SARS Cases in China Pass 5,000

BEIJING - The number of SARS cases in China passed 5,000 on Monday, while Taiwan recorded eight deaths and a record jump in infections and a hospital boss was fired for allegedly covering up an outbreak.

As grim statistics rolled in, the World Health Organization visited a poor and medically backward Chinese province that could be fertile ground for a future, and potentially devastating, epidemic. Four ritzy hotels in Shanghai, including its historic Peace Hotel, closed temporarily for lack of guests.

"The situation is serious and the tasks are tremendous," Chinese President Hu Jintao was quoted as saying by state television. "We must be prepared for the worst."

Highlighting the disease's global nature, Canadian officials angrily rejected suggestions that a Finnish man contracted SARS in Toronto, a city which insists its outbreak is under control.

And Nigeria was screening incoming visitors for signs of the disease on Monday after a Taiwanese businessman died of suspected SARS in the west African nation.

Health officials believed the man — who died Feb. 28 — had been in contact with about 30 Nigerians in Kano and Lagos, the country's biggest city. All have been placed under medical surveillance and six developed "flu-like symptoms" but fully recovered, Nigeria's health minister Alphonsus Nwosu said.

In Malaysia, German Chancellor Gerhard Schroeder pressed on with a Southeast Asian tour with a drastically reduced entourage after strong last-minute pressure not to go because of SARS.

"I said 'go away' to all those people who said 'you can't go.' My wife ended up understanding, and I hope other people will understand it also," he said.

Schroeder described the SARS threat as a "theoretical danger" compared with the certain "political damage" that would have resulted from canceling the four-nation tour at short notice.

Monday's fatalities in Taiwan, as well as 12 more in China and three in Hong Kong, brought the international death toll from severe acute respiratory syndrome to at least 559. There were at least 7,400 known SARS cases.

China remains the hardest hit country with at least 252 dead.

Although some Chinese infection rates, particularly in Beijing, have been declining, Monday's 75 cases raised the mainland's tally to 5,013.

Thousands of people have been quarantined amid fears that the disease is spreading from cities into the impoverished countryside, where medical facilities would not be able to cope with a sweeping outbreak

WHO visited the southern Guangxi province, fearing it could be hit by an epidemic that could possibly be brought in by hundreds of thousands of returning migrant workers.

"Guangxi is susceptible to infection because of its location," WHO spokeswoman Mangai Balasegaram said. "It's a poor region. It would be ... less able to cope."

Taipei's city government dismissed the president of a public hospital that was sealed off on April 24 to contain a SARS outbreak. He and at least one other doctor are accused of misdiagnosing SARS cases or not reporting infections.

Taiwan's tally stood at 27 fatalities and 207 cases of infection. It also reported 23 new cases on Monday — its worst one-day jump since its outbreak began two months ago.

One death, that of a dentist in the southern city of Kaohsiung, proved that the disease was heading south across the island from Taipei.

Officials said the man had a history of tuberculosis and that he might contracted SARS from one of his patients.

Meanwhile, officials are worried because they haven't been able to trace at least six SARS patients to previous cases, said the vice chairman of Taiwan's SARS Control and Relief Committee, Dr. Lee Ming-liang.

This suggested SARS has spread to the public at large. In the past, transmission has usually been traced through family members or others who had close contact with known SARS cases.

Morning commuters started the working week by complying with a government order to wear masks on Taipei's subway. Also, authorities are installing video cameras to keep watch over about 8,000 people quarantined in their homes in case they have contracted the illness.

For more than a week Hong Kong has reported falling infection rates, including only five new cases on Monday. Encouraged by this, the WHO said it might ease conditions for removing a travel advisory against the territory, although the ban itself will stay for now.

In Finland, the University of Turku Central Hospital said a Finnish man who had been on vacation in SARS-hit Toronto in late April had probably contracted the illness.

It said the patient was recovering well, and that no one who had been in contact with him had shown any of the disease's symptoms: fever, aches, dry cough and shortness of breath.

Dr. Colin D'Cunha, health commissioner in Ontario province, said the idea of a Toronto link was "preposterous."

"I'm sure the (Finnish patient) had some respiratory symptoms and, simply put, was diagnosed with SARS because the person had spent some time in Toronto."

In Malaysia, where two people have died of the illness, officials said a 10-day quarantine will be imposed on students and workers arriving from SARS-affected areas.

In Hong Kong, about 250,000 primary students headed back to class Monday after a six-week school closure. High school students resumed studies recently.

South Korea on Monday reported its second case of SARS after an American man in his 80s showed symptoms of the disease after arriving the previous day from the Philippines.

The Asian Development Bank said it will help the region's economies better fight the SARS virus with up to US$27 million in grants and reallocated loans.

Research Provides Leads on Blocking Diabetic Kidney Disease

New York, NY, — People with type 1 diabetes are at an increased risk for developing kidney disease, known as diabetic nephropathy. About one third of these people develop a severe form by age 50. As a result, diabetes is the leading cause of kidney failure in the United States, accounting for 40 percent of new cases each year.

The body's two kidneys are its natural filtering and waste removal system. With every heartbeat, blood passes through a complex system of delicate filters within the kidneys. When these organs are damaged, they are unable to do their job.

One biological pathway known to contribute to diabetic kidney disease is the formation of harmful proteins in the body called Advanced Glycation Endproducts (AGEs). These proteins change their shape after reacting with glucose, and, in an irreversible, progressive process, build up over time, interfering with some cell functions and damaging small blood vessels, which can eventually cause the kidney to fail. AGE-damaged proteins have also been implicated in diabetic eye, nerve, and cardiovascular complications.

AGEs form in every person to some degree, but their accumulation is closely related to two factors—concentration of glucose in the blood and age. In people without diabetes who have normal glucose levels, AGEs still accumulate, but at a slow rate, so that they only reach significant concentrations in the elderly. (In fact, the accumulation of AGEs is thought to play an important role in the aging process.) In people with diabetes, high blood glucose speeds the AGE buildup.

Blocking the AGEs Pathway

Recently, a director of one of JDRF's flagship, multidisciplinary Research Centers has published some important new findings. Mark E. Cooper, Ph.D., director of the JDRF-Danielle Alberti Memorial Centre for Diabetes Complications at the Baker Heart Institute, Melbourne, is a leader in the study of AGE formation and the development of methods blocking the chain of events that produce diabetic nephropathy. He has been investigating new drugs that not only hinder AGE formation but may also reverse the process—causing AGEs to return to a normal protein structure.

Now, Dr. Cooper and his colleagues report in the November issue of the journal Diabetes the results of two studies, partly funded by JDRF, investigating two possible approaches to AGE blockage, and finding both to provide some benefit. These results could help in the development of better drugs to hinder or prevent kidney disease in people with type 1 diabetes.

Study debunks drinking-lung cancer link

Light to moderate drinking of alcoholic beverages does not increase the risk of lung cancer, according to a study that involved more than 9,000 people over two generations.

The study, appearing this week in the Journal of the National Cancer Institute, found that people who consume one to two alcoholic drinks a day have no greater chance of developing lung cancer than do nondrinkers.

Data from the study was adjusted so that the effects of smoking, known to be the major cause of lung cancer, were statistically eliminated as a factor in the conclusion, the researchers report.

Alcohol drinking has been associated with lung cancer in some past studies, but the findings are considered by some experts to be uncertain because drinking and tobacco smoke exposure often go together. The new study attempts to avoid this problem by removing the confounding effects of smoking, the researchers report.

Dr. Luc Djousse of Boston University School of Medicine, the first author of the study, said his group used data from the famed Framingham, Massachusetts, study that followed the health of thousands of participants since 1948. The research also includes data from the Framingham Offspring Study, which started in 1971 and involves children of the original study participants.

For the lung cancer study, Djousse and his co-authors examined health and survey data from 4,265 subjects in the original Framingham study, and 4,973 from the offspring study.

The alcohol study was funded by the National Heart, Lung and Blood Institute. Djousse and a co-author received grants from research organizations supported by the beer and the wine industries.

Heavy drinking's effects still studied

Researchers found 269 cases of lung cancer among the study participants. They were matched by age, gender and smoking history with participants who were not diagnosed with lung cancer. The researchers then compared the drinking habits of the group and concluded that light to moderate alcohol consumption was not a factor in the cancers.

Djousse said that only one subcategory -- offspring who drank more than two drinks a day -- showed an increased risk of lung cancer. The incidence of cancer in this group was double that of the nondrinkers of the same age, smoking history and gender.

However, Djousse said the numbers in this subcategory are too small to draw a valid statistical conclusion.

Dr. Mary C. Dufour, deputy director of the National Institute on Alcohol Abuse and Alcoholism, said the researchers doing the study make up "a highly respected team using an extensive data base," but that the results do not eliminate alcohol drinking as a risk for lung cancer.

Dufour said that the Djousse study analyzed only the effects of one to two drinks a day on lung cancer rates. She said other studies that looked at heavy drinkers -- five drinks or more a day -- found a direct link between alcohol and lung cancer.

"The jury is still out on the heavy drinkers," said Dufour.

First AIDS vaccine in final testing stages

The situation is critical: Every day in 2002, an estimated 14,000 people worldwide are infected with HIV, the virus that causes AIDS, according to the World Health Organization and National Institutes of Health. About 2,000 of them are children under age 15, the organizations say.

"We're in a situation where, unless we can really sharply cut down on the transmissibility, the toll of HIV/AIDS is going to go well beyond what anyone could have imagined a few years ago," said Dr. Anthony Fauci of the National Institutes of Health.

Many experts say they believe the best way to stop the spread of AIDS is with a vaccine, but so far there is none. However, that may change soon.

Dr. Don Francis with the California-based company VaxGen is leading the way in developing a vaccine. After seven years of testing, Francis plans to finish the final stage of human testing for Food and Drug Administration approval in January.

No vaccine is 100 percent effective, but Francis said he would be pleased with a success rate far lower than that figure.

"There's certainly very good data out there in computer models that a 30 percent effective vaccine will ultimately drive the epidemic into the ground," Francis said.

Assuming the final stages of human testing are successful and the FDA approves the vaccine, the next hurdle would be getting it licensed and manufactured, which Francis said would take "another couple of years."

During that time, researchers may concentrate on making different versions of the vaccine to treat different strains of HIV.

"It'll take us a year and a half, two years to do that, and think about how many infections are going to occur in that year and a half, two years while we're developing this African vaccine," Francis said.

If everything stays on schedule and the current vaccine proves successful, it will be ready for use in the United States by about 2005.

Alcohol linked to raised risk of breast cancer

Alcohol may be good for the heart but a daily glass of wine or beer can increase a woman's risk of breast cancer, researchers said Tuesday.

One unit, or eight grams of alcohol per day, raises a woman's chances of developing the disease by about six percent but smoking, which is linked to a range of other diseases and different cancers, does not contribute to the illness.

"The more women drink, the higher their risk of breast cancer," Professor Valerie Beral, of the Radcliffe Infirmary in Oxford told a news conference.

The scientists, who analyzed the results of 53 previous studies into the effects of alcohol and smoking on breast cancer, estimated that alcohol accounts for about four percent of breast cancers in the developed world.

Although the risk is small and represents only a tiny part of the picture of what contributes to the disease, Beral said women should be aware of it because it is a preventable risk.

About 40,000 cases of breast cancer are diagnosed in Britain each year. If women stopped drinking alcohol there would be about 2,000 fewer cases annually, she said.

Unraveling risks

Until now, doctors had not been able to examine the separate effects of alcohol and smoking on breast cancer. But the size of the analysis which included data on 150,000 women worldwide allowed them to unravel the results to show a clear link between alcohol and breast cancer risk.

"When we did this we found that drinking, but not smoking, increases the risk of breast cancer," said Sir Richard Doll, a co-author of the report in the British Journal of Cancer. "This report is giving us a definitive answer."

But Doll stressed that although smoking is not linked to breast cancer, it is a leading cause of lung cancer which is notoriously difficult to treat, as well as other diseases.

Although the researchers do not know how alcohol raises the risk of breast cancer, they suspect it may alter levels of the female hormone estrogen.

Breast cancer is the most common cancer in women. Early puberty, late menopause, a family history of the disease, delaying childbirth or not having children are risk factors.

Because alcohol has a protective effect against heart disease and stroke but a negative impact on breast cancer, Beral said the balance between the two may depend on a woman's age.

After the age of 65, women are more at risk of dying of heart disease than breast cancer so the benefit of moderate drinking could outweigh the negative impact on breast cancer risk.

"It's very personal. You can't make a blanket policy for everyone," said Dr Gillian Reeves, who contributed to the study. "It's important women know about this risk even if it is small."

Health expectancy can be increased 5-10 years

WASHINGTON -- Unhealthy habits common in wealthy countries -- such as smoking, drinking, and overeating -- are becoming prevalent in developing countries, where, coupled with risk factors in those countries, are shaving off years of healthy life, the World Health Organization said.

The WHO called the contrast between rich and poor people shocking: "The burden from many of the risks is borne almost exclusively by the developing world, while other risks have already become global," it said in a news release that accompanied its World Health Report 2002.

One major difference, the report notes, is that while some 170 million children in poor countries are underweight, mainly from lack of food, more than 1 billion adults in richer countries are overweight or obese.

According to a report earlier this month from the Centers for Disease Control and Prevention, in the United States nearly 59 million people 20 years and older are obese, and among people ages 6 to 19, three times as many are obese as in 1980.

The report lists the following as the top 10 preventable health risks in the world:

•childhood and maternal underweight

•unsafe sex

•high blood pressure

•tobacco

•alcohol

•unsafe water, sanitation and hygiene

•high cholesterol

•indoor smoke from solid fuels

•iron deficiency

•overweight/obesity

"This report brings out for the first time that 40 percent of global deaths are due to just the 10 biggest risk factors, while the next 10 risk factors add less than 10 percent," WHO senior science adviser, Alan Lopez, said.

Cardiovascular disease is the top cause of death in the world, according to medical statistics, with more than three-quarters of the cases resulting from tobacco use, high blood pressure, or cholesterol.

The WHO says that combined government and individual efforts against major health risks in the world could add five healthy years to the lives of people in developed countries and an extra 10 years to those in most of the poorest countries. And in parts of Africa such as Malawi, where current healthy life expectancy is as young as 37 years, 16 or more years of healthy life could be added, the WHO said.

The report recommends steps that could be taken to counter each risk factor and to improve health worldwide.

It suggests governments consider partnerships with the food industry to reduce the salt content of processed foods, which along with agricultural and trade policies are changing the diet of millions, or community interventions to reduce salt and treat people who are at risk for a cardiovascular event within 10 years.

To battle nutritional deficiencies in developing countries, the report says, making vitamin and mineral supplements available would be very cost-effective. It also urges counseling new mothers to continue breast feeding and providing complementary food as necessary.

To counteract the effects of tobacco, the report notes that a substantial increase in tobacco taxes would produce significant health benefits at very low cost.

The WHO report gave the following statistics on various risk factors:

•In developing countries, underweight children account for more than 3 million deaths a year. The WHO estimates 27 percent of children under age 5 are underweight, and 3.4 million of them died in 2000, mostly in Asia and Africa.

•High blood pressure causes an estimated 7 million premature deaths each year, tobacco almost 5 million, and high cholesterol more than 4 million.

•Smokers of all ages have death rates two to three times higher than non-smokers.

•Alcohol causes almost 2 million deaths a year and is linked to esophageal cancer, liver disease, epilepsy, motor vehicle accidents, and homicide and other intentional injuries.

•HIV/AIDS, spread primarily by unsafe sex, is now the fourth leading cause of death worldwide. Of the 40 million people currently infected, 70 percent are in Africa. But the next phase of the epidemic is expected in India, China, and the former Soviet Union.

• Life expectancy in sub-Saharan Africa is currently about 47 years; without AIDS it would be around 62.

•Risks such as unsafe sex and tobacco consumption could increase global deaths substantially in the next few decades and could decrease life expectancy in some countries by as much as 20 years unless they are brought under better control.

•Diet changes, along with changes in living and working patterns that have led to less physical activity, have brought about a rise in obesity rates of threefold or even more in some parts of North America, Eastern Europe, the Middle East, the Pacific Islands, Australia, and China since 1980.

•Obesity kills about 220,000 a year in the United States and Canada, and about 320,000 in Western Europe. High blood pressure and high cholesterol, often seen in overweight people, are even more deadly when combined with tobacco. It's estimated there were 4.9 million deaths attributable to tobacco in 2000, up more than a million from 1990.

One in three suffer arthritis, joint problems

Arthritis and other chronic joint problems are far more widespread than estimated just five years ago, affecting one in three U.S. adults, or 69.9 million people in all, the government said Thursday in the first comprehensive survey of the disease.

Health officials and advocates said the numbers -- and related health care costs -- are expected to continue to rise as the baby boom generation reaches old age.

The survey shocked even advocates for arthritis sufferers.

"We just think that's alarming in terms of the number," said Tino Mantella, president of the Arthritis Foundation.

The numbers were 63 percent higher than a 1997 estimate that said about one in five U.S. adults, or nearly 43 million in all, had arthritis and other chronic joint problems.

The new survey by the Centers for Disease Control and Prevention reflects, in part, a real increase in arthritis, connected to the aging of the baby boomers. But it also reflects a more thorough survey, the CDC said.

Previous estimates were much lower because many people do not tell doctors about their joint pain, and others do not consider their aches and pains to be arthritis, officials said. The latest survey employed more penetrating questions.

A total of 212,000 people from all 50 states were interviewed by telephone and asked if, in the previous year, they had pain, stiffness or swelling around a joint for at least a month. About a third of those with arthritis-like symptoms said they had not consulted a doctor about their symptoms.

"There are many people with chronic joint symptoms who don't see a doctor," said Dr. Chad Helmick of the CDC's arthritis program. The latest survey "is a better way of capturing people who have always been out there with arthritis or different symptoms."

The arthritis level ranged from 17.8 percent of adults in Hawaii to 42.6 percent of adults in West Virginia. States in the central and northwestern parts of the country had the highest rates.

Last year, arthritis patients cost the country about $80 billion in medical care costs and lost work, health officials said.

People can reduce their risk of arthritis through exercise, weight management and a healthy diet.

"The public has very little understanding about arthritis," said Dr. John Klippel, medical director for the Arthritis Foundation. "Many people associate arthritis with the process of aging, they assume aches and pains are an inevitable part of aging when in fact it is not a natural part of aging."

The survey confirmed previous studies that indicated arthritis tends to rise with age and that it is more common in women. In addition, arthritis is more common in those who are overweight or physically inactive.

OSTEOPOROSIS

Cutting Your Risk of Osteoporosis by Linda Pachucki-Hyde R.N., M.S., C.D.E. 

When you look at old family pictures, does your mother look taller and stand straighter in the photos than she does now? Does she look a little shorter and more hunched over each time you see her?

Or maybe your son seems taller every time you see him, and you have to stretch up that much further to give him a kiss. "How is that possible?" you ask yourself. "He's an adult now. Surely he stopped growing years ago."

It's unlikely that your adult son is still growing. But it's entirely possible that your mother—and you—are getting shorter. Loss of height and spinal curvature (a "dowager's hump") are common among older women, and they are almost always signs of osteoporosis, a progressive condition in which the bones lose mass, become weak and brittle, and, often, fracture.

Osteoporosis is a common disorder; it currently affects about 25 million Americans. While men can get osteoporosis, it is much more common among women, especially postmenopausal women. Having Type 1 diabetes places a woman at higher risk of developing osteoporosis. Whether and how Type 2 diabetes affects the risk of developing osteoporosis is not clear but is the subject of ongoing research.

Because osteoporosis is much more easily prevented than treated, it makes sense for everyone to take some common-sense preventive measures long before any signs of osteoporosis would be expected to show up. Among other things, such measures include consuming adequate amounts of calcium and vitamin D and exercising regularly.

Bone growth and loss

In spite of its permanent appearance, bone is living, growing tissue that is constantly being broken down and rebuilt (a process doctors call "resorption and formation"). In children, more bone is built than is broken down. However, as a person ages, the balance shifts, and bone begins breaking down faster than it is rebuilt. Bone loss generally begins around age 35 at a rate of about 0.25% to 1% per year. At menopause, the rate of bone loss can accelerate to 2% to 3% per year for three to seven years or longer among women who do not take hormone replacements. Later, the rate of bone loss slows down again.

In osteoporosis, so much bone is lost that the inner structure of the bones actually looks porous when compared with healthy bones under a microscope. In many cases, osteoporosis leaves bones so fragile that fractures result not from serious trauma (like getting in a car accident or falling out of a tree) but from everyday movements such as lifting something heavy, twisting around to reach for something, or stepping off a curb.

It is estimated that one in every two women will sustain an osteoporotic fracture in her lifetime. The most vulnerable sites are the hip, spine, and wrist, but any bone other than the skull is at risk.

There are two main factors that influence your risk of osteoporosis: the maximum amount of bone you ever have, called your peak bone mass, and how much bone you lose as you age. The strongest predictor of peak bone mass, which occurs between ages 20 and 30, is heredity. Other factors, such as childhood nutrition and anything that delays or interrupts normal menstruation, can also affect bone formation.

Heredity is also the strongest predictor of developing osteoporosis. If you have family members who have had hip or spine fractures, your risk of developing osteoporosis is probably higher. Caucasians, especially those of European ancestry, and Asians have an increased risk of osteoporosis. However, many other factors affect bone loss. You can control some of these risk factors, but not all of them.

Diet and lifestyle. Calcium is the primary mineral component of bone. However, your body uses calcium for many things besides building bone. Therefore, if you don't get enough calcium from your diet, your body leaches calcium from your bones for its other needs, making your bones weaker.

Getting adequate amounts of vitamin D, which aids in calcium absorption, is another important part of the picture. The main food source of vitamin D is fortified milk. Some vitamin D is also available in egg yolks and oily fish. Your body also manufactures vitamin D when skin is exposed to sunlight. However, in the northern part of the United States and in Canada, the sun is not bright enough during the winter to produce any vitamin D.

Excessive alcohol intake (usually defined as more than one drink per day for women and more than two drinks per day for men) is thought to decrease bone formation and to reduce the body's ability to absorb calcium. Smoking increases bone loss and is considered a major risk factor for osteoporosis. Excessive caffeine intake has also been suspected of contributing to osteoporosis, but no one can say just how much is too much.

Exercise, especially weight-bearing exercises such as walking, jogging, and dancing, helps to strengthen bones, while a sedentary lifestyle raises the risk for osteoporosis. Being tall and thin is also a risk factor for osteoporosis, so having a little extra weight on your bones if you're tall is actually protective.

Medical conditions. In addition to Type 1 diabetes, certain medical conditions, including thyroid disorders, rheumatoid arthritis, asthma, and organ transplantation, are all associated with increased risk of osteoporosis, chiefly because of the medicines used to treat them. Conditions that interfere with your body's ability to absorb nutrients, such as stomach surgery or celiac disease (an allergic intolerance to gluten, a protein in wheat, rye, and other grains), will limit the amount of calcium you can absorb from your diet.

Drugs used to control seizures block the absorption of calcium. Steroids such as prednisone and cortisol accelerate bone loss, impede bone formation, and reduce calcium absorption. If you must take one of these drugs, talk to your doctor about monitoring your bone density and taking other drugs to help prevent bone loss.

Diabetes and osteoporosis

The relationship between diabetes and osteoporosis is complex. Because insulin is necessary for bone growth, having too little insulin leads to increased calcium loss through urine, decreased absorption of calcium from food, decreased levels of active vitamin D, and fewer bone-building cells, known as osteoblasts. All of these factors interfere with bone growth. The effects of inadequate insulin are most apparent at the onset of Type 1 diabetes. At the time of diagnosis, people with Type 1 diabetes have about a 10% lower bone density than people of the same age and sex who do not have diabetes. Once insulin and glucose levels are controlled, however, bone loss can be stabilized.

People with Type 2 diabetes, who usually get diabetes after they have reached their peak bone mass, may actually have a lower rate of bone loss than the average person without diabetes. One reason for this may be that people with Type 2 diabetes have, on average, a higher body-mass index, which seems to offer some protection. Studies also suggest that people with Type 2 diabetes experience less bone turnover than people who don't have diabetes, which reduces their net bone loss even if they start out with a lower peak bone mass.

Diagnosing osteoporosis

Often, the first sign of osteoporosis is a bone fracture. Fractures of the bones of the spine (the vertebrae) can cause painful backaches, but occasionally they go unnoticed. This is probably because the vertebrae are often crushed, or squashed, rather than broken. Such crushing fractures are what lead to loss of height and curvature of the spine. Repeated spinal fractures can also lead to breathing and digestive problems. Other fractures, such as those of the hip and wrist, are much more obvious when they occur. Hip fractures lead to death in 15% of cases and loss of independence in more than 50% of cases.

Luckily, you don't have to wait for a fracture to find out if you have osteoporosis. Instead, you can have a bone-density test. There are many ways to measure your bone density, but the most reliable test is called dual energy x-ray absorptiometry (DEXA). At one time, this test could only be done at large medical centers, but now you may find it at clinics and even in some doctors' offices. The test takes only 10 to 15 minutes to perform, and the radiation used is lower than that used to take a chest x-ray. (Regular x-rays cannot detect osteoporosis until you have lost 30% or more of your bone density.) If a DEXA test shows a low bone density, blood tests that measure calcium levels may be used to monitor the progress of treatment. (Such blood tests cannot be used to diagnose osteoporosis.)

Treatment

Treatment and prevention of osteoporosis have a lot in common. The first step for both is to ensure that you are getting an adequate supply of calcium and vitamin D. No form of therapy will be effective if you are not getting enough of these nutrients to meet your body's needs.

If you are unable to take in enough calcium in food to meet your daily needs, you may want to think about taking a supplement. Many forms of calcium are sold as supplements. The two most common forms are calcium carbonate and calcium citrate. Calcium carbonate, often called oyster shell calcium, is the least expensive type of calcium supplement. (This is the kind of calcium found in Tums.) The only drawback is that it may cause constipation. It works best when taken with meals. Calcium citrate, while more expensive, does not cause constipation and is absorbed very easily. It does not have to be taken with meals. Whichever type of supplement you take, keep in mind that your body can only absorb about 500 to 600 milligrams of calcium at one time. So be sure to take no more than that at one time and to wait three to four hours before taking another calcium supplement.

Vitamin D can also be taken as a supplement, if necessary. Currently, the Recommended Dietary Allowance for vitamin D is 400 international units (IU) per day. However, many osteoporosis experts believe this may be too low and recommend taking 700 to 800 IU each day. Most multivitamins contain 400 IU of vitamin D per pill. Many calcium supplements also contain some vitamin D, but the amount varies widely. You can also buy individual vitamin D supplements. But be careful not to take too much: Taking more than 1,000 IU daily of vitamin D can be harmful.

Exercise is as important for treatment as it is for prevention. Since your back muscles help hold you erect and can help lessen the load on your spine, keeping them strong helps keep your spine strong. Back exercises known as extension exercises are good for your upper spine. If you have osteoporosis, ask your doctor for a referral to a physical therapist who can teach you how to do extension exercises and other back strengtheners safely at home.

Drugs. While calcium, vitamin D, and exercise are essential to treating osteoporosis, they may not be enough. Fortunately, new drug therapies have been developed to prevent bone loss or slow its progression. These include estrogen replacement therapy for women, bisphosphonates, calcitonin, and, most recently, selective estrogen receptor modulators.

Estrogen replacement therapy effectively prevents and treats osteoporosis in postmenopausal women. The chief reason for accelerated bone loss after menopause is the loss of estrogen. Studies show that women who replace the estrogen their ovaries no longer make experience much slower bone loss than postmenopausal women who do not take estrogen. Both estrogen pills and estrogen patches have beneficial effects on bone health. However, oral estrogen can raise triglyceride levels in susceptible individuals. Since many women with Type 2 diabetes already have or are predisposed to having elevated triglyceride levels, they may be better off using a patch.

In December 1997, a drug called raloxifene (brand name Evista) was approved for the prevention of postmenopausal osteoporosis. Raloxifene belongs to a class of drugs called selective estrogen receptor modulators (SERMS), nicknamed "designer estrogens." These drugs offer some of the benefits of estrogen, including protecting the bones and lowering cholesterol levels (although not as well as estrogen), without the same risks. SERMS do not stimulate breast or uterine tissue and therefore do not increase the risk of breast or uterine cancer or cause menstrual bleeding.

Another osteoporosis drug, called alendronate sodium (brand name Fosamax), belongs to a class of drugs called bisphosphonates, which work by slowing the rate of bone loss. Alendronate sodium is used both to prevent and treat osteoporosis. Studies have shown that it reduces the risk of fractures. When used correctly, alendronate sodium causes very few side effects. However, it is important to follow the directions for taking it exactly: Alendronate sodium must be taken on an empty stomach first thing in the morning. Always take it with a full, 8-ounce glass of water. Studies show that any other beverage severely limits its absorption. After taking the drug, wait at least half an hour before eating or drinking anything besides water, and don't lie down for at least 30 minutes. If you do not take this drug according to the instructions, it may not be absorbed and it may cause heartburn and inflammation of the esophagus.

Calcitonin, a hormone normally produced in the thyroid gland, also decreases the rate of bone loss. It is sold under the brand names Calcimar and Miacalcin. Until recently, calcitonin could only be taken by injection, but now Miacalcin is also available in a nasal spray. Like the other osteoporosis drugs, calcitonin has minimal side effects as long as you take it correctly. However, the nasal spray has been known to cause nasal irritation in some people.

Avoiding fractures

Drug therapy can slow the progression of osteoporosis, but if the damage has started, you will have a higher risk for fractures. That's why it is important to safeguard your home against any hazards that might trip you up.

Most hip fractures result from falls. While it is impossible to eliminate every hazard from your life, you can take steps to "fallproof" your home. Start by keeping floors and stairways clear of clutter. Throw rugs can be dangerous when they slide or bunch up, so avoid using them. Do not wax your floors to the point that they become slippery. Make your bathroom safer by using adhesive grip pads or a mat inside the tub, and install grab bars to help you steady yourself.

Having good lighting in your home is another important safety measure. Plug your lamps into outlets that are controlled by a wall switch so you don't have to lean over a table or walk through a dark room to reach them. Use night-lights, and place reflective strips on steps and doorways to make sure you see them.

To keep yourself steady on your feet, wear supportive, flat shoes that have good traction. Use a cane or walker if you need the extra support. Get up slowly from sitting or lying positions to avoid dizzy spells, and consider purchasing a cordless phone to keep by your side so you won't lunge for the phone when it rings.

Spinal fractures are more likely to occur after any bending, twisting, or jarring motion. To avoid these movements, try not to bend at the waist; bend your knees instead if you need to lower your body. This may mean doing some exercises to strengthen your thigh muscles. Avoid lifting anything heavy, especially if you have to bend to do it. Walk around tables and furniture rather than reaching over them. And place frequently used kitchen items in cabinets where you can reach them without bending or stretching. You might also want to consider investing in tools and gadgets that can help you avoid bending. For instance, you can buy a "reacher," or metal claw on a pole, to retrieve items from high shelves, and elastic shoelaces that allow you to slip your feet into and out of your shoes without untying them.

Certain drugs can disrupt your balance or make you dizzy. Be careful with strong pain relievers, especially narcotics, since these can make you dizzy. Blood pressure medicine and some antidepressants may also cause dizzy spells, especially when you get up from a chair or bed. Alcohol, too, can disturb your sense of balance.

Certain diabetic complications increase your risk of falling. Retinopathy that is serious enough to affect vision, and nerve damage of the hands or feet that is serious enough to cause numbness can lead to falls. If you have either of these conditions and osteoporosis, you will want to use extra caution to prevent falls.

Pain control

Osteoporotic fractures of the spine can cause significant and chronic pain. One of the best treatments to minimize pain and prevent future fractures is exercise. Visit a physical therapist as soon as possible after a fracture to learn proper posture and back-strengthening exercises. While exercise may seem like the last thing you would want to do, you may find it is the most helpful. Your physical therapist or doctor may also recommend supports and braces that can help you. To relieve pain, sitting against an ice pack often has the best pain-numbing effect.

Standing up to bone loss

Osteoporosis is known for being a sneaky disease, but you don't have to let it sneak up on you. Regardless of your age, make sure you consume at least the minimum recommended daily amount of calcium and vitamin D. Remember to take that daily walk: Exercise is key to keeping bones healthy. And if you are approaching or have already passed menopause but haven't yet talked with your doctor about bone-density studies, hormone replacement therapy, and other therapies to slow bone loss after menopause, do it now. Just as good diabetes self-management lowers your risk of developing diabetic complications, taking steps to lower your risk of osteoporosis and to treat it if you have it also improves your chances of living a longer, healthier life.

DIABETES DEFINITIONS

ANGINA

 Pain or tightness in the chest, a symptom of coronary heart disease (CHD). People with diabetes are at increased risk for CHD, a condition in which the heart muscle does not get a sufficient supply of blood, oxygen, and nutrients to meet its needs because of partial or complete blockage of the coronary blood vessels. This is usually due to atherosclerosis, the buildup of plaque (fatty deposits) on artery walls in the coronary vessels that feed the heart. There are a number of risk factors for CHD, including high blood pressure, diabetes, a family history of CHD, smoking, high cholesterol levels, high triglyceride levels, obesity, and inactivity.

Angina can vary considerably from person to person. It usually takes the form of chest pain that comes on gradually over a period of 30 seconds to several minutes. In some cases it may become more severe; in others it may remain mild and go away. The pain may also affect the left arm, shoulder, armpit, neck, or jaw. It may be brought on by exercise or emotional stress, but it may also occur at rest. Sometimes angina may produce symptoms of nausea and upper abdominal discomfort, when it can be mistaken for heartburn.

Two different types of drugs are commonly used to treat angina. Coronary vasodilators (such as nitroglycerin) cause the vessels of the heart to relax and widen, allowing for improved blood flow. Blood-pressure-lowering drugs can decrease the heart's workload and need for oxygen.

Another method for restoring blood flow to the heart is percutaneous transluminal coronary angioplasty (PTCA), also known as balloon angioplasty. In this method, a special balloon at the end of a catheter is threaded up to the site of arterial blockage, inflated to compress the plaque, and then withdrawn. This procedure enlarges the inner diameter of the blood vessel to allow for greater blood flow. In many cases, a stent (a small metal device in the shape of a spring or mesh cylinder) is placed in the vessel to keep it open. There is evidence that angioplasty may not be an optimal choice in people with diabetes, because their coronary vessels tend to abruptly close again following angioplasty.

Another technique is coronary artery bypass grafting (CABG), in which a blood vessel from another part of the body (usually the leg or inside the chest wall) is used to form a detour around the blocked part of the coronary artery. Studies have shown that in people with diabetes, CABG is much more effective than balloon angioplasty over the long term.

There are a number of preventive measures you and your doctor can take to lower your risk of developing angina and CHD:

If you smoke, stop!

Follow a diet that is low in cholesterol, saturated fat, and salt, as recommended by a dietitian. This can help control high cholesterol levels and high blood pressure, both of which are risk factors for coronary heart disease

Exercise regularly. This can help you maintain your weight and lower your blood pressure. (People with diabetes are advised to consult their doctor before embarking on an exercise program.)

If proper diet and exercise aren't enough to sufficiently lower your cholesterol levels or blood pressure, there are a number of very effective cholesterol-lowering and blood-pressure-lowering drugs available.

Keep your blood glucose within goal range.

INSULIN RESISTANCE.  A condition in which the body needs extra insulin to maintain normal blood sugar levels. Along with abnormal insulin secretion, it is a hallmark of Type 2 diabetes.

Ordinarily, insulin prods the liver to decrease its production of glucose. It also helps the body's fat and muscle tissues use glucose in the blood for energy. Insulin resistance generally takes two forms: the liver may produce too much glucose, or the body's tissues may not use glucose from the blood efficiently.

Insulin resistance can occur even before someone develops Type 2 diabetes. In the early stages, the pancreas secretes extra insulin to compensate for insulin resistance, so blood glucose levels remain in the normal range. Eventually, the pancreas may be unable to keep up with this extra demand, blood glucose levels may begin to rise, and Type 2 diabetes may develop. A growing body of research suggests that any degree of insulin resistance can increase a person's risk of heart disease, even if the person does not have Type 2 diabetes.

Some oral pills used to treat Type 2 diabetes, including glyburide (brand names Micronase, DiaBeta, and Glynase), glipizide (Glucotrol, Glucotrol XL), glimepiride (Amaryl), and repaglinide (Prandin), lower blood glucose levels by boosting insulin secretion. Others work by helping the body to overcome insulin resistance. Metformin (Glucophage) works primarily by decreasing the liver's glucose production. Pioglitazone (Actos) and rosiglitazone (Avandia) work primarily by making muscle and fat tissues more responsive to insulin, so that they use glucose more readily. Weight loss and exercise, which have long been known to reduce the risk of Type 2 diabetes, appear to help fight insulin resistance as well.

TIPS FOR INCREASING ACTIVITY

Improving your cardiovascular fitness level doesn't have to involve complicated movements, large blocks of time, or special equipment. In fact, just a few minutes of any kind of activity performed at intervals throughout the day can do the job. The following are some simple strategies for working more of a workout into your routine and for sticking with it. You'll be surprised at what a difference a few extra steps can make.

GETTING GOING Take the stairs instead of the elevator or escalator whenever possible. Park at the far end of the parking lot. Walk a few blocks before getting on the bus. Get off the bus a few blocks before your stop. Get up from your desk periodically during the day to stretch and walk. Take a 10-minute walk before or after lunch or dinner. Walk your dog. Mow your own lawn (with a push mower) and rake your own leaves. (Leave snow shoveling or other chores involving intense activity or heavy lifting to someone else if you have any evidence of cardiovascular disease.) Walk or bike short distances instead of driving your car. Limit TV and computer time and spend time outdoors. Plan active weekends and vacations. Schedule long walks, hiking trips, or walking tours. STICKING WITH IT Keep records of your activity. Reward yourself in ways that are personally meaningful for each goal you attain. Listen to music or books on tape while exercising. Exercise with a partner or group if it helps you. Savor the time alone when you exercise by yourself. Imagine yourself exercising and rehearse your workout in your head every day. Set realistic goals. Don't expect to see immediate results. Seek out positive social support and avoid those who discourage you. Don't give up if you miss a day; just get back on track the next day. Include some rest days in your exercise schedule. Keep it simple. FOR MORE INFORMATION Make The Link! Heart Disease and Stroke Initiative of the American Diabetes Association. www.diabetes.org/main/info/link.jsp National Heart Lung and Blood Institute Information about blood pressure and heart disease. www.nhlbi.nih.gov

USING A PEDOMETER

Pedometers are pager-size devices that can be clipped onto a belt or waistband to count and record the number of steps you take. A pedometer can be a great motivator for increasing your activity level once you start monitoring how many steps you take in a day. The newer pedometers don't have to be calibrated to your stride length before use: You can just put one on and go.

Getting started. Wear your pedometer from morning until night every day for one week. Record your daily steps in a log, and at the end of the week, calculate your daily average. This is your baseline activity level. You don't have to start increasing your activity level during the first week; simply observe how many steps you take.

Setting goals. The current recommendation is to take 10,000 steps per day. Depending on your stride length, one mile is approximately 1900-2400 steps. Don't get discouraged if you currently take fewer than 10,000 steps. Any activity is better than none, and you can always work toward a goal of 10,000 steps a day.

Stepping it up. Try increasing your steps by 5% to 10% each week. For example, if you average 3,000 steps daily, try increasing your daily walk by 150 to 300 steps each week. In a few months, you'll be up to 10,000 steps per day.

Keep it simple. Purchase a device that measures steps only. Some pedometers can calculate distance walked or calories burned, but these devices must be calibrated and are more trouble to use. In general, the simpler the device, the better.

Polycystic Ovary Syndrome . A syndrome in women characterized by elevated levels of male hormone, absence of ovulation, infertility, and insulin resistance. It is estimated to affect up to 10% of premenopausal women. Polycystic ovary syndrome (PCOS) often causes the body to express male characteristics such as facial or chest hair and male-pattern hair loss, as well as obesity. Researchers first noted “the diabetes of bearded women” in 1921, since women with PCOS tend to experience significant insulin resistance. About 30% of obese women with PCOS develop glucose intolerance or Type 2 diabetes by age 40. Like people with Type 2 diabetes, women with PCOS appear to have increased susceptibility to cardiovascular disease.

Traditionally, doctors have treated PCOS with oral contraceptives to lower androgen levels and normalize menstruation -- sometimes in combination with the drug spironolactone to correct excess hair. A study published in The New England Journal of Medicine showed that insulin-sensitizing drugs, in addition to alleviating insulin resistance, can restore normal menstruation in women with PCOS. Proper diet, exercise, and weight loss can also improve insulin sensitivity and help ward off heart disease.

If you are premenopausal, have irregular periods, and are experiencing symptoms such as excess body hair, consult your doctor. You may have PCOS and may benefit from these treatments.