Editor's Corner

Prof. Margaret Rees
Editor-in-Chief

The Editor's corner is a new feature of Maturitas. It summarises for the public the most important research published in the journal on midlife and ageing and the papers are openly available.

Schizophrenia and bipolar disorder are severe mental illnesses (SMI) that Affect around 1% of the population. They are amongst the leading causes of disability and impact social, work, occupational, interpersonal and self-care functioning. Following the introduction of antipsychotic medication in the 1950s, the lives of many people with SMI have been transformed. As treatments have improved, there has been an increasing awareness of their side effects. There are concerns that treatment with certain antipsychotics may lead to the development of osteoporosis. The most likely mechanism linking antipsychotics with decreased bone density is through hyperprolactinaemia and secondary suppression of sex steroids. The prevalence of hyperprolactinaemia is higher in people receiving antipsychotics than virtually any other patient or population group. Cross-sectional studies have indicated that the prevalence of hyperprolactinaemia ranges from 42% to 93% in women and 18 to72% in men. Hyperprolactinaemia varies markedly between antipsychotics. The author concludes that health professionals caring for people with SMI to consider osteoporosis and take steps to prevent and treat this to reduce the risk of fracture.

Following the media scares after publication of the results of the US Women's Health Initiative (WHI) study and the UK Million Women Study (MWS) in2002 and 2003, the search for alternative treatments that were perceived to offer beneficial effects with less risk intensified. Herbal products were considered to be more natural and hence safer. A recent report suggested that about 49% of older adults in the US use dietary supplements concurrently with prescription medications. The authors of this review examine the safety of herbal products.

They conclude that there are concerns about herb-drug interactions and long-term safety assessments because women may use these products for prolonged periods of time. Products produced to high quality standards are essential for ensuring consumer safety. Regulatory frameworks must be in place to ensure that herbal ingredients’ identities have been verified, that they have been properly quantified per unit dose, that the product is within tolerance limits for contaminants, that the product's safety and effectiveness under the recommended conditions of use have been assessed before sale to the public, and that a system is in place to detect and deal with adverse reactions when they arise.

International collaboration in the development of harmonized quality specifications and causality algorithms specifically tailored to herbal products is highly advisable, as is stronger collaboration between regulatory agencies around the globe for the early detection of any significant safety issues associated with a particular product.

From 2002 to 2003, the breast cancer incidence in the United States, as reported by the National Cancer Institute's Surveillance Epidemiology and End Results (SEER 9) database, appeared to decrease by 6.7%. This was attributed to a reduction in the use of menopausal hormone therapies (HT) after the initial publication of the Women's Health Initiative (WHI) study results in July of 2002. However, while prescriptions of estrogen-plus-progestin HT, which are associated with increased rates of breast cancer, fell by 53% from 2002 to 2003, those of estrogen-only therapies fell by only 27%. The authors analyzed the effects of the higher rate of discontinuation of estrogen-plus-progestin HT relative to estrogen-only treatments in 2002–2003. They found that the relative persistence with estrogen-only therapies — as compared to estrogen-plus-progestin therapies — can explain the reduction in breast cancer incidence from 2002 to 2003. They conclude — as previously demonstrated in the estrogen-only arm of the WHI trials — that menopausal estrogen-only use is not responsible for increasing the risk of breast cancer in menopausal women and may, in fact, be protective. Thus it is essential to make a distinction between the effects of different types of HTs on the risk of breast cancer.

This systematic review is included in thefirst part of a special issue on complementary and alternative therapies. Womenhave increasing been exploring these because of concerns about the safety ofestrogen-based hormone therapy. The advantage of mind body therapies is thatthey avoid interactions with standard therapies such as can occur with herbalremedies.The authors have systematically reviewed the peer-reviewed literatureregarding the effects of self-administered mind-body therapies on menopausalsymptoms.

Interventions included yoga and/or meditation-basedprograms, tai chi, and other relaxation practices, including muscle relaxationand breath-based techniques, relaxation response training, and low-frequencysound-wave therapy. Collectively, findings of these studies suggest thatyoga-based and certain other mind-body therapies may be beneficial foralleviating specific menopausal symptoms. However, the limitationscharacterizing most studies hinder interpretation of findings and preclude firmconclusions regarding efficacy. The authors conclude that additional large,methodologically sound trials are needed to determine the effects of specificmind-body therapies on menopausal symptoms, examine long-term outcomes, andinvestigate underlying mechanisms.

As more women are surviving breast cancer, lifestyle interventions to prevent recurrence, new breast cancer events, and mortality is of considerable public health importance. The authors of this review have focussed on physical activity, diet, and adiposity. The most consistent finding from observational studies was that adiposity was associated with a 30% increased risk of mortality. Physical activity appeared to be associated with a 30% decreased risk of mortality. Given that a high proportion of breast cancer patients appear to be both sedentary and obese/overweight, clinical trials are needed to investigate whether the combination of increased physical activity and reduced adiposity can improve breast cancer prognosis.

Male breast cancer is an unrecognised uncommon condition. In recent years, the incidence of breast cancer in women appears to be falling. In contrast, the incidence of male breast cancer appears to be rising. In this review the authors examine the new treatments available for the disease.

Coronary heart disease mortality in women increases after the sixth decade. The authors looked at risk factors for the disease in 1730 women included in the French MONICA cross-sectional survey. They found that cholesterol levels were higher in postmenopausal women compared to their premenopausal counterparts.

The authors examine the consequences of obesity on health at midlife and beyond. The article is in a special issue devoted to predictors of midlife heath. A burgeoning pandemic of obesity is well characterized. The wide spectrum of morbidities related to excess body mass includes risks for diabetes, hypertension, coronary artery disease, dyslipidemia, malignancy, venous thrombosis, degenerative joint disease, pulmonary compromise, sleep apnea, cholelithiasis, depression and overall reduced quality of life. Bariatric surgery literature suggests that, in the morbidly obese, increase in the lifespan is achievable with reversal of obesity, reinforcing the realization that sequelae therein are by no means inevitable. This article concludes that the consequences of obesity are major and aggressive efforts must be targeted towards population-based strategies to prevent and reduce excessive body mass.

Interstitial cystitis or painful bladder syndrome, is a debilitating condition, which affects women more than men, where there is sensory hypersensitivity of the bladder. Consequently a small volume of urine will generate an exaggerated sensation of pain or pressure resulting in urinary urgency and frequency day and night. The precise cause is unknown. Therefore managing patients with interstitial cystitis or painful bladder disease still remains a challenge in the twenty-first century. Over 150 types of treatment have been recorded. There is clear need for further research into causes and effective treatments.

With the advent of highly active antiretroviral agents, women with HIV infection can expect to live longer than ever before. This increased survival has led to concerns about the long-term implications of HIV disease and its treatment. Women with HIV appear to become menopausal early and can have worse symptoms such as hot flushes. They have an increased risk of osteoporosis, diabetes and heart disease. The risk of some cancers such as lung and cervical cancer is also increased. It is too early to declare victory on the war against HIV and AIDS. As better treatments have been developed both women with HIV infections and their doctors now need to focus on the long term health implications.

Since publication of the US Women's Health Initiative and the UK Million Women Study, women have had concerns about using standard hormone therapy to treat menopausal symptoms. They have turned to "bioidentical hormones." These are defined as compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body and which are made chemically from plants such as yams.
Bioidentical hormones are available in some countries from compounding pharmacies and these formulations have not been approved by regulatory bodies such as the FDA in the US. There are therefore concerns that we have no evidence from clinical studies that they are as good as or safer than standard hormone therapy which has been approved by regulatory bodies.
So what can women do? "Bioidentical hormones" are available as approved drugs. For example oestradiol is available as tablets, patches or gels. Progesterone is available as a tablet.

Population health outcomes are determined by complex interactions between individuals and the environments in which they live, work and play. Environments encompass streets and buildings (physical environment), attitudes, supports and relationships with others (social environment), as well as social and political systems and policies. The impact of environments on the physical, mental health and functioning of individuals is a growing area of health research as current long term care policies are shifting the care of older adults away from nursing homes and into the home and community setting. The authors reviewed the current state of the health literature on physical environments for healthy ageing. They found a growing body of work identifying environmental effects on a wide range of physical and mental heath outcomes in older adults. These findings stress the role of supportive, barrier-free environments particularly for older adults who are at greater risk for disability and poor health. They conclude that interdisciplinary training that brings together health professionals with urban planners has the potential to generate initiatives that could minimize the negative consequences of underlying disease and impairments for the independence of older adults, so that they can continue to maximize their health, well-being, and participation within their communities as they age.

Obesity is currently a major public health concern and is reaching epidemic proportions. In the U.S. 41% of adults are projected to be obese by 2015. This review article examines the impact of obesity in an elderly population looking at studies undertaken in people aged 50 or over. The authors found that among elderly persons, obesity increases the risks for a variety of conditions including cancers, diabetes, high blood pressure, stroke, heart disease, obstructive sleep apnea syndrome, osteoarthritis, depression, disability, and lower quality of life. In some reports, obesity has been linked to Alzheimer's disease. Obesity significantly increases healthcare costs and nursing homes are currently ill equipped to address the needs of the rising number of obese residents. It is therefore imperative that research efforts and funding are devoted to studying the effects and the reduction of obesity in the elderly population.

Ageing is often associated with the aged and the diseased, nevertheless ageing is a process that starts before birth. This paper describes the results of a meeting of international experts whose purpose was to identify potential mechanisms and interventions to improve healthy life expectancy of the population; and to highlight areas within ageing research that should be prioritised in the future. General agreement was reached in recognising ageing research as a field with little communication between basic science. A more holistic, multi-disciplinary approach is urgently required. Future research should concentrate on understanding the mechanisms that allow individuals to maintain optimal health. Finally it is fundamental that scientific research findings are constantly translated into clear messages delivered to governmental institutions, the industry and society in general.

Diabetes affects almost 6% of the world's population. The number of diabetic patients will reach 300 million in 2025. More than 97% of these patients will have type 2 diabetes, which increases the risk of heart disease. Type 2 diabetes is one of the fastest growing public health problems worldwide. This is mainly as a result of the obesity epidemic. Functional foods are defined as foods having health-promoting benefits over and above their usual nutritional values. The may have the potential to improve control of blood glucose, but little evidence is known about the efficacy of these foods. This literature review examined the effects of functional foods - such as nuts, omega-3 fatty acids (found in oily fish) and cinnamon — on blood sugar control in type 2 diabetes. It found that while nuts and omega-3 fatty acids appear to have an overall beneficial effect on heart disease; however, their effect on glucose control is uncertain. In addition, cinnamon appears to inconsistently improve blood sugar control. The most effective intervention is weight loss. A large amount of research has to be undertaken on functional foods before they can be recommended to help control blood glucose.