LiveLongAgeWell

Several weeks ago I detailed some problems with the common over-the-counter pain reliever acetaminophen (otherwise known as paracetamol, and the biggest U.S. brand name is Tylenol). The issue is that this medication, even in what many consumers feel is a safe dose, can lead to permanent liver damage.

Just today there was a big FDA meeting in Maryland, and a number of  recommendations were made (likely to be accepted by the full FDA) which will soon limit your choices for OTC and prescription pain relievers. The committees voted to limit the maximum pill size from 500 to 325 milligrams for acetaminophen, and lower the accepted maximum daily dose to well under the current 4000 milligrams. Further—and significant for many people in chronic pain—it looks like Percocet and Vicodin, two exceedingly popular drugs that mix acetaminophen with a stronger narcotic, will be banned. Read more details here

Normally I publish a post on Monday or Tuesday, and again later in the week. This week has been particularly busy for me, so…sunless tanning, part III of the sunscreen series, will be posted later in the week rather than today. In the meantime, if you are lucky enough to have sun where you are, I suggest you put on a good sunscreen and get outside!

At the end of this post I’ll tell you how you can be considered to enter the study…

If you follow LLAW, you might know that my “favorite supplements” are, currently, fish oil tablets and vitamin D. In various posts I have detailed all sorts of possible benefits from these two supplements, and note that you can get both through natural sources (such as small doses of sunshine, or salmon) as well as from pills (and generally, natural sources are the better option).

The problem is that various other supplements have been heralded in the past as being wonderful and great for a variety of problems, especially for cutting the risk of cancer and cardiovascular disease. But then when really well-designed research studies are done, the supplements often fail to show a good effect, and sometimes they even result in more harm than good.

Vitamin E, folic acid, selenium, and beta-carotene all fall into this category, like Michael Jackson, of “fallen super-stars”, and, who knows, in five years we might be saying the same thing about vitamin D or fish oil (though I doubt it). The type of study that needs to be done—to see if vitamin D and fish oil are really any good—is a double-blind, randomized, prospective clinical trial. This sort of study is not commonly done as it’s expensive and it takes years to see the results.

Such a study starts with a large group of people, preferably many thousands, and splits them up into equal groups, that is, groups that are equally healthy or unhealthy, and then the researchers give some of them an active pill, for example, vitamin D, and the other group a fake pill, a placebo, and then a few years later compare the two groups to see how they did. Best if neither the people taking the drug nor the researchers know who is taking what (“double-blind”), and only break the “code” at the end of the experiment.

But most studies on vitamins and supplements are not like this; instead, they are “retrospective”…the researchers look at the health of different groups of people and look backwards in time (retrospectively) and see what they were taking or doing or eating, and try to deduce if a particular behavior or vitamin or whatever was responsible for the good or bad effect. But this research method leaves a lot to be desired, and it’s one reason you read a study that comes out stating that such-and-such is great, then a year later, you read the opposite. The problem could well be that either study, or both, was poorly-designed, and unless you really dig into an article to see if the study was prospective, double-blind, etc, you don’t know which research to better believe.

So starting early next year Harvard University is going to be doing one of the prospective clinical trials with vitamin D and fish oil (they are calling this the VITAL study). The research will study the subjects for five years into the future (prospective) and see how they all do. In 2016, then, we should know if fish oil and/or vitamin D are good for decreasing the risk of stroke, heart disease, or cancer—the three diseases the research is studying. Now even this is not going to be a perfect study, as it relies on people self-reporting their health via questionnaire (at times inaccurate), and while the researchers try to disguise the placebo pills, some people will try to figure out what they’re taking, try to outguess the researchers, and/or will take extra vitamin D or fish oil or other agents on the side, or not take the pills as they promised to if they think they are placebo.

But still, this study is probably the best we’ll get, and is better than any retrospective study. Here’s your chance to be a part of it… Harvard is now recruiting potential “subjects”. If you are interested in participating, or just want to read more details about this study, click here.

Last week I presented some of the issues surrounding sunscreens and today I’ll give some practical hints. Unfortunately, there is still no sunscreen available that is even close to perfect; they all have potential issues regarding how well they block both UVA and UVB, how long they are effective, and how safe they are (particularly regarding absorption into the bloodstream). Still, protecting yourself from excessive sunlight is critical, not only to help protect from the number one cancer of all—skin cancer—but to avoid early aging. Consider this quote from the U.S. Environmental Protection Agency’s excellent pdf fact-sheet “The Burning Facts”:

Up to 90 percent of the visible skin changes commonly attributed
to aging are caused by sun exposure.

11 Hints…What You Can Do

1. If you are very concerned about the potential toxicity of sunscreens, consult this summary from the Environmental Working Group, a non-profit consumer “watchdog” organization that has issued a list of what they consider recommended and relatively safe products. One problem is that you probably won’t find many of their recommended ones at your local drugstore, but you can probably find most online.

2.If you are not so concerned about theoretical chemical risks, you can consult this short list of American Academy of Dermatology (AAD) “recognized” products (while not as cautious as the EWG list, the AAD is still quite a careful group). One brand from their list I particularly like is Aveeno, which you will be able to find locally. Aveeno makes high-quality products that are not terribly expensive.

3. The last several years has seen release of several products that have longer-lasting, stablilized UVA protection (as well as the more standard UVB protection), and Mexoxyl and Helioplex are two components to look for. Helioplex seems to be the superior product, and of those brands with Helioplex, I like the Neutrogena brand, particularly Neutrogena Ulta-Sheer SPF 70 with Helioplex. It’s what I use. Some researchers have claimed that since these chemicals are partially absorbed into the bloodstream, that they might have an estrogen, hormonal-type effect internally. Talk to your physician if you are concerned about possible hormonal effects,  and you may not want to use one that is absorbed, on children.

4. If you want a sunscreen that is not absorbed, find a zinc oxide or titanium dioxide product (and see EWG report above), though these often leave the skin with an unattractive white cast.

5. It is probably best to avoid spray and powder sunscreens that have (ultra-small) nano-particles which might be inhaled.

6. Besides using a broad-spectrum UVA/UVB product, buy at least a SPF 30, and use enough of it! Shockingly, you need to use a “shot-glass” amount, about 1 oz. (1/3 of a typical 3 oz. tube) for your entire body, if you want to get the advertised SPF factor. Bottom line: use more than you think you should.

7. Apply 30 minutes before going in the sun to allow it to absorb.

8. Sunscreens lose potency over time. Look at the expiration date when you buy or use, and throw away any product at 3 years.

9. Reapply after going in the water, after significant sweating, and about every 2 or 3 hours. Even “waterproof” sunscreens come off after 40 minutes in the water, so if you are a water person, look for “very waterproof” which should give double water protection.

10. Don’t forget to apply to areas commonly forgotten such as: the entire surface of the ear (I can’t count how many ear skin cancers I excised and re-constructed when I was in California), any bald spots, the tops of your feet….and use a lip-sunscreen too (lip cancer is common)!

11. Avoid the sun during peak times, 10 am to 3 pm, wear a hat and don’t forget quality sunglasses to protect your eyes from cataracts! (a subject for a future post…)

Next: self-tanning products.

Anti-Aging Supplements

The American Medical Association AMA) has issued a report about hormones promoted on anti-aging websites. These include such products as Human Growth Hormone (HGH), DHEA, and testosterone, and they are sometimes available through online websites, or at many stay-young clinics around the world. HGH is one of the most popular, and the AMA states “evidence suggests long-term use can present more risks than benefits”. I agree. The research regarding this product, in particular, is turning more and more negative. I would be very suspicious of anything you take by mouth and especially injections, even of  “natural” products, that promise to keep you young.

Zinc Nasal Products and Loss Of Sense of Smell

Speaking of natural, one of the most popular over-the-counter products sold to prevent and treat the common cold is Zicam spray, and the active ingredient is the metal zinc. Here’s a glowing report from 2003 citing research showing that if you start Zicam within 48 hours of the onset of a cold, your symptoms can be cut by 50%. Now it turns out that the makers of Zicam have received over 800 reports of partial or complete loss of the sense of smell, often permanent. The company has settled 340 lawsuits regarding the product, and many more will be filed. Fortunately, the company has withdrawn many of their products from the market. “Natural” doesn’t mean effective, nor safe. Some of them are, but most probably are not, and like Zicam, can be found to be harmful years later when serious side effect reports roll in. Most are not regulated by the FDA. Buyer beware, even for “natural” over-the-counter products.

Vitamin D and Dieting

Here’s another possible benefit of what is currently the “hottest” vitamin, that is, vitamin D. (You can search on this blog to see the various recent reports.) The latest research, just presented at the Endocrine Society Annual Meeting in Washington, showed that people who had a higher vitamin D blood level before dieting lost a significantly greater amount of weight during their diets than people with lower vitamin D levels, and the higher the level, the greater the weight loss. This doesn’t prove that if you take vitamin D, you will lose weight. More research will be done to see if taking vitamin D supplements allows you to lose weight more successfully.  While there is no proof at this point, vitamin D in reasonable doses is considered safe, so if I was trying to lose weight, I would make sure I was getting enough of this vitamin, either through sunshine, diet (especially fatty fish, such as salmon), or supplements.

First, the big picture: the most important measure you can take to keep a “youthful” appearance—as much as your particular genes will allow—is to minimize exposure to UVA and UVB irradiation from the sun. Of course staying out of the sun as much as possible is the most sure way, but also it’s inconvenient, impractical, and not healthy from many aspects, including the psychological ones, so most people use sunscreens. The problem is finding a good one.

Sunscreen use is critical both to minimize wrinkles and cut the risk of skin cancer, which ranks as the most common cancer of all. But the subject has become complex in the past few years, so today let’s go over some of the current science of sunscreens, and the next post I’ll give some specific ideas on what you can use.

A few years ago it was easy to know what to do. Most people, even dermatologists, felt that if you used a SPF 15 or, then…wow…a 30, you would be highly protected and would not have to worry much, because a 30 was thought to allow you to be in the sun 30 times as long as if you didn’t use any sunscreen. But in the last few years as more products have been released, with higher and higher SPFs, the sunscreen field has become much more murky and confusing.

Some doctors have even gone so far as to state that using sunscreens will increase the risk for the deadliest form of skin cancer, melanoma, because many products will stop the burn (mostly from UVB), but will not stop UVA. This UVA irradiation doesn’t cause as much redness, but penetrates more deeply into the skin causing worse aging damage and a higher melanoma risk. So since you don’t get red, you think you are fine, while the sneaky UVA rays are causing their deep damage.

One simple way to remember the basic difference between A and B is: UVA,  a longer wavelength, is the aging radiation, and UVB causes more burning…however, both, in excess, lead to wrinkles, skin cancer, and even a diminished immune system. And if you sit by a sunny window, know that UVA radiation penetrates glass.

Here is a summary of some recent issues. But don’t get discouraged as you read this, because there are some solutions, which we’ll discuss in the next post…

1. The “SPF” rating only concerns the level of UVB protection. There are no good FDA standards or labeling or SPF ratings for UVA, and many products don’t offer, or even claim, good protection from UVA.

2. Many of the chemicals that do provide UVA protection, perhaps ironically, break down quickly in the sun, which is one reason sunscreens should be re-applied every 2 to 3 hours.

3. Toxicity: some of the chemicals used in sunscreens are absorbed into our bloodstream and may be toxic. Particular concern has been raised about two popular components, oxybenzone and avobenzone, which theoretically could alter our internal hormonal balance, and some doctors advise: don’t use these on pregnant women or children. Then there are the super-small, nano-particles used in some expensive new products. Again, while some have claimed these tiny particles might be absorbed, the super-cautious Environmental Working Group has concluded they are not. But the EWG recommends staying away from spray or powder products that might cause lung damage from the inhaled nano-particles. Finally, some sunscreen chemicals have been shown to produce free radicals when mixed with sunlight, and free radicals (which we try to neutralize with antioxidants) lead to skin aging.

4. While many of those issues are controversial, most doctors agree: very few people use enough sunscreen to provide adequate protection. A large Australian study showed that even “diligent” sunscreen users were only applying about half of what they should to get the advertised SPF protection, and most people only get about a quarter of the protection they think they are.

5. “Waterproof” sunscreens only last for about 40 minutes in the water, and for typical beach use, even these should be re-applied regularly.

6. If you read this blog often, you know I am a big fan of vitamin D, which we naturally get from sun exposure on our skin, and many people are vitamin D deficient. For some, this D vitamin shortage is rooted in excessive paranoia about sun exposure and many of these people use too much sunscreen. Like most things in life, moderation is the best route.

Next: SPFs and good sunscreens.

Have you been reading the reports in the news regarding (the newly discovered) health problems that can result from long-term inadequate sleep? In the past, many felt that regularly sleeping less than seven hours a night was no big problem, but now, research is showing that if, on a regular basis, we aren’t getting enough sleep, the bad effects go way beyond just looking and feeling tired.

The most recent report is about the association between high blood pressure and short sleep times. Previous research has suggested a link between inadequate sleep and diabetes, and even obesity. One reason may be that the human organism requires a minimum amount of sleep to reset and calibrate our internal hormonal system.

Scientists have discovered that—surprisingly—people who undersleep tend to get fat, and one way to keep at a good weight is to make sure you are getting enough sleep. Only with enough sleep will our body have good healthy responses to ghrelin and leptin.

Maybe they sound like new diseases: ghrelin and leptin…but, ghrelin is a hormone we all have that’s formed in the lining of the stomach, and after being secreted, it goes deep into the brain and excites the same mechanism that causes some people to become addicted to say, food or alcohol. The other one, leptin, is a hormone secreted by our fat cells (!) that puts the breaks on appetite by acting on our brain in the opposite fashion. You can only imagine that biotech drug companies are racing to find and sell a pill that acts like leptin.

Bottom line: if you don’t sleep enough, you tinker with this leptin/grhrelin balance in a bad way; the tendency is to get fat. Many of us suffer, at least occasionally, from sleep problems, and I’m briefly covering this issue so that if you are one of those sleep-poor people, well…let’s think about the problem in a more serious way, with more attention to fixing whatever are the underlying issues.

I’m curious if my readers are interested in hearing more about sleep, and about what happens if you don’t get enough, such as the effects on your blood pressure and heart (besides the diabetes and obesity issues). Leave a comment if you are, and if readers say they want,  I’ll write a more detailed report in the near future.

In my last post I gave a link to a scandalous blog written by two 80-something women, and if you haven’t looked at it, I suggest you do. For sure, these are some unusual women, but it shows what’s possible when a couple older people learn how to use a computer.

This recent New York Times article reveals how many oldsters have blossomed with a little social networking…it is happening! The benefits go beyond relieving isolation because—while the research proof is still not in—it’s likely that middle age and older adults who use online social networking have a significantly lower risk of becoming demented in later life. An older relative with dementia is no picnic for the sufferer nor for the spouse or children, so whatever can be done to lower that risk is well worthwhile for everyone.

This LLAW blog has a wide range of readers: subscribers range from age 23 to 94, but what is true for the youngest is true for the oldest—we all need a social network to live long and in good health, and the internet can be the vehicle that carries us there if our real-world network is insufficient.

Twenty- to 30somethings probably have a Facebook or MySpace (filled with ads now however) or Orkut page or at least MSN Messenger, so you know the potential of online connections. Now think about your older relatives or acquaintances who—for reasons of health or divorce or distant children, whatever—are more isolated. How about suggesting they consider online social networking, and then follow through to see that they really try it? There are new social networking sites for baby boomers and older, like eons.com. Many colleges have alumni networks, and Facebook’s growth is now greatest in the older crowd.

The big problem is getting some people to approach the computer, but you can start by pointing out that the computer is the most efficient and cheapest way to keep them up to date with family and friends. Mention that if they hope to see recent photos, those probably won’t arrive anymore in a photo album, and their only hope is to see them on the computer.

You can yourself tutor your computer-illiterate relative/friend, but this might be a big task, requiring lots of patience. Perhaps better if you research classes or tutors through the local “senior center” or community college (craigslist might be a little risky—you want these new, more vunerable users to be safe,  away from viruses, phishing, etc…).

While few 80somethings will end up online as wild and raw and funny as Margaret and Helen, you can still do a lot for others and yourself, fight the isolation that is too common in older folks, and along with that, cut the risk of a helpless, brain-weak relative in your future. Don’t wait.

My next blog will be about health and social networking on the internet, but today I suggest you check out this outrageously funny blog, (supposedly) written by two women in their 80s…it’s wild and raw and if you can imagine something written by the Golden Girls on steroids, this would be it.

These women—assuming it’s not a hoax blog, but I believe somehow two old ladies are writing—are definitely going to drop dead dancing in their 90s…at least dancing on their scooters (see their homepage). The best word I think to describe them—feisty; these are two feisty women, getting older and having a great time at it.

Warning: if you love Rush Limbaugh, Dick Cheney and/or don’t like to read strong language, probably best to avoid the blog, but otherwise, check it out:

http://margaretandhelen.wordpress.com/
I hope I’m not violating any copyright here, but here’s a sample of one of their posts, so you can see what I’m talking about:

Let me tell you a little story about my shit for brains nephew who actually does live in California. He was married ten years and had two children. Sadly, it didn’t work out. Honestly she was horrible, but you never really want to see a marriage end. So we were all a little sad when she left and he fell apart. Eventually he got his shit together, picked up the pieces and met another girl. I don’t like her much, but she makes him happy so what do I care if they want to get married? However, the Catholic church cared a great deal. You see, he was still married in the eyes of the church even though his moron of an ex-wife had been gone 4 years. And the new one is also divorced… and (oh my) a Baptist.

Problem? Not for long. Two annulments later and wallah – they were never married. Never mind the kids. Bastards all of them I guess. Funny but I didn’t know the Catholic church could annul a Baptist marriage, but you live and learn.

I’ve lived a long time and I have learned many things. For instance, I now know that even if the marriage is annulled, you don’t get your wedding gift back. I also learned that the previously married then divorced then never really married and now newly engaged couple can actually have the gall to print on their invitation where they are registered. As if that blender I purchased for the first wedding was annulled as well. But I digress…

Medical Bankruptcy

Health care costs have been one big reason we are in the Great Recession right now, and a majority of personal bankruptcies also have medical bills as a cause…. check out this New York Times blog post:

http://well.blogs.nytimes.com/2009/06/04/medical-bills-cause-most-bankruptcies/

Something seriously needs to be done to fix the medical care system. Usually I love Paul Krugman’s op-ed pieces in the Times, and today’s is about the insurance industry and health care reform:

http://www.nytimes.com/2009/06/05/opinion/05krugman.html?em

bottom line:

1) Don’t trust the insurance industry.

2) Don’t trust the insurance industry.

Finally, here is the single best article I have read that explains why the U.S. has been going bankrupt medically. (I am sure the same forces are taking shape in many other countries as well.) It’s long, but, in true New Yorker fashion, is a sample of writing perfection and well worth your time:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

I will leave you with a quote from the article:

the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue….

The U.S. Food and Drug Administration (FDA) will be considering later this month, at a meeting in Maryland, new restrictions on the labeling and strength of the pain-reliever acetaminophen (known internationally as paracetamol; the most famous brand is Tylenol). Studies show most consumers are unaware of the risks of the drug. It is not a bad medication—it can be a wonderful alternative to aspirin—but you need to be extra cautious with its use…let’s discuss why.

Drugs can be classified as to their “safety margin”, which refers to a comparison of the dose of a drug needed to be therapeutically effective compared with the amount of the drug needed to produce toxicity. Some drugs, for example, penicillin, are considered to have a rather wide safety margin because a relatively small dose of these drugs can be therapeutically effective (here, cure an infection), but normally you need a very large dose to get serious toxicity.

On the other side of the safety margin scale are drugs like acetaminophen, which have a NARROW margin of safety, meaning, the difference between a normal therapeutic dose and a dose that will produce toxicity or even death is relatively small (“narrow”).  So you need to be extra careful when taking a drug with a narrow safety margin, like Tylenol. Overdosage is common, and serious Tylenol overdosages are NOT easy to treat or reverse. Sometimes the only treatment is a liver transplant. Milder overdoses that occur over a period of time might not even be recognized by the patient, but result in chronic liver damage.

Shockingly, acetaminophen overdosage is the “leading cause of acute liver failure in the United States”. Meaning this drug is worse than alcohol for causing acute liver failure (note that “acute” in a medical sense does not mean serious, rather, acute means a condition that arises or appears over a very short period of time).

Severe liver damage from this OTC drug can occur from a dose that you might not consider excessive. A person who already has some level of liver problem—for example from chronically drinking too much alcohol—can suffer irreparable liver damage from taking only four or five 500 mg. tablets over one 24 hour period.

Currently, the maximum safe dose (as listed on the product label) is 4000 milligrams per day, meaning: a maximum of two-500 mg. “extra-strength” tablets every 6 hours for a day. But…how often do you think this dose is exceeded, if not by you, by others in pain who, rather than wait 6 hours between doses, take a new dose after only, say, 4 hours? It’s happens a lot.

So at the FDA meeting later this month, the group will consider a recommendation to lower the maximum daily dose from 4000 mg. to 2600 mg., and cut the size of the biggest allowable tablet from 500 mg. to 325 mg. No matter what they decide, take caution with this drug, especially if you already have any liver disease, have elevated “liver enzyme” blood levels, take statin drugs to lower cholesterol, or you drink a moderate or greater amount of alcohol daily. It’s not clear at what level of daily alcohol use you have to be concerned; the Tylenol label says to “ask your doctor if you drink more than 3 drinks per day”, but many experts believe if you drink less than that you should be extra careful with acetaminophen.

Your physician should be able to answer any questions about your liver function with some simple blood tests, and if you have concerns about your daily alcohol intake combined with acetaminophen.  For everyone however, even those who drink rarely, if you “binge”—drink significant alcohol at any one time—don’t use acetaminophen to try to treat a headache or hangover (however aspirin is not great either, because it can irritate the stomach).

Be aware that acetaminophen (or paracetamol or APAP as it is known in some countries), is not only found in the Tylenol brand, but is a component of many other common OTC medications… over 200 formulations contain acetaminophen but don’t carry the Tylenol label, and the presence of acetaminophen is only discovered by reading the fine print on the back. Consult this list for examples; and better, read the ingredients of every pain or anti-fever medication you take to see what’s inside. You might take Tylenol in the evening, then at bedtime take a slug of, say, Nyquil, not realizing it too contains the same drug.

I will let you know what the FDA decides after their meeting at the end of June, but for an interim FDA report, with more details about acetaminophen, click here (pdf).

In summary, acetaminophen can be a wonderful drug, but with a narrow “safety margin”, it deserves special caution.