August 2008

Q. I have been sending you emails since 2002 and you have been so kind to answer all of them. Now I have a question about my husband who will turn 78 in December. First of all, we exercise on weight machines and a Heart Moves class 3 times a week and we play golf twice or more a week, so we get plenty of exercise and weight bearing exercises.

My husband had a Dexascan Bone Density test in Florida in Feb. of 2006. His scores were good, we thought. These are the scores:

AP Spine Age 75 BMD 1.140 T Score 0.4 Total L. Hip " " 0.877 " -1.0 Neck L Hip " " 0.632 " -2.2 Total R Hip " " 0.886 " -1.0 Neck R Hip " " 0.672 " -1.9

The following scores were from a CT Bone Densitometry done on Feb. 2008:

BMD of lumbar spine was calculated at 46.7 mg/cc (?) compared to an age-matched normal value of 98.9, giving a Z-score of -1.9 and a T-score of -4.7. This indicates advanced osteoporosis at high risk for future fracture. BMD of the left hip is calculated at .83 g/cm2, giving a T-score of -.84, and within normal limits. I copied this from the actual report.

My question is this: how much difference is there between a Dexascan and a Bone Densitometry? Which is more accurate? Why would or could there be so much difference between his scores of 2006 and 2008? The doctor put him on Fosamax immediately after the test in February. NOW he wants him to start on a program called FORTEO. I guess it is fairly new, but involves giving himself a shot every day for 2 years. It is supposed to build bone and after the 2 years, he would go back on Fosamax to maintain the bone. My husband has no pain in his back and is very strong for his age. I was just curious as to whether you had heard much about Forteo and what your opinion is. I just am not convinced that his scores could have changed so much without any symptoms at all. The Interpreting Radiologist's comments were: "Advanced osteopososis of the lumbar spine at high risk for future fractures." The 2006 test was normal?

Thank you so much for your time and whatever comments you have.

A. Thanks for writing to me. I hope you are well. I too would be quite surprised and suspicious with these two results in the spine - how could they be so different over only two years time without intervening health issues (such as beginning high dose cortisone/prednisone therapy which could quickly lower bone mass of the spine). The fact his hip BMD remains normal if fabulous but also adds to my concerns as to why the spine changed. High dose prednisone can selectively reduce bone mass density of the spine quite dramatically as can estrogen loss for women. I presume your husband has not been on Prednisone.

It is optimum to have a bone density test (also called DXA scan) using the same machine/location but often not possible. The two main brands are Hologic and Lunar. However I have never seen such a huge discrepancy in only two years without a major medical event (steroids would decrease bone density). Has your husband had a urine test looking for markers of bone loss and calcium loss? Is his thyroid and other blood tests all fine? Is he on any other medication such as Dilantin that could lead to reduced bone mass? Has he suffered any height loss? No evidence of spine fractures? It just doesn't add up. I would also make sure he has normal vitamin D levels (you live in florida and must have plenty of sun but with aging our skin can produce less vitamin D).

We have no long term studies of Forteo and with any drug, there are always potential risks as well as benefits. Since your husband is in such good health - I wouldn't jump to any therapy until you are sure it is necessary and the right one. Have you expressed all your concerns to his physician? I think you are right to ask questions....just not sure I can help you get to the bottom of it. In the end, you sound like you have an excellent and thorough physician - so that is a great start.

Best to both of you.

Q. I just want to let you know that reading your book has been so distressing to me. I have to get my weight down so low to get it to come off my waist. I’m not even overweight by the standards I’m referencing. I WOULD like to lose 5-7 pounds. But at 56 yrs old, 5’2” and 130 pounds, very conscious of what I’m eating (maybe just eating a touch too much), and faithful exerciser (walking, body sculpt, weights), I finished your book feeling like a complete loser because my ratio is .85 (waist 33 and hips 39). All my bloodwork is really good. I did not get much of a message of hope – it seemed like no matter what I do I’m pretty much doomed in some fashion. I almost wish I hadn’t read it because I basically knew belly fat was bad, but now I just feel cursed or something.

A. Thank you so much for writing to me and giving me the feedback. My motivation in writing the book was to assure pear-shaped women who are so hard on themselves and critical of their bodies to feel not so bad. On the other hand, for women who don't have the protective lower body fat - I meant to convey the message that you need to be more alert to health risks - HOWEVER if you have no metabolic abnormalities then that is terrific peace of mind. All too often I see women who have borderline blood test abnormalities such as low HDL cholesterol, high Triglycerides and/or borderline blood sugar and they are told they are fine. My sister was told this for years until she had full-blown diabetes. It sounds like you are in excellent health and do not have the effects of excess visceral fat which is great. And as you are 56 and presumably postmenopausal - any excess fat will be stored in the visceral/belly area. As I say in the book - nature is determined to make apples of all of us. Bottom line - if you are in great health with normal blood parameters - you can rest assured you do not have the risks that some apple-shaped women do. Again - I think I was perhaps overly concerned about apple-shaped women getting the important message to be vigilant - and yet failed to assure most women that their shape is determined by nature - not so much nurture - and that most (but not all) women will be healthy regardless of their shape.

Thanks again for sharing your feedback with me. It is very important to me.

Q. Thank you for your response. I do appreciate the reminders to stay away from white flour products, etc. I'm sure pear shaped women appreciate the boost you gave them in the book, but I hope you don't have the impression that the apple shaped women feel good about their bodies. Granted, I am not a really big person, but a fat tummy is not anything to show off. My legs are not thin and shapely and never have been. My legs are like tree trunks. My upper body is small (arms, chest, bust, etc). I believe I was probably a pear when I was younger because I always wore a larger size on the bottom than on the top. I could never buy a suit. After pregnancies and as the years have gone on and recently menopause, I just find that the weight tends to settle around my middle as well as everywhere else. Your book says it comes off the waist easily; it doesn't. I really have to be at my IDEAL weight for my waist to look good. I've given up on the thighs, etc. I feel like I'm an apple and a pear.

A. Thin apple-shaped women (straight up and down) are often considered the ideal in fashion magazines/centerfolds yet ironic as it may seem, having larger hips, butt, thighs is actually more protective/healthy. Your description of your body sounds similar to women in my family as we aged and went through menopause - and a number of women have written describing their bodies as you have - and many called themselves "papples" as they changed from pear-shaped to apple-shaped with menopause. As long as pear-shaped women aren't so hard on themselves...and apple-shaped women understand their potential health concerns whether they like their bodies or not - and that ALL women understand why with aging and menopause they will change towards apple-shaped....

Again, thanks so much for your helpful feedback.

Q. I have just finished reading "Apples and Pears." It was just the lens that I needed to be able to focus the health, nutrition, and exercise information floating around in my head. Thank you for being able to translate all the research into terms that make sense. I truly feel that this has a lasting and transforming effect on my life and not just a short term fix to try. I have already seen a reduction in my waist circumference and others are beginning to notice.

I still have a question about when is a good time to include a fiber supplement. I seem to remember that because fiber can slow the digestive process that it was recommended to avoid taking it too closely to vitamin supplements. On the other hand, it was recommended to take a multivitamin at breakfast and two more calcium supplements, one at lunch and one at supper. What is the recommendation to most effectively include all of the supplements?

Thank you again to your commitment to my health as well as so many women.

A. Thanks so much for your comments. Although I too am concerned that fiber supplements such as psyllium husk could potentially interfere with calcium absorption, I have not seen convincing evidence that this is true. Calcium carbonate requires stomach acid for absorption so is best taken with or after your meals when there is plenty of stomach acid to absorb calcium. If you prefer, calcium citrate is less constipating and doesn't require as much acid - so can be taken spread out any time. Back to fiber - I have recently stopped taking fiber supplements and have relied on unprocessed plant sources for all my daily fiber (which are devoid of antioxidants and other phyto estrogen and other protective compounds which you would get if your fiber came from fruits/vegetables and grains.

I take a multivitamin, fish oils, 1000 IU of vitamin D and an occasional aspirin BEFORE breakfast and then take calcium between meals. Not sure if that makes sense but separating the pills somewhat makes sense to me to maximize absorption??

Thanks again for your thoughts/feedback.

Q. Having read about Waist Hip Ratio, I am wondering how to tell which I am. I am 5'7" and weigh 105 pounds. My family members are thin and lanky also. Obviously fat isn't an issue. I am a 52 year old female with a boy-shaped body. My waist is 28 and hips 33.5. This puts me above 8 points in the calculation. Do I still rate an "apple" shape? I think this issue should be addressed when discussing WHR.

Thank you for any input.

A. Thanks so much for writing....you are what I was for many years - a tall thin apple-type (or jokingly a banana). However, as hard as it is to believe, women who have no protective healthy butt/hip/thigh fat actually still have the potential to develop the health concerns of apple-shaped women as they age and replace muscle mass with visceral fat. The scale may not change, but the per cent visceral fat increases. Ideally, preserving muscle mass as you get older with resistant exercises - and avoiding stress/reduced sleep that also tend to add visceral fat = is still important for you. Obviously, if you have great longevity in family and no metabolic problems such as low HDL cholesterol, high TG/triglycerides, etc. you are in great shape!!

Thanks again, hope this helps. And yes, I didn't emphasize this is the book - yet important.