to analyze data on 96,000 Seventh-day

Adventists in all 50 states and in Canada. Members of this religious grouphave unique dietary habits and a generally healthy lifestyle. Adventists areencouraged to follow a vegetarian diet, but about half the populationsometimes eats meat. These variable eating patterns allow scientists tocompare a wide range of dietary habits and look for links between dietand disease.

To date, the researchers have found that the closer people are tobeing vegetarian, the lower their risk of diabetes, high blood pressureand metabolic syndrome—a condition that raises the risk of heart dis-ease and stroke. “The trend is almost like a stepladder, with the lowestrisks for the strict vegetarians, then moving up for the lacto-vegetarians

and then the pescatarians and then thenonvegetarians,” Fraser explained.Earlier studies found that vegetarianAdventists also tend to live longer thanboth meat-eating Adventists and non-Adventists. The vegetarians also havefewer instances of coronary heart diseaseand lower rates of some cancers.

BECAUSE VEGETARIANS BY DEFINITIONdon’t eat meat, some people jump to theconclusion that simply cutting meat fromtheir diet will lead to health benefits.“But it’s actually more complicated thanthat,” said Fraser. “Differences in lifeexpectancy and other health mattersmight be related to the extra fruits, veg-etables, nuts and legumes—includingsoy—that vegetarians tend to eat. Youcan’t necessarily conclude it’s based onthe absence of meat.”

Experts generally agree that vegetarians who eat a wide variety offoods can readily meet all their body’s needs for nutrients. However, theyneed to be sure they take in enough iron, calcium and zinc. Studies showthat most vegetarians do get enough, in part because so many cereals,breads and other foods are fortified with these nutrients. “Vegans in par-ticular need to be certain to get enough vitamin B12 and omega-3 fattyacids,” said Rachel Fisher, a registered dietitian involved in nutritionresearch at NIH. Omega-3—found in fish, flaxseed, walnuts and canolaoil—is important for heart health and vision.

Some vegetarians take dietary supplements to ensure they’re gettingeverything they need. Talk to a registered dietitian or other health profes-sional if you’re a vegetarian or thinking of becoming one.

Whether you’re a vegetarian or not, Fisher said, you can benefit fromthe high fiber, low fat and rich nutrients of a vegetarian diet.

-Excerpted from NIH News in Health

experts’ opinionNational Institutes of Health

Is a Vegetarian Diet Healthy?

Vegetarians have fewer instancesof coronary heart disease andlower rates of some cancers.

ISTOCKPHOTO/M

ARIABOBROVA



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