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Why Older Women Break Their Hip Bones So Easily

Drotumdi O

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Otumdi Omekara, MD., MPAHA - Member of Society of Physician Entrepreneurs

Fifty five percent of all Americans aged over 50 years have osteoporosis or thin spongy bone, that is highly susceptible to compression and breakage. One out of every two white women in US will fracture a bone in her lifetime. Although all long bones and vertebral bones are vulnerable, the most common fractures affect the hip bones. About 20% of post-menopausal women who fracture their hip bone die within a year of the fracture, while 20% of these women often have a second fracture one year down the road. 

 

The cost of treatment and nursing home rehabilitation of hip bone fracture patients runs into about one billion dollars a year. Currently about 10 million Americans have mild bone thinning or osteopenia. Another 34 million people have severe bone thinning or osteoporosis. This number is expected to increase in the years ahead with many more US citizens growing older. 

 

 Osteoporosis is mostly attributable to bone thinning usually after the age of 35 years, for various reasons. The normal rate of bone thinning due to age is 0-3% to 0,5% per year. Bone density usually peaks at the age 25 and remains there for another 10 years. Genes (family history), environment, sex, ethnicity, hormones, and medications influence bone density. 

 

 Men tend to have heavier bones than women, even as African Americans tend to have heavier bones than Caucasians and Asian Americans. The short supply of sunshine in North America reduces the availability of Vitamin D, which normally helps the absorption of dietary calcium. 

 

 Women are particularly vulnerable to osteoporosis because of the progressive decrease in the level of estrogen needed to support bone density after the menopausal age of 45 years. Bone thinning is accelerated to 2% - 4% with up 25 % to 30% loss of bone density by age 55. The spongy nature of the bone is produced by normal formation of protein structure (collagen) of the bone without adequate calcification. 

 

 Cigarette smoking, alcohol consumption, low protein and low calcium diets, as well as malabsorption from celiac sprue or biliary cirrhosis can all contribute to low bone density and easy bone fracture in older women. Diseases like hyperthyroidism, anorexia nervosa or vigorous exercises (common among teenagers) can eventually cause amenorrhea (cessation of menses) with secondary bone thinning. 

 

 Stroke and chronic arthritis, which cause immobility, also lead to loss of bone density. Abnormally high level of parathyrioid hormone, which normally maintains the normal level of blood calcium ends up stripping the bones of calcium, with marked reduction in density. High level of parathyroid hormone is often found in some forms of lung cancer as a paraneoplastic syndrome. Long-term use of heparin (blood thinner), phenythoin (anticonvulsant) and prednisolone (steroid) may also lead to loss of bone density. 

 

 Based on the what has been discussed so far it becomes necessary for every woman above 45 years to be aware of the high risk of bone fracture from osteoporosis and seek to be on a physician-prescribed preventive program. This includes X-ray and DEXA scan monitoring (T score of - 2.5 of or higher), adequate moderate outdoor exercises, and preventive medications like Alendronate (Fosamax) and estrogen replacement therapy (ERT).  See more of similar articles and product recommendations. 

Reliability of Body Mass Index In Obesity Measurement

Drotumdi O

Otumdi Omekara thumbnail.jpg

Otumdi Omekara, MD. MPAHA, Member of Society of Physician Entrepreneurs

After many years of argument researchers have seemingly come to terms with the fact that an overweight person can also be metabolically healthy to the same extent that a normal weight person can be metabolically unhealthy (Jeffrey Hunter et al, 2016).

This paradigm change comes at a time when the US fashion industry has just started promoting plus-sized models to challenge the notion that being large-sized automatically means being unhealthy and being thin automatically means being healthy and beautiful.

The only problem with this government observational survey is that it is a relatively lower level research study, hardly usable for establishing causal relationships between any two variables. Higher level randomized clinical intervention studies still uphold body mass index BMI as the yard stick for measuring obesity alone, excluding overweight patients (Mora, IM Lee et al, 2006).

This same study also acknowledged an increased positve correlation between BMI and cardiovascular risk factors, after adjustment for physical activity. But the federal survey team did not factor that into their explanation for the higher sensitivity of metabolic risk factors alone.

High level research has also established that both overweight and underweight patients have higher cardiovascular, renal and endocrinological morbidity and mortality rates (Bleich S. et al, 2008 ; WHO, 2015).

As such, it ought not to be too surprising that the government survey found many (marginally) normal weight adults with abnormal metabolic risk marker results (high blood pressure, high blood glucose, high cholesterol and high c-reactive protein, etc.). Even more so, it should not be the basis for downplaying the role of BMI as the gold standard for measuring obesity and over weight .

Mora S. et al (2006) used a double blind clinical trial to establish direct association between BMI and cardiovascular risk factors in 27,138 adult women averaging 50.4 years in age. Only a similar clinical trial can contradict their findings.

While BMI and metabolic risk factors (metabolic index) have been shown to be equally sensitive in identifying obesity and over- weight when present, they are better used in combination for synergistic reasons (Buchholz A.C. et al, 2005).
Another important consideration when addressing low BMI sensitivity in obesity and overweight measurement relates to the classification of obesity.

At optimum weight a US adult has a BMI of 18.5 - 24.9 Kg/m2, an overweight adult has a BMI of 25.00 - 29.90Km/m2, while an obese adult has a BMI of 30 Kg/m2 or more. Any BMI below 18.50 Kg/m2 is classified as underweight. The overweight BMI also corresponds to the premorbid stage of obesity, when there is no sickness involved, other than the psychological embarrassment of feeling shapeless and sloppy.

Morbidity or abnormal metabolism only sets in at the obese weight level. Thus a large-sized premorbid overweight person may still weigh in as metabolically healthy. On the other hand, a marginally normal weight person may weigh in as metabolically unhealthy.

The healthy overweight person manifests what is called hypermetabolic syndrome, characterized by generalized increase in the anabolic metabolism. In people with hypermetabolic syndrome, there is increased production of normal bony tissue , muscle tissue and fat cells.

To adequately maintain the increased body mass, the anabolic hormones, including growth hormone, thyroxine and insulin are also increased within normal limits. There is also increased food demand by way of voracious appetite to meet the high metabolic demand.

How this increased appetite is managed usually determines how fast a person tilts from overweight into obesity. Poor food choices will lead to raised blood cholesterol and blood glucose, with secondary diabetes, coronary heart disease and chronic kidney disease. This is when the person becomes metabolically unhealthy.

The marginally normal weight person is usually tilted into metabolically unhealthy state by cachexic pro-inflammatory toxins (C-reactive proteins) that affect not only the heart health, but also account for the generalized weight loss.

This form of weight loss is often seen in chronic obstructive lung disease (COPD) and cancer patients. These patients also tend show normal metabolic marker results for heart health, except in cases like juvenile diabetes and familial hypercholesteremia.

Rather than castigate BMI as an obesity measurement tool, researchers should start focusing on optimum weight, which varies for individuals. By definition, the optimum weight for any individual is the weight above or below which an individual becomes metabolically unhealthy.

At optimum weight a person can be skinny or plump and still be metabolically healthy. A clearer understanding of how the weight classification of an individual can affect his/her BMI measurement, is therefore essential to the accurate evaluation of BMI reliability as a measuring tool for obesity.

References

1) Jeffrey Hunter, et al, "New loci for body fat percentage reveal link between adiposity and cardiometabolic disease risk" Nature Publishing Group,
© 2016 Macmillan Publishers Limited. All Rights Reserved.

2) S Mora, IM Lee, JE Buring, PM Ridker - Jama, 2006 - archpedi.jamanetwork.com

3) "Obesity and overweight Fact sheet N°311". WHO. January 2015. Retrieved 2 February 2016.

4) Bleich S, Cutler D, Murray C, Adams A (2008). "Why is the developed world obese?". Annu Rev Public Health (Research Support) 29:273–95.doi:10.1146/annurev.publhealth.29.020907.090954. PMID 18173389.

5) Buchholz, A. C., and J. M. Bugaresti. "A review of body mass index and waist circumference as markers of obesity and coronary heart disease risk in persons with chronic spinal cord injury." Spinal cord 43.9 (2005): 513-518.

Dr. Otumdi Omekara is a preventive/business medicine specialist and medical publisher with over two decades of clinical practice experience and over a decade of provider management experience. His passion for patient education drives his medical content article writing and publishing. He was a health educator at Oregon DHS Center for Disease Control from 2001 to 2002. Prior to that he volunteered at NE Portland Neighborhood Clinic as a health educator from 1997 to 2002. Since 2002 he has been the Medical Publisher at Drotumdio Health Publications (dHp). He lives in Portland Oregon and can be reached through his website at www.health-pub.com or by text at +1971-2085909.

Risk Management In Health Care

Drotumdi O

Otumdi Omekara, MD. MPAHA, Member of Society of Physician Entrepreneurs

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Risk management in the health care industry is not too different from other industries, since every industry basically manages money, men and material. Each of these three core management areas poses its own risks that ultimately affect any company's bottom line or net worth. Anything that takes away from a company's net worth is a risk that has the potential to put it out of business. Any company that fails to effectively manage its risks basically plans to fail. In the health care industry, the tendency is for only for profit health care organizations to pay serious attention to risk management. Social health care services funded by governments and not-for-profit organizations generally focus more on service delivery with little attention to risk management, counting on the funders to always provide the funds.   

But the irony is that government funded agencies are managed by human beings who belong to the "men" category of the three main risk sources. Politicians dictate how much fund is allocated to the health care and other industries. If they are not managed well, they pose the risk of reduction in health care capital, which impacts the establishment and maintenance of health care infrastructure and professional manpower. This in turn impacts accessibility of health care services due to limited service points. Professional health care associations like the American Medical Association have learned to manage this risk by hiring the services of professional lobbyists in Washington DC to ensure that no laws are passed that are detrimental to health care funding and practice. Individual retired health care professionals have also contested for congressional and senatorial offices at state and national levels to ensure that the necessary protective health car laws are created and passed in a timely manner.    

While the traditional emphasis in preventive medicine had been to break the vicious cycle of poverty, ignorance and disease, current preventive medicine now stretches to monetary loss prevention and material over-utilization and loss prevention. Poverty, ignorance and disease all focus mainly on patient related risks without addressing the money and material related risks. Money and material risk prevention have in the past been viewed as outside the area of responsibility of preventive medicine experts. But well informed patients earning average income are still constrained by affordability of adequate health insurance for  accessing the health care system to treat their diseases. The risk management need in this case is for an appropriate health insurance law like the current ACA passed by the Obama administration to accommodate individuals not covered by Medicare and Medicaid insurance laws.  

In general, health care management risks fall into two broad categories: revenue reducing and revenue wasting risks. The revenue reducing risks include inadequate budgetary allocation to government funded health care agencies, legally restrictive private provider insurance billing rates, inefficient revenue collection system from insurance payers and inefficient account receivable system for patient billing system. The revenue wasting risks include inefficient organizational budgeting, inefficient budgetary control system, inefficient audit system, inadequate electronic and physical financial security, inadequate organizational property security, inadequate loss prevention policies, inadequate employee injury prevention, inadequate regulatory compliance policies and inadequate law suite prevention policies. How each of these risk factors affects the net worth of a health care organization will now be further explored to create increased management sensitivity to their riskiness.  

The way politics affects budgetary allocation for health infrastructural and manpower development has already been touched on above. A US administration  or state government that does not believe in abortion will reduce allocation of funds to Planned Parenthood and prohibit insurance payment for abortion related patient care. Similarly an administration that does not believe in a large military establishment will reduce military budget, which in turn will reduce Veterans Administration's funding of physicians and nurses education. Less number of doctors ultimately reduces patient access to health serves. Thus the control of revenue reducing risks starts at the Federal government level with the employment of professional lobbyists.  

Private health institutions  have the option of accepting large volume of Medicare or Medicaid patients at a reduced fixed government rate or limited volume of direct pay and other insurance pay patients. Very few health organizations in US can function successfully without accepting Medicare and Medicaid patients. Again, to contain this revenue reducing risk, US health services managers lobby hard for more favorable Medicare and Medicaid laws.  They also lobby hard for the appointment of favorable candidates for the offices of Secretary of Health and Human Services and US Surgeon General.   

For individual health facilities, dealing with insurance payers is such a night mare with the complicated coding system. Inability to effectively submit patient bills to insurance payers can frustrate an organization out of business. Insurance payments can take weeks to months after a patient's visit. Providers can hardly count on current month's revenue to pay current month 's bills. A simple mistake or multiple payers for one patient can even further lengthen the payment time. Not being able to generate cash for payroll each month forces management to borrow money from the banks and further lose money on interest payment. The portion of patient bills not legally covered by insurance plans also need to be aggressively collected by the accounts receivable teams. So most health facilities now make sure to have very efficient case management and billing teams who are always on top of their games, as a way of managing these last two revenue reducing risk factors.  

Coming to the revenue wasting risks, the first is bad organizational budget, which fails to represent the ultimate working document for any organization's strategic plan. A good organizational budget should be addressing the vision, goals and action plans of the organization. A good budget makes it easy to compare financial projections with actual performance and apply necessary financial controls. When and where to apply financial control is usually determined by independent monthly or quarterly audits by the CEO or an internal auditor.   

The financial security of any organization has to do with where it stores its physical cash/checks and how it control access to its bank accounts. There should be clear policies on who should have access codes to company safe onsite and its online banking sites. At least two top level officers, like the CEO and CFO should have the ability to access the onsite safes and bank accounts. If the CEO alone signs the checks, the CFO alone should sign major purchase invoices. Both should receive alerts about every major transaction on the accounts. There should be an agreed limit to maximum daily or monthly withdrawals. The bank account pass words should be changed at least quarterly and never be saved on the bank website. A good IT unit helps to protect an organizational website from hackers. Just one  major fraud by any company executive could easily cripple or bankrupt a health facility.   

Loss prevention in a health facility requires an in-house or contracted security service. Loss of major equipment and installations prevention requires a skilled maintenance unit. The security service provides public safety, patient safety, provider safety, and prevents property theft and vandalism. Work site injury and falls are both major risk sources in any health facility. Workman compensation claims could add up to millions of dollars a year. Employee safety training and safety procedure enforcement have proved very effective in workman compensation claims. Staying in compliance with the ADA laws by creating disability friendly facilities protects them against expensive law suits by fall victims. Very few health facilities can survive more than one or two major law suits.  

If a health facility survives the risks of heavy law suits, it could still be caught by the most dangerous of them all, regulatory non-compliance. In fact regulatory non-compliance in the areas of unreported patient negligence, physical abuse, financial abuse, sexual abuse, verbal abuse, rights violations, privacy violation or racial discrimination could lead to facility failure of re-certification surveys and suspension of facility operating license or outright closure of the facility. Most health facilities manage this dangerous risk by retaining the services of independent health care regulatory compliance consultants to continuously audit patient care and correct any non-compliant practices prior to re-certification surveys. 

What has been discussed so far should awaken or re-awaken a high sensitivity in health facility executives to the various risk factors plaguing the industry. Both the veteran executive and a new health facility  administrator will benefit from this discussion. Employees will, on their part probably begin to understand why their facility executives tend to be very touchy about seemingly unimportant events in their facilities. However we look at it, efficient risk management in health care remains at the core of successful management and facility survival.  

Author: Otumdi. Omekara, MD., MPAHA 
https://www.health-pub.com 
PO Box 91221, Portland OR, 97291 
drotumdi.o@health-pub.com 
(971) 208-5909 

Dr. Otumdi Omekara is a preventive/business medicine specialist and medical publisher with over two decades of clinical practice experience and over a decade of provider management experience. His passion for patient education drives his medical content article writing and publishing. He was a health educator at Oregon DHS Center for Disease Control from 2001 to 2002. Prior to that he volunteered at NE Portland Neighborhood Clinic as a health educator from 1997 to 2002. Since 2002 he has been the Medical Publisher at Drotumdio Health Publications (dHp).

Dr. Otumdi Omekara is a preventive/business medicine specialist and medical publisher with over two decades of clinical practice experience and over a decade of provider management experience. His passion for patient education drives his medical content article writing and publishing. He was a health educator at Oregon DHS Center for Disease Control from 2001 to 2002. Prior to that he volunteered at NE Portland Neighborhood Clinic as a health educator from 1997 to 2002. Since 2002 he has been the Medical Publisher at Drotumdio Health Publications (dHp). He lives in Portland Oregon and can be reached through his website at www.health-pub.com or by text at +1971-2085909. . 

 

Outdoor Treatment for SAD Time Blues

Drotumdi O

Otumdi Omekara, MD., MPAHA - Member of Society of Physician Entrepreneurs

Otumdi Omekara, MD., MPAHA - Member of Society of Physician Entrepreneurs

Sad feelings come and go following bad news, disappointments, financial losses, rejections, health failures, job losses, relationship failures, etc. But when we get SAD during the fall and winter months, we are diagnosed with seasonal affective disorder or SAD Time Blues. This is one of the six recognized types of clinical depression, differing mainly in its timing. It has been associated with the sudden switch from longer summer days to shorter fall and winter days in temperate regions of the world.

Day light entering the eyes helps the hypothalamus in the brain to maintain the normal sleep - wake cycle or circadian rhythm. The light stimulates the pituitary, and pineal glands to release hormones that stimulate the ascending reticulated activating system (ARAS) to keep us awake. The same light normally suppresses the release of serotonin from the enterochromaffine cells of the raffle nuclei of the brain. Thus with sudden drop of light supply during the fall and winter months, the blood level of serotonin rises dramatically causing increased sleepiness, tiredness, irritability and ultimately depression. Severe depression may lead to suicidal thoughts and suicide attempts, which also generally increase during the winter months.

Like other major depressions, SAD may present with, sadness and irritability, loss of interest in previously exciting activities, feeling of hopelessness, social isolation, excessive sleep, increased appetite and weight gain. The diagnosis is mostly clinical and therapeutic. Hormonal assays are mainly used to confirm the diagnosis and track clinical progress. With or without treatment, seasonal affective disorders tend to improve by the onset of spring season. This is what differentiates it from the other five forms of major depression.

Treatment modalities include, light therapy, cognitive therapy and antidepressants (when severe). Light therapy substitutes 10,000 Lux light for day light for the short fall in normal day light (Danilenko K. V.V et al). Cognitive therapy helps patients to actively substitute optimism for hopelessness, social involvement for social withdrawal, and thoughts of living for suicidal thoughts (Melrose Sherri, 2015). Both light therapy and cognitive therapy have been shown to be effective in the treatment of SAD (Rohan, K. J. et all, 2015). But patients treated with cognitive therapy have been also been shown to have lower recurrence rate in subsequent seasons because they have thought through their conditions and adopted positive interpretations (Sitnikov L. et al, 2013).

Social integration or outdoor treatment has the advantage of combining light therapy and cognitive therapy. 'Outdoor' here is relative to a patient's seclusion environment. Since most social environments like the malls tend to be well lit up, the SAD patient gets supplemental light while socializing. The outdoor patient also sees how other people are coping with shorter days and finds hope for making it through another winter. Seeing less privileged people in the community actively striving to survive also helps the SAD patient to switch from death wish to life wish. Volunteering in social recreational activities away from their homes may, therefore, be the easiest way for patients to take advantage of the outdoor Treatment for SAD.

References:

Danilenko, K. V., and I. A. Ivanova. "Dawn simulation Vs. bright light in seasonal affective disorder: Treatment effects and subjective preference." Journal of affective disorders 180 (2015): 87-89.

Melrose, Sherri. "Seasonal affective disorder: an overview of assessment and treatment approaches." Depression research and treatment 2015 (2015).

Rohan, K. J., et al. "Randomized Trial of Cognitive-Behavioral Therapy Versus Light Therapy for Seasonal Affective Disorder: Acute Outcomes." The American journal of psychiatry (2015): appiajp, 201514101293.

Sitnikov L, Rohan K. J, Evans M, Mahon J. N, Nillni Y. I."Winter depression recurrence one year after cognitive-behavioral therapy, light therapy, or combination treatment." Behav Res Ther. 2013 Dec;51(12):872-81. doi: 10.1016/j.brat.2013.09.010. Epub 2013 Oct 17. PMID: 24211338

Dr. Otumdi Omekara is preventive medicine specialist and medical publisher based in Portland Oregon. He publishes health & Fitness articles for consumer information and webmaster republication to boost traffic on their websites. He also features selected well priced medical products. He can be reached at PO Box 91221, Portland OR 97291, drotumdi.o@health-pub.com, or 971-208-5909.