Women's Health Articles - General Medical Problems

Guidelines for Healthy Weight

Frederick R. Jelovsek MD

What should I weigh? The answer might be based on your age (older women will need to weigh less) , on your desire to be at low risk for death due to obesity-related diseases, or just according to how you wish your body to look. As far as your health goes, avoiding an excessive amount of body fat is the best way to lower your risk from heart disease, hypertension, diabetes and even from developing gall bladder disease. Sometimes, it is questionable as to what is ideal body weight. A recent journal supplement, Chez RA (ed.): Weighing the options on managing obesity. Contemporary Ob/Gyn 1999; June supplement:3-30, looks at the issues of weight and health and what is the best way to manage weight problems.

Body mass index, BMI, is only an indirect measurement of body fat. For scientific research purposes there are more accurate methods of measuring what percent of a body's weight is composed of fat such as hydrodensitometry (underwater weighing) and dual-energy x-ray absorptiometry. Physical measurements such as waist and hip circumferences and skin fold thickness in the back of the elbow are also used.

The BMI happens to be the most commonly used measurement in epidemiologic studies and for middle-aged men and women, it correlates over 90% with fat mass densitometry. For older adults who tend to have less muscle mass proportionally, it loses some of its accuracy as an absolute measurement. The BMI is also called the Quetelet index and is calculated by the weight in kilograms divided by the square of the height in meters. While it does not distinguish fat mass from lean or muscle mass, it is a very useful approximation to what one should weigh depending on height.

In order to determine what people should weigh, researchers have looked at risk of death by different BMI categories in order to determine what would be ideal. Keep in mind that excess weight can have health-associated problems that do not result for quite a while. It can make arthritis or low back problems worse, cause diabetes and gall bladder disease. Risk of Type II diabetes (usually adult onset) rises in women at a BMI of over 22 even though the normal range for BMI is 19-25. Deaths from cardiovascular disease in non-smoking women rises slightly at a BMI of 22-25 but takes a dramatic jump at a BMI of over 30. Each kilogram (2.2 lbs) of weight loss will reduce systolic blood pressure (the first number) by .43 mm Hg and diastolic blood pressure (the second or bottom number) by .33 mm HG in women who have hypertension.

Certain cancers have also been associated with excess weight. Cancer of the gall bladder, breast, uterus and ovaries are more common in obese women and weight loss seems to significantly reduce these risks. Obesity is also a risk factor in for osteoarthritis which is the condition responsible for more than 70% of hip and knee replacements. In overweight individuals weight loss of an average of 11 lbs (5 kg) reduced the risk of developing osteoarthritis by more than 50%.

BMIs of 28-30 have a 2.4 times risk of infertility and ovulatory disorders compared to women with a BMI of 20-22. Excess hair growth and acne can also be associated with increased weight and disappear with weight loss.

While BMI is not the perfect measurement for assessing increased body fat, it is the most easily obtained measurement that has a high correlation with percent of body fat so most of the standards are set using BMI. Even though there can be some increased health risks within the upper limits of the normal range, various groups such as the World Health Organization, the American Institute of Nutrition and the International Obesity task force, among others have given some guidelines.

Weight Category Definitions

It can be extremely difficult for an obese person to lose weight down to an ideal level. Fortunately many studies show a huge reduction in mortality and weight related problems with even a modest reduction of 5-10% weight loss which is maintained for at least a year. In fact, losing large amounts of weight does not lower the mortality further than just a 10% weight loss does. Nurses who lost 11 kg (24 lbs) had a risk of type 2 diabetes that was 75% lower than nurses with unchanged weight. Thus the overall goal should be weight loss but not necessarily all the way to ideal body weight. A 10% loss occurring at a rate of 1-2 lbs per week is what most weight management specialists recommend.

Various prescription medicines that aid in weight loss have come on and off the market over many years. Some have had dangerous side effects only discovered after years of use. Most have only a temporary effect on aiding weight loss. As each newer medicine comes available promising effortless weight loss, weight management experts still prefer non medication aided dieting and behavioral modification. There are circumstances in which the experts resort to medicines.

• individuals with a BMI of over 30 and who have serious health complications
• individuals with appetite problems to the extent that a women reports she is always thinking of food or has constant food cravings
• more than one or two failures at weight loss or maintenance of weight loss using behavioral therapy

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Cellulite - Is There Hope?

Frederick R. Jelovsek MD

Very frequently, women (and men) make requests to doctors to prescribe a medication or treatment that will smooth out the contours of the body - eliminate cellulite. It presents a problem for the doctors who are not dermatologists, plastic surgeons or obesity experts because they are somewhat removed from the latest concepts regarding adipose tissue distribution and problems. Medical literature is fairly thin on this subject while the lay literature describes numerous questionable treatments that promise to rid the body of irregular appearing fat deposits. It is apparent that this topic - cellulite - has not been studied by medical science very much. It is perhaps time to look at what evidence does exist is on this subject.

Dimpling of the skin of the buttocks and thighs, especially in women, is known as cellulite. Many people have heard stories about the existence of two types of fat - brown and white - in which the brown is the type in cellulite, but medical studies have failed to confirm that there are any different types of adipose tissue. One study, Rosenbaum M, Prieto V, Hellmer J, Boschmann M, Krueger J, Leibel RL, Ship AG :An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg 1998 Jun;101(7):1934-9 looked at both the anatomical structure of cellulite as well as its physiologic function.

Ultrasound examination of the thigh showed a diffuse pattern of extrusion of underlying fat (adipose) tissue into the reticular dermis in individuals with cellulite, but not not in unaffected, individuals. Studies also demonstrated that women had a generalized pattern of irregular and discontinuous connective tissue immediately below the skin (dermis), but this same layer of connective tissue was smooth and continuous in men. They also found no significant differences in they way the fat tissue looked under the microscope, how it responded to fat deposition and resorption, or even regional blood flow between affected and unaffected sites within individuals. They did find there were structural characteristics of connective tissue below the skin that predispose women to develop the irregular extrusion of adipose tissue into the dermis, which characterizes cellulite. In other words, cellulite represents areas of a "break in the fence" where fat cells come into the skin area and the dimpling represents where the support structure of the skin (the original "fence") is still intact.

In spite of the above paper, most scientists really do not know what causes cellulite. They have studied fat metabolism and deposition and had many and varied findings. Most areas of fat deposits are the result of two factors

• the number of fat cells - adipocytes
• the amount of fat inside the adipocytes

Occasionally there are reports that cellulite fat has more proteoglycans that lead to more water retention or that there are more or less receptors for various physiologic hormones or proteins, but it does not appear that these are the causative factors. Cellulite fat will respond to calorie restriction just as any other fat cell, but it is the stored fat that goes away; the cell is still present and can refill if calorie excess resumes. That is why most treatments of cellulite are directed at removal of the cells surgically.

Yes, women are more predisposed to cellulite than men. The Rosenbaum study found that women have a much more irregular, discontinuous supporting skin matrix than men do so there is more opportunity for fat cells to extrude into the dermis area. To some extent this must be hormonally controlled through estrogens because most men are not as prone as women to cellulite but men who are given estrogens as treatment for medical problems are known to develop new areas of cellulite.

Fat distribution is different also in women and men. Women have more fat deposits under the skin but tend not to accumulate it inside the abdominal cavity; men seem to have less room for fat over their muscles and under the skin but they will accumulate much more excess fat inside the abdominal cavity. Regionally, women have a tendency for more fat deposition in the buttocks and thighs (gluteal/femoral areas) but that tendency only starts after a women's ovaries become hormonally active.

The medical literature does not support evidence that I could find of any topical creams or ingested medicines or substances that get rid of cellulite unless those treatments result in significant loss of total body fat. In those cases, the dimpling from cellulite becomes less apparent but does not actually go away. This observation must be tempered by the realization that medical science does not seem to have studied this subject very rigorously, thus the room for many "claims of cure" that cannot be refuted as well as they should be.

Most physician-based treatments are surgical. Either fat cells are removed by various excision or suction techniques or/and the cells are redeposited in areas of dimpling so the contour looks more even. None of the surgical treatments are directed at fixing the underlying cause but merely fixing the result. Cellulite areas will recur as long as there is any excess fat deposition over the natural metabolic rate.

Malignant Melanoma Skin Cancers in Women

Frederick R. Jelovsek MD

Malignant melanoma is a potentially fatal skin cancer that is not very common, but it is the most frequent cancer in women ages 25-29 and the second most frequent cancer in those age 30-34. In these age groups, melanoma is more frequent in women than men. It is important to diagnose these dark, pigmented skin lesions early because late-stage, disseminated melanoma rarely responds to therapy.

A recent article, Guerry IV D: Melanoma in Women : Prevention, detection and treatment. The Female Patient 1999;24:33-42, outlines which women are at risk for this and what steps to take for early detection of skin melanomas.

Melanomas occur most frequently in persons of Caucasian race, especially those with light colored hair or iris eye color. Their skin is more susceptible to ultraviolet light rays. Any woman that freckles and burns in the sun regularly without tanning has increased susceptibility. Living in the "sunbelt" has a two-fold risk. The use of tanning parlors makes a woman at higher risk but the most dangerous exposure is thought to occur with off-season recreation or exposure that produces a sunburn in skin that has not been exposed to the sun for awhile. In other words, a mid-winter trip to the Caribbean can sometimes be dangerous in the long run.

A personal or family history of melanoma or other common skin cancers increases the risk for melanoma. A woman who has a large number of common moles (i.e., greater than 25 lesions) is also melanoma-prone. Some families have an inherited increased risk of melanoma but fewer than 10% of melanoma cases are the result of strong genetic susceptibility. If a woman has had a mole biopsied and it turned out to be a "dysplastic nevi", then she has a two-fold risk of melanoma. If she has had 10 or more of those dysplastic nevi, the risk for melanoma is raised by a factor of 12.

There is no special method to detect melanomas. A careful examination of the skin is the only method; no special equipment is needed. In women, melanomas occur many times on the arms and legs, but also on the back and upper chest. A partner or spouse can help look at all the freckles, moles and any pigmented (darkened) skin lesions.

What should you look for? The mnemonic used is "ABCDE":

• Asymmetry: melanomas generally have an irregular border.
• Border irregularity: the border is irregular and often notched.
• Color variation: although melanomas are usually dark brown or black, they may sometimes have a range of colors including tan, brown, blue, pink or white.
• Diameter: eventually melanomas become larger than ordinary moles. Any pigmented spot greater than 5 mm (1/5 inch) in diameter should be examined and followed carefully.
• Elevation: some early melanomas are slightly elevated. A pigmented lesion that elevates quickly or develops a bump should be checked immediately. Ulceration, bleeding and oozing are generally late signs of a melanoma that is likely to already be advanced.

Do hormones, birth control pills or pregnancy increase the incidence or severity of melanoma?

One study noted a a six-fold increase in melanoma risk in women who noticed that their moles darkened and increased in diameter during pregnancy. Several other studies, however, have shown no convincing evidence that birth control pills, hormone replacement or pregnancy worsen the risk for melanoma. In spite of the lack of evidence of a hormonal effect, some physicians advocate deferring pregnancy after treatment for a melanoma until the highest risk of recurrence, the first 3 years, have passed. Estrogens in pills, hormones and pregnancy stimulate melanin production in the skin but do not appear to be a major stimulant for the cells containing the melanin such as moles or freckles.

Treatment for a melanoma is usually a wide local excision of the skin around and underneath the pigmented lesion. Generally a lesion that is confined to the most superficial layer of skin and is less than a millimeter (mm) thick is excised with a 5-10 mm margin of normal skin tissue and closed primarily with suture. Thicker lesions are removed with margins of 1.0 - 4.0 cm (10-40 mm). The nearby lymph nodes are also excised and if they are involved, all of the nearby lymph nodes are removed with "radical " surgery. Subsequent chemotherapy or immunotherapy treatments are often given to treat or prevent recurrence.

Ulcer Symptoms and Helicobacter pylori

Frederick R. Jelovsek MD

Before 1982, we used to think that ulcers were caused by spicy food, acid, stress and the "Type A" personality. Then a bacterium called Helicobacter pylori was discovered. Now we know that up to 80% of stomach ulcers and 90% of duodenal ulcers are caused by the bacterium, H. pylori. As a result, ulcers are often cured now by medical therapy rather than surgical therapy.

The Center for Disease Control and Prevention now puts out a fact sheet for health care providers to make sure the message is out that this is often a curable problem. From this July 1998 Fact Sheet and the H. pylori web site that is maintained by the CDC, we can learn the answers to several questions about ulcer disease and the H. pylori infection.

The most frequent symptom noted with ulcers is a gnawing, burning pain in the mid stomach area just below the rib cage. Its onset is usually gradual over weeks or months rather than an acute beginning. The pain typically occurs when the stomach is empty between meals and in early morning hours. It can last from minutes to hours and is relieved by eating or taking antacids.

Less frequently occurring are symptoms such as nausea, vomiting, and loss of appetite. Bleeding from the ulcer may result in black, tar-like stools, vomiting of blood or even coughing up of blood.

Anyone who has been diagnosed with an ulcer or who has had a history of ulcers should be tested. Also, people who have a history of gastric (stomach) cancer or a mucosal-associated-lymphoid-type (MALT) lymphoma should also be tested. H pylori is strongly associated with these latter two malignancies. It is not currently clear whether persons with just stomach upset (dyspepsia) that do not have ulcers should be tested. Remember that over 2/3's of the world's population is infected with H.pylori and most do not have any symptoms or ulcers from it.

There are several methods currently available to diagnose H. pylori infection. There are antibody tests that can determine if a person has ever been exposed to the bacteria. They pick up about 80% of all people who have been or were infected. If the test is negative, it only misses about 5% of people who actually have been infected.

There also is a breath test in which patients are given radioisotope labelled liquids to drink and the H. pylori metabolizes the labelled compounds which can then be measured in a person's breath. These tests are more accurate than the antibody tests.

The gold standard diagnostic test is is at time of upper esophagogastroduodenal endoscopy (EGD) in which an endoscope is put into the stomach to look for ulcers and take a biopsy. The biopsy is then examined either by a urease test, a microscopic look at the tissue or a bacterial culture of the tissue.

Other than ulcer disease and its complications, gastric cancer is the biggest risk of long term infection. In places like Columbia and China where over half the population is infected in early childhood, there is a high incidence of gastric cancer. In the U.S., H. pylori is is less common in young people and the incidence of gastric cancer has been decreasing since the 1930's.

It is not known how H. pylori is transmitted or why some people become symptomatic while others do not. It is thought most likely to be spread from person to person through the food or water supply.

There are several different treatment regimens used.

FDA-approved treatment options for H. pylori (1998)

Insulin Resistance Syndrome

Frederick R. Jelovsek MD

Insulin resistance is an impaired metabolic response to our body's own insulin so that active muscle cells cannot take up glucose as easily as they should. In that situation, the blood insulin levels are chronically higher which inhibits our fat cells from giving up their energy stores to let us lose weight. This disorder is associated with obesity, hypertension, abnormal triglycerides, glucose intolerance (syndrome 'X") and Type 2 diabetes mellitus. Many women with polycystic ovaries have this as well as women who have gestational diabetes in pregnancy. Up to 50% of patients with hypertension are estimated to have insulin resistance. The main problem is that this condition can exist unrecognized and metabolic damage can occur before a full blown Type 2 diabetes is finally diagnosed. Insulin resistant diabetics are 2-5 times more likely to die from heart attack or stroke than are non diabetics.

What are risk factors for insulin resistance?

Many of the risk factors are the same as they are for developing diabetes. Women who are overweight, especially with central obesity, a strong family history of diabetes, a history of gestational diabetes in pregnancy, hypertension, women with dyslipidemia especially having low HDL cholesterol and high triglycerides, and women with polycystic ovary syndrome. Another strong predictor is a skin change called acanthosis nigricans which is a velvety, mossy, flat warty-like, darkened skin change occurring at the neck, the armpits (axillae) and underneath the breasts. Almost 90% of women with these skin changes have insulin resisitance. Additionally, insulin resistance may be worsened by reduced physicial activity, aging, tobacco smoking, or drugs such as diuretics, certain anti-hypertensives, or steroids.

The "gold standard" for diagnosis is a test called the hyperinsulinemic euglycemic clamp study. It is a complicated and expensive study in which insulin and glucose is infused intravenously at several different doses to see what levels of insulin control different levels of glucose. Most physicians use fasting insulin levels of over 15 uU/ml to diagnosed it because they have been shown to highly correlate with the euglycemic clamp study. Some doctors use a fasting glucose to insulin ratio or even a hemoglobin A1c to determine if further testing is needed. Remember that the main reason to diagnose insulin resisitance is to go further on to look for Type 2 diabetes. This is diagnosed by a 2 hour post 75 gram glucose load blood sugar of over 200mg/dl, a random blood sugar of over 200 mg/dl, or a fasting glucose of over 127 mg/dl. Most doctors would agree that if there was only impaired glucose tolerance -- fasting plasma glucose >= 110 mg.dl and <127 mg/dl, or 2 hour post 75 gm glucose load >=140 mg/dl and <200 mg/dl, -- and addtionally there was an elevated fasting insulin level, then dietary control at least should be begun as soon as possible.

Treatment is based on improving glucose control and preventing complications, especially cardiovascular disease. Diet is a mainstay of treatment along with exercise and weight loss. A low calorie diet reduces insulin resistance in days even before much weight loss takes place. Ten to twenty pounds (5-10 kg) substantially helps glycemic control and a loss of 16% of body weight improves glucose metabolism by a 100%.

Medications such as metformin (Glucophage®), troglitazone (Rezulin®), and acarbose (Precose®), alone or in combination, have been used to improve insulin sensitivity mainly by reducing plasma glucose by different mechanisms. All of these treatments can be employed to prevent the development of Type 2 diabetes.

1. If you have any one of the following risk factors for insulin resistance or Type 2 diabetes, tell your doctor why you are at risk.
   • have a family history of type 2 diabetes
   • have high blood pressure
   • have central obesity with a waist circumferance (at the navel) to hip circumferance ratio of more than 0.8 or have a body mass index over 27
   • have a low HDL level or elevated triglycerides
   • have atherosclerotic or coronary heart disease
   • have polycystic ovarian syndrome
   • have a history of gestational diabetes in pregnancy
   • have darkened skin changes in the neck, axillary and/or breast folds consistent with acanthosis nigracans
2. Ask your doctor to order a fasting insulin level (look for over 15uU/ml) or a fasting plasma glucose and a 2 hour plasma glucose after a 75 gram oral glucose load. If the doctor suggests a hyperinsulinemic euglycemic clamp study or an intravenous 75 gram glucose tolerance test instead, go along with those because they sometimes can improve on diagnosis.