Stephen D. Dow, MD
Four years ago I submitted an article to the Bulletin titled “Shift from Intervention to Prevention.” It was my opinion that as orthopaedic surgeons, we need to take a more proactive role in helping and educating our patients on preventive life-style changes that could help avoid or delay many of the degenerative conditions associated with aging. Conditions such as arthritis, osteoporosis and other age-related diseases are major causes of disability in our society today.
Since that time I have become board-certified in anti-aging medicine and have done extensive reading on this subject, as well as attended several annual meetings of the American Academy of Anti-Aging Medicine (A4M). This exposure has convinced me even more strongly of the need and the potential rewards—to our patients, to us as physicians and to society—of taking a preventive approach in treating patients.
About a year ago, I was notified of an opening on the Academy’s Aging Committee. Having served for six years on the Board of Councilors and for another six years on the Committee for Healthcare Delivery, I felt that participation on the Aging Committee would provide the ideal forum to increase the level of awareness among the Academy membership of the need to help our senior patients prevent or delay the wide spectrum of degenerative diseases that characterize aging. I submitted an application to serve on the committee.
No sooner had I received a request to attend an Aging Committee meeting, than I received notification that the meeting was cancelled pending a decision by AAOS leadership on discontinuing or substantially downgrading the committee. This article articulates my view that the Aging Committee has a potentially very important role to fill and should be continued. My remarks should be interpreted in the context of my not having had an opportunity to participate on the committee, meet its members or become familiar with its agenda.
Let me begin by quoting from the presidential address of Ronald Klatz, MD, to the A4M annual meeting a few years ago. “As we all know,” said Dr. Klatz, “America is in deep trouble. Our nation today faces the most perilous threat to our social stability since the Civil War. The threat comes, not from an apocalyptic failure, but from the stunning success of our scientific, technological and medical systems. America now stands at ground zero, facing financial and sociological destruction, burning in the flashpoint of 76-megaton age bomb. Over the next 25 to 30 years, the fallout from this bomb will begin its slow wind-drift over the American landscape, as 76 million aging baby boomers cause an unprecedented crisis in geriatric medicine and in our social and economic support systems. The largest generation ever born on earth will require medical and economic resources unmatched in history as they enter their twilight years. According to U.S. Census Bureau projections, the population traditionally defined as ‘elderly’ will more than double to 80 million between now and the year 2050... Treating their degenerative diseases and, in many cases, supporting them through 30 or 40 years of retirement will place unmatched demands on this nation’s economic resources.”
As an appropriate response to this threat, Dr. Klatz emphasized the importance of physicians acting in a new, more preventive way. “Anti-aging medicine offers a new paradigm of health care: it prescribes a proactive, preventive course of medicine that will lead to longer, healthier human lives, free of the disease processes now synonymous with advanced age,” he explained. “Not only does anti-aging medicine offer heretofore undreamed of benefits to all of us as individuals, it also offers a way out of the potentially crippling financial problems this country faces as a result of the aging baby boomers. For example, with a delay of one month in admission to nursing homes, the U.S. health care system will see $3 billion in savings each year. If the onset of Alzheimer’s could be delayed by five years, the nation would save $40 billion per year. And if the age of retirement and the onset of aging-related disease could be delayed by just one year, the nation would enjoy increased productivity and savings of over $500 billion each year.”
The Chinese symbol for crisis is made up of two characters—one representing danger and the other representing opportunity. The danger of our current situation with respect to the oncoming age explosion is that by doing nothing, maintaining the status quo, we will find ourselves confronted with the economic, sociologic and health care dilemma described by Dr. Klatz. On the other hand, the AAOS, and more specifically the Aging Committee, has the opportunity to take a leadership role in directing our members toward the adoption of a new paradigm of preventive care.
In many areas, preventive intervention has the potential to make a dramatic improvement in the health of our senior patients, and a dramatic reduction in health care costs. Orthopaedic surgeons have a unique opportunity to make a huge contribution in the rapidly evolving area of the inflammatory process. Many recent studies confirm that inflammation is a common denominator underlying many age-associated degenerative diseases, from cardiovascular disease to Alzheimer’s disease, from osteoporosis to syndrome X.
As orthopaedic surgeons we, more than most specialties, are involved in the treatment of patients who have inflammation as a major component of the problem. A wide spectrum of conditions—ranging from arthritis to back pain, bursitis, tendonitis, musculoskeletal injury and even surgical intervention—are all characterized by varying degrees of inflammation. However, a lack of understanding of the many ramifications of the inflammatory cascade results in a treatment armamentarium that is all too often limited to a few options, such as pain medications, NSAIDs or local hydrocortisone injections.
What we often fail to consider is that the patient who does not demonstrate the expected response to our treatment program may, in fact, have underlying genetic or metabolic factors that predispose him or her to a high level of inflammation. The typical western diet that has characterized our society for the past 40 to 50 years has been overloaded with the omega-6 family of fatty acids, chiefly linoleic acid, found primarily in vegetable oils, and deficient in the omega-3 fatty acids, chiefly alpha-linolenic acid. The omega-6 fatty acids are metabolized through the arachidonic, acid pathway lending to pro-inflammatory ecosanoids. The omega-3 fatty acids, on the other hand, are metabolized through the eicosapentaenoic acid pathway leading to anti-inflammatory ecosanoids.
By doing a laboratory evaluation of fatty acids, we can determine whether the ratio of arachidonic acid to eicosapentaenoic acid is out of balance, predisposing the patient to a pro-inflammatory state. Having determined this, we then have a basis for recommending that the patient take a supplement with pharmaceutical grade fish oil (omega-3) to correct the imbalance and thereby reduce the level of inflammation.
In the management of inflammation, orthopaedic surgeons tend to rely on NSAIDs, particularly COX-2 inhibitors, partly due to a strong marketing campaign by the pharmaceutical companies. We might even compare our position to that of the ob-gyn specialists a few years ago, who were the object of heavy marketing in the promotion of Premarin and Provera, synthetic (patentable) hormones. But in 2002, both the Women’s Health Initiative Program and the Heart and Estrogen/Progesterone Replacement Study confirmed an increased rate of stroke, blood clots, breast cancer, heart disease and colorectal cancer in patients who had been taking these synthetic hormones. Both studies were prematurely discontinued.
If you have read John Grisham’s King of Torts, you understand the potential impact of a class action lawsuit. Recently, I noticed an advertisement encouraging women who took either Premarin or Provera to contact a local attorney. Unfortunately, most ob-gyn physicians have not been aware of the much safer and more physiologic option of a bioidentical hormone (un-patentable), which Suzanne Summers brought to the level of public awareness in her recent book The Sexy Years.
Similarly, most orthopaedic surgeons are not aware of options, which may be preferable to COX-2 inhibitors, for the long-term management of inflammation. Metagenics has recently developed, tested and is marketing a product, Kaprex, which, on the basis of their testing, is not only as effective as the COX-2 inhibitors, but is much safer in terms of potential gastrointestinal toxicity. Along with glucosamine and fish oil, I have found Kaprex to be an effective, safe alternative.
NSAIDs are responsible for 16,500 deaths per year, constitute the 15th leading cause of death in our country and are responsible for more than 107,000 hospitalizations per year. Recently, the journal Immunology reported that inhibition of COX-2 has the long term effect of increasing the cytokines TNF-a and IL-b, both of which have been shown to promote cartilage destruction.
So we have the ironic situation where COX-2 inhibitors may decrease inflammation in the short-term but may cause serious gastrointestinal and cardiovascular complications and cartilage damage over the long-term. Orthopaedic surgeons and our Academy leadership would be well advised to take a lesson from the ob-gyn experience and recognize the importance of becoming more knowledgeable about and offering safer and more physiologic options for managing inflammatory problems in patients.
This is but one example of an area where the Aging Committee could have a major impact. By increasing the level of awareness of our membership in this area, we have the opportunity to take a leadership role with dramatic, far-reaching effects, including the improved management of our patients’ orthopaedic conditions, and the potential of decreasing inflammatory risk factors that predispose patients to a broad spectrum of diseases that constitute a major cause of death and disability in our society today.
Stephen D. Dow, MD, is an orthopaedist in private practice in Reno, Nev., and a member of the AAOS Aging Committee.