Obamacare: The Good, The Bad and the Trojan Horse

A bird’s eye view of the medical regulatory landscape since the late 1700s reveals skirmishes and battles over physician qualifications, education standards, hospital and physician accreditations, medical ethics, drug and device development and, last but not least, payment mechanisms. From a distance we also see a steady march toward a centralized bureaucracy administering all aspects of health care– standards, regulations, choices, availability of services, payment methods and more. The latest steps came in 2010, when, after a contentious battle, one party of Congress passed the massive Patient Protection and Affordable Care Act, also known as the PPACA, the ACA or Obamacare.

Some good

During the legislative haggling over the ACA, the House Speaker famously said that we had to pass the law to see what was in it and after six years, some things are clear. We can no longer be denied insurance because of pre-existing conditions and there can be no cap on payments over time. Some people are buying insurance for the first time because they can receive federal subsidies that make premiums more affordable. Medicaid has been widely expanded and made available for many whose incomes had made qualification impossible before. The number of people who are uninsured has fallen back to 13-14% -the best since the 1990s.

Some not so good

The law improves access to healthcare via additions to the labyrinthine system in which costs remain invisible to doctors and patients and the largest profits go to hospitals and insurance companies. For many people, insurance costs and out of pocket deductibles are now higher and choices of doctors and hospitals reduced. Carrying health insurance is a new legal requirement and our policies must include services we don’t need (such as maternity care). Breaking the law means paying a tax penalty of up to 1% in the initial years after passage, more in years to come. And of course there are innumerable rules.

A failure to address costs

Despite clamor for reform because of the outrageous prices attached to medical care, the legislators crafted a law that addresses medical costs only by increasing taxes and threatening funding. The 2700 page ACA includes new taxes on investment income and on medical devices, fees to be paid by drug companies, new taxes on every Medicare and private insurance company policy, as well as additional policy fees that finance an independent and unaccountable organization dedicated to clinical effectiveness research. Insurance companies must pay fees to sell their policies on the health care exchanges. Half of the law’s estimated $1 trillion cost will come from cuts in Medicare spending, pain not yet felt.

The Trojan Horse

Most noteworthy for those readers concerned about the long term effects of the ACA is a new agency called the Independent Payment Advisory Board (IPAB), composed of 15 people chosen by the President, serving 6-12 years, but able to stay in their posts indefinitely if the President chooses not to replace them. The controversy spawned by the stunning powers granted to this board and the fact that the President has yet to appoint any members to it have convinced many that the board will never be functional. Nevertheless, IPAB is a Trojan horse inside the city’s gates. Should it come to life, the process of herding everyone into a bureaucratically controlled healthcare system will be easy to complete.

Getting around democratic messiness

The Independent Payment Advisory Board is deliberately designed to get around the messiness of democracy and the reluctance of politicians to act responsibly when they risk unpopularity. For instance, for over a decade Congress repeatedly blocked the cuts that current legal formulas demand in Medicare reimbursements to doctors because the cuts were too onerous. They also feared the effects of Medicare cuts on the private sector, where payments are tied to the Medicare schedule. The ACA removes political considerations from efforts to control costs by handing the problem to the IPAB, which then inverts the normal process of legislation and effectively ties the hands of Congress, the President and the courts. IPAB’s recommendations will be presented as completed legislation that must be enacted unchanged unless the President and three-fifths of both Senate and House of Representatives reject the proposal and present an one that cuts spending equally. IPAB’s proposals, once implemented, cannot be subject to judicial review.

No oversight

The Board’s proposals are exempt from administrative responsibilities such as citizen review and must be must crafted yearly if projected Medicare expenditures per enrollee are determined to exceed a predetermined figure. Growth projections regularly exceeded the trigger point up until the law was enacted in 2010. The sudden, unexpected decline in projections since ACA enactment is not understood, but it took the negative spotlight off the advisory board for the time being.

Handing the power of healthcare cost allocation to one, unelected individual

Should Medicare cost projections balloon before the President has appointed IPAB members, the ACA allows the Health and Human Services Secretary to assume the responsibilities of the board – making it possible that one unelected individual could decide how to allocate healthcare resources. The President’s executive discretionary power is forbidden in this situation. He is not allowed to shelve the Secretary’s proposal and must present it to Congress within two days.

Perpetual life for the IPAB

Congress’s only way to repeal IPAB is to present a bipartisan proposal created between Jan. 1 and Feb. 1, 2017 (about 15 working days in the midst of the start of a new presidency) and then to get the proposal approved by three-fifths of Senate and House members by August 15, 2017. If the attempted repeal fails, no Congress may ever again attempt to repeal the Board. After 2020 Congress may never enact substitutes for the proposals the board makes about healthcare payments.

At present, most people seem less concerned about the potential for unconstitutional government action than about the practicalities of getting insurance under a law that seems here to stay unless it is repealed in toto. While many people might welcome continued movement toward a federally administered healthcare system, they should remember that we already have two. One is the Indian Health Service and the other is the VA. Both have huge problems.

Posted by medical plaintalk

Physician turned medical writer.

Health Insurance: How We Became Passengers on a Runaway Train

Once upon a time, when a man felt unwell or was injured, someone fetched the doctor. The doctor might not have done much for his patient except explain symptoms and urge endurance, but the interaction eased the patient’s worry. He paid the doctor in money, or maybe chickens, and very often got better because the body is good at fixing itself. With time doctors gained more knowledge and tools. More treatments became possible. Along came offices and hospitals and then insurance against the unexpected costs of hospitalization.

The birth of health insurance

After WWII, when wages were frozen, employers attracted workers by offering “hospitalization insurance” as part of an employment package. No one foresaw the chains that came to bind patients to employers and doctors to insurance companies, because no one foresaw the explosion of technology that drove a perpetual escalation of costs. That awaited another well-intentioned idea – a government sponsored system to pay for the health needs of the elderly (Medicare), and later the poor (Medicaid). The infusion of federal money (also known as someone else’s money) into health care spurred medical advances and hospital care in ways never seen before. Sensing unlimited growth potential, big business came calling and dragged the entire enterprise onto Madison Avenue, labeling it “health care.” Hospitalization insurance morphed into the medium of transaction for all services rendered.

Out of control

If, in this new medical world, you feel like a faceless passenger on a runaway train, you are not alone. And if you seek out the locomotive, you will find that there is no engineer – just a bunch of firemen madly shoveling coal into the engine. The firemen are your friends and neighbors. They work for insurance companies, pharmaceutical and medical device companies, advertising agencies, the media, and the government and, of course, universities, hospitals and clinics. The health care industry is a giant machine employing millions of people and consuming close to 20% of the gross national product. (Note: the original version of this column was written in the 90s, when the figure was 12%; when it was published in early 2008, the number was 15%). Changing direction is no simple matter, but staying the current course seems foolhardy.

The power of invisibility

We fear the costs of health care, we resent the power of insurance companies, and we are submerged under a tidal wave of scare tactics designed to sell products we don’t understand and have no way to evaluate. We lack physicians who know us well, and we use emergency rooms and urgent care facilities as family doctors. Unless we are seeking “non-essential” care, like cosmetic surgery, the transaction of worth in medical encounter – the bill – is mysterious, hidden under an economic invisibility cloak that rivals Harry Potter’s. While we all know and weigh the costs of life’s other “essentials” such as food and shelter, we are not allowed to make value judgments about medical interventions that grow more numerous by the year.

Invisibility of cost interferes with responsibility on the part of doctor and patient alike in judging the worth of these interventions. The impulse to “just check things out” is much easier to indulge when little or no money changes hands. When “insurance pays,” doctors feel fewer qualms about ordering expensive tests, and no urgency about understanding and explaining the arcane statistics behind the studies that prompt the treatment fashions of the day. Ever-present fear-mongering sells us on the need for diagnostic tests and interventions to treat “risk factors” and patients feel guilty if they have the temerity to question recommendations for life-long drug taking and repetitive screening tests and X-ray exposure. And in the meantime, medical costs have risen to levels that bear no relationship to the costs of the rest of life, the arcane language of medicine is so rarefied that the non-medical “consumer” has no hope of understanding it and must rely on interpretations by the “purveyor,” and all too many of the purveyors have only a rudimentary understanding of the products they pitch.

What is the goal of all the money spent?

As long as we hide costs in the accounting books of insurance companies, we can fritter away one political season after another pretending the “healthcare problem” is just about access to medical care. We can avoid the tough questions about the goals of health care. Do we want to tie up the bulk of our resources in the last 6 months of life (as happens in Medicare spending), or can we acknowledge that intense intervention at the end of life adds a great deal of distress without any gain? How much do we waste and how much anxiety do we cause with extra tests and rules aimed at keeping lawyers at bay? As we now begin to watch upcoming generations fail to exceed or even meet the life expectancy of their elders, can we admit that the high tech medical road we’ve chosen may be the wrong one? That real prevention is better than treatment? That real prevention requires education, patience, consistency and self-discipline more than obsessive searching for disease already present? That cures of disease come from full understanding of the science involved, not from premature attempts to sell the products of research to as many people as possible?

Resisting manipulation

As you negotiate the jungle of media hype and medical sales pitches, you must resist being manipulated by fear, and regain the trust in your body. It is not a fragile edifice that will crumble without constant examination and intervention. It is a marvel of engineering that attempts to protect you from what you do to it. It will never be free of minor, self limiting ailments, but it responds well to good care that befits its design for life 40,000 years ago. Be glad modern medicine is there for the catastrophes that cut young life short, and to help with cataracts and hearing aids and artificial joints. Be relentless in questioning of the need for drugs and procedures, and ask what will happen if you opt not to go ahead. Don’t be steamrolled by statistics – ask for absolute numbers rather than percentages, which tend to make results look more impressive than they actually are. For instance, 50% reduction may mean that only 1 person instead of 2 out of a thousand died of a given disease after the new treatment.Whatever the statistics, you are an individual and the complication or success either will or will not happen for you. As you get older, seek doctors who see you as a whole person, not one organ or another. And remember that life inexorably winds down and ends, no matter what you pay and do. Don’t spend it all worrying about your health.

Wall plaque, author unknown

“Life should not be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather skidding in sideways, chocolate in one hand and wine in the other, body thoroughly used up, screaming “WOO HOO what a ride!”

Posted by medical plaintalk

Physician turned medical writer.

Cholesterol Phobia

Cholesterol research is difficult, esoteric and accessible in journals that seldom make it beyond their target audience – other people doing the same type of work. One theory about the relationship of cholesterol and heart disease has dominated medical practice for over half a century, but there has always been dissension in the ranks of scientists, some of whom labor away in obscurity, slowly building a case that may one day topple the current dogma. I have attempted to make this subject accessible to a non-medical audience because the current paradigms for thinking about heart disease and treating it affect everyone who sees a doctor, listens to the news or reads the popular press – even children, because they eat what their parents believe is healthy for them.
Cholesterol phobia: is the end in sight?

Cholesterol earned a villain’s reputation because it got caught at many criminal scenes where victims succumbed to heart attacks. It was found lurking in the walls of arteries too narrowed by “plaques” to allow blood passage. Even in young healthy men, cholesterol- laden “fatty streaks” were surprise findings at autopsy after accidental or war-related death. Experimentally, fat choked arteries were easy to produce in experimental animals by feeding them food pellets saturated with fat – even olive oil worked. The laboratory work bolstered attempts to show that different populations consuming different amounts of fat had different rates of heart disease. Though both the laboratory and epidemiology studies were fraught with contradictory results, and the dietary cholesterol theory of heart disease was initially rejected by the American Heart Association, the personalities and scientific politics involved eventually catapulted the theory into the lives of all Americans, over 20 million of whom are now on potent drugs to combat the evil substance.

The dietary theory of heart disease

After more than half a century of war on cholesterol, the dietary theory remains just that – a theory – no matter how many commercials remind you that you need to lower your cholesterol. You may be surprised to hear that cholesterol could be absolved of its villainous status, within your lifetime. But don’t expect your doctor to agree, at least not yet. The cholesterol theory has a grip on our culture that is almost religious. The current dogma, advertised everywhere, is simple: there is good cholesterol, labeled HDL, and bad cholesterol, labeled LDL and anyone who cares a whit about his health will do whatever it takes to get those numbers in line with the current recommendations of the American Heart Association –eat a low fat diet, exercise, and take the right drugs.

Inconvenient facts

Inconvenient facts have always dogged the theory. Cholesterol levels plummet in seizure patients treated with high fat, no carbohydrate diets. Heart attacks occur despite normal cholesterol levels. Low fat diets raise cholesterol levels -President Eisenhower was one of the most famous examples. And buried in the literature of the last half century are many clues pointing a blaming finger away from cholesterol and toward the complex lipoproteins that ferry it around the body. As more and more questions are raised about the efficacy and dangers of drugs that reduce cholesterol, more attention may turn to these lipoproteins. After all, like cholesterol, they have been part of the statistic most closely associated with heart disease – the LDL (low-density lipoprotein) cholesterol.

What are lipoproteins?

Total cholesterol measures cholesterol attached to lipoproteins. Lipoproteins are combinations of phospholipids (fats that dissolve in water) and specialized proteins that fit like keys into receptors on cells. Lipoproteins function like cargo ships, carrying fats to cells for fuel, to fat tissue for storage, and back to the liver for reprocessing when demanded. More or less cholesterol crowds aboard each boat depending on the number of boats available. The size of the fleet, in turn, depends on the amount of triglycerides (another type of fat), awaiting shipment – not on the amount of cholesterol.

Triglycerides rule

Triglycerides and cholesterol are very different fats. Triglycerides provide the fatty acids that fuel most cells and are stored in fat tissue for later energy demands. Cholesterol yields no energy at all. It is a building block, used in the construction of all cell membranes and in the making of hormones and bile. Not all cholesterol comes from fat in the diet. The brain makes its own, and the liver and skin make whatever the body needs – raising production whenever dietary intake is low. Cholesterol and triglycerides attached to lipoproteins are like citizens of two different countries travelling together on one of the country’s boats. That country that builds the boats belongs to the triglycerides. The more triglycerides present in the body, the more lipoproteins in the fleet.

The varying density of lipoproteins

Lipoproteins fully loaded with cholesterol and triglycerides are fluffy and buoyant (fat floats) and called very low density lipoproteins, VLDL for short. They dock at cells in need of fuel or cholesterol, unload some cargo, lose some buoyancy, and become a little denser. Eventually they become low-density lipoproteins (LDL) and , with no energy or building material left to give up, they return to the liver for recycling. Another particle type called high-density lipoprotein (HDL) is even less buoyant – and less well understood. In contrast to cholesterol bound to LDL and VLDL, the cholesterol carried by HDL particles, like the cholesterol carried away from the intestines by chylomicrons (very large lipoproteins) does not contribute to the storage of fat in any tissues so is not associated with plaque formation in arteries. Normal to high levels of HDL cholesterol are associated with lower risk of heart disease.

What do the anti-cholesterol drugs do?

The widely prescribed statin drugs block the body’s ability to make cholesterol, which makes less cholesterol available to be loaded on to the lipoprotein boats. But boat making proceeds apace because it is driven by the amount of triglyceride awaiting transport- and the triglycerides, remember, come from dietary carbohydrates. Lowering cholesterol manufacture does not lower lipoprotein production – the lipoprotein boats will simply carry less cholesterol per lipoprotein particle, making each particle smaller and denser. Will this magically keep cholesterol out of artery walls? Not a good bet. Lipoprotein research labs have identified seven different particle types within the LDL fraction of total cholesterol. Heart risk appears to be correlated with the smallest and densest sub-fraction – the kind carrying the least amount of fat per molecule. (The anti-cholesterol drugs do have an independent anti-inflammatory effect which may be the way they diminish risk of a cardiac event in people with heart disease.)

Take-away message

So how does this complicated information change your life? Triglycerides, the stimulus for VLDL and LDL production, are a product of carbohydrate processing – especially of sugars and refined grains. Lowering VLDL production and hence LDL production requires lowering dietary carbohydrates – not fat, not cholesterol. Blood cholesterol isn’t even a good marker for total body cholesterol, which includes cholesterol squirreled away in artery walls. Cholesterol in arteries behaves much like cholesterol stored in fat tissue. It is responsive to the entire array of interconnected feedback loops involving not only fats, but carbohydrates and insulin and all the other hormones. It is time to respect its complexity and quit expecting that coaxing the body to make less cholesterol by taking drugs to block its production, or by eliminating it from the diet will end the scourge of heart disease.

Posted by medical plaintalk

Physician turned medical writer.

A Case History *

Today, just for laughs in a world where medicine and a few other subjects make us worry unnecessarily, a case history.
Case history

13 month old, ambidextrous WM presents with chief complaint of “something wrong with legs,” noticed by his aunt. History obtained from caretakers, as the patient does not speak English.

HPI: Several weeks ago, the patient switched suddenly from four point locomotion on hands and knees to upright posture and ambulation on legs. His caretakers were pleased with this event and recorded his progress to share with interested parties. Upon viewing one recording in which the patient was hurrying to catch up with his mother, his aunt, who works in a health field, noted that “something is wrong with his legs.” There has been no sign that the patient is uncomfortable with his new choice. In fact he seems to revel in it and consistently pushes away the hands of those who attempt to support and assist him. He does not appear to be uncomfortable when he loses his balance and falls, which happens less and less frequently as he practices his new skill. Initially he reverted to 4 point locomotion when he seemed eager to reach his destination, as if valuing speed over the upright posture. Of course this is an inference, because, as noted previously, the patient does not speak English (aphasia might also be considered). Now, however he chooses to ambulate in the upright position most of the time. He has also demonstrated increasingly frequent and increasingly more skilled ability in squatting and rising, picking things up and carrying them – and other more subtle indications that he is multitasking with his motor system while engaging in his new form of locomotion. And he is able to rise from sitting to the upright posture without using his hands or shifting to his knees, a skill that eludes many people who have used the upright posture for many years – a skill that some believe correlates well with life expectancy.
ROS: Of note and possible relevance is the fact that he is incontinent and as a result wears a bulky diaper and rubber pants.
PE: 1. Examination of the video in question reveals a small male at some distance from the camera. As he comes into clearer view it is evident that he is walking unsupported in bare feet on uneven ground. He uses gross motor groups of the trunk and hip to move his weight from one foot to the other, leaning from one side to the other as he unweights the new balancing leg to move it into the new planting position, slightly in advance of the weighted leg. His base is broad and his toes point outward. The aforementioned diaper and rubber pants may slightly exaggerate these two features. He also moves rapidly and since his build includes relatively short legs and large head, he appears a bit ungainly and off balance, as though he might topple over (prompting the aforementioned but usually spurned offers of help). His timing appears somewhat irregular, and he plants his feet without any finesse, leaving the observer with an overall impression of unsteadiness (recall Lurch, of the Adams Family).

2. Physical examination several weeks later and in the patient’s usual environment was remarkable for its normality. Neurological evaluation revealed a similar gait pattern, but with an appreciably narrowed base, and less outward deviation of the feet in forward motion (see supplemental video). He does remain aphasic, but responds appropriately to non-verbal accompaniments of speech (at times this leads to the conclusion that he understands some words, but unless the response occurs in a vacuum of other elements of communication this is hard to evaluate precisely).

Impression: Reversible gait dysfunction indicative of incomplete development of the cortico-cerebello-pontine pathways
Treatment plan: 1. Encourage patient to get on with getting older

2. Practice, practice, practice

*This post is not based on an Elks Magazine column, but written in response to a request for advice

(Video removed for privacy. Available on request to friends and family)

Posted by medical plaintalk

Physician turned medical writer.

Partners: Fiber and Bile

Everyone knows you need fiber in your diet. Everyone knows fiber comes from plant foods. And everyone knows that fiber helps move food through the system – just like a lot fiber in grass and hay help move a horse’s food through its unusually long and tortuous bowel. Fiber in the human diet helps package waste in softer, bulkier bowel movements, and a high fiber diet reduces constipation, which in turn reduces the risk of hemorrhoids, diverticulitis and even colon cancer.

More than a laxative

What is not obvious is just how a diet high in fiber lowers cholesterol levels and improves the other cardiovascular risk factors associated with the metabolic syndrome (obesity, high blood pressure and diabetes). How can the indigestible component of food, which releases no energy and is not absorbed into the body, affect metabolism? And how does moving food through the body with greater ease and efficiency alter body chemistry? The answers are interesting and worth knowing, since they provide impetus for even the unconstipated to pay attention to fiber intake.

What is fiber?

By definition, fiber is the indigestible component of food. Both cooking and chewing break fiber-rich food down in size, but fiber is impervious to stomach acid and digestive enzymes. The stiff portions of the plants – the parts that that give them shape and cover– are carbohydrates called cellulose and lignins. Since this type of fiber doesn’t even dissolve in water, it is called “insoluble fiber.” Insoluble fiber is what most people think of when they read about the virtues of a high fiber diet. It is like the horse’s hay and grass.

The softer plant parts provide a different kind of fiber which does dissolve in water and is therefore “soluble.” Soluble fiber is made up of carbohydrates called pectins, mucilages and gums. Because it attracts water, soluble fiber helps ease the passage of food by making it softer and bulkier. So far, then, this kind of fiber seems like nothing more than a softer version of insoluble fiber. But along with water, soluble fiber attracts bile, making soluble fiber much more than a passive factor in the transit of food. The bile connection is the key component in the role of dietary fiber in cholesterol metabolism.

What is Bile?

Bile is a solution of chemical compounds called bile salts that act like detergents in breaking down fat and making it ready for absorption from the intestine. Using cholesterol as the main building block, the liver makes about 4 cups of bile a day, storing it in the gall bladder until food arrives in the stomach. The gall bladder then squirts bile into the small intestine. Without bile we could not absorb necessary fats and fat-soluble vitamins. The liver also uses bile as a shipment device for the fat soluble debris and toxins it filters from the bloodstream, especially the breakdown products of hemoglobin. Bile is the trash hauling contractor for the liver.

Elimination or recycling?

Bile breaks down once it has completed its digestive work. Its pieces get absorbed in the last part of the small intestine and carried back to the liver via the blood – or it escapes the body via the waste in the colon (bile imparts the color to bowel movements). Like the oil in your car, which accumulates dirt and get sluggish, bile that is re-circulated concentrates more and more fat-soluble waste. Escaping bile takes the waste along with it. And the less bile returned to the liver for recycling, the more cholesterol the liver has to use in the bile manufacturing process – making less cholesterol available for clogging up arteries.

In the small intestine, soluble fiber also sops up other carbohydrates, slowing their digestion and the absorption of sugar into the blood stream. This function appears to improve insulin sensitivity, making soluble fiber beneficial to people who have type 2 diabetes. Slowing carbohydrate absorption indirectly improves fat metabolism as well.

Soluble fiber and the colonic environment

Once soluble fiber reaches the colon, it begins another phase of its work. The colon, unlike the sterile small intestine, contains numerous bacteria. Bacteria need to eat, and they take whatever they can from the food passing through. Soluble fiber, for bacteria, is eminently digestible. They chew it up and produce short-chain fatty acids, creating an environment favorable for the absorption of minerals like calcium and iron. Some researchers think the acid environment helps slow cancer development.

Getting enough fiber

Is it hard to get enough fiber in your diet? Yes. Not because it is not available, but because we opt for easy food – easy to get, easy to prepare, and easy to eat. On average adult Americans get about half the 25-35 grams of fiber a day that they need, and children only about 20%. Constipation is a cardinal sign of a fiber poor diet. Bowel movements that are hard and dry, with frequency of less than once every three days, and the regular need to strain to evacuate the bowels are all signs of constipation. Constipation is also made worse by inactivity. Other results of a fiber deficient diet are less visible and occur over the long term: development of outpouchings of the colon wall called diverticuli, inflammatory changes in the colon lining, cancerous changes in colon cells, and the possible contributions to the metabolic syndrome and heart disease.

The best sources of insoluble fiber are the plant foods with tough structures: vegetables and whole grains. Soluble fiber comes in the form of oat bran, fruits, nuts, beans, and peas. The most useful fiber shopping rules are to stay as far as possible from manufactured foods and to choose liberally from the fresh produce section of the grocery store. Fiber supplements? Studies of their metabolic effects are contradictory, but supplements such as psyllium, guar gum and pectin appear to do no harm. If they produce satisfactory results in terms of easing bowel symptoms, they are probably helpful.

Posted by medical plaintalk

Physician turned medical writer.

When Diets Fail: Bariatric Surgery

“A Roux-en-Y gastric bypass is the strangest operation I have ever participated in… (It) removes no disease, repairs no defect or injury. It is an operation that is intended to control a person’s will and to manipulate a person’s innards so that he will not overeat again.” Dr. Atwul Gawande, Complications, 2002.

Human evolution occurred in a world of varying food supply. The body’s ability to store some fat insured survival when food was scarce. For most of us now there are no lean times when a few extra pounds disappear, so getting rid of them means voluntarily diminishing food intake to amounts less than we require for normal activity. This is easy if we haven’t strayed more than 10-20lb over normal weight. Above this level, gains and losses tend to become cyclical – weight that comes off reappears easily, and tends to increase with each round of dieting. When obesity becomes “morbid” – in the neighborhood of about 100 excess pounds – weight loss by conventional means is all but impossible.

A surgical way to restrict calories

So far, bariatric (from Greek words bari:heavy weight, iatr: physician, ic: pertaining to) surgery has provided the only long-term solution to morbid obesity, by restricting the amount of food entering the stomach and by altering the route the food takes through the small intestine. Patients who undergo bariatric surgery often see immediate results. Pounds finally melt away and, surprisingly, so do many previous food compulsions. Many patients maintain losses of 60-65% of their excess weight for many years. Most interesting is a profound effect on diabetes that appears before any significant weight disappears. This rapid reversal of impaired glucose control that the surgery triggers has opened a whole new frontier of research. But weight loss surgery is a drastic measure, and no one knows the results of living 30 to 50 years with this type of intestinal re-routing.

Early attempts

Beginning in the 1950s, pioneers in bariatric surgery, doctors and patients alike, learned from early negative experiences. The first approach, stapling the stomach to reduce its size, made patients lose weight, but long term results were poor. Tiny stomach pouches stretched, staple lines broke down and patients were able to eat their way back to obesity. The next approach blocked absorption of food by rerouting its path from the stomach to distant portion of the small intestine, bypassing the upper small intestine where much nutrient absorption normally occurs. Early procedures bypassed too much small intestine and caused malnutrition, foul smelling diarrhea and a very unpleasant set of symptoms called the dumping syndrome (cramps, nausea, faintness and diarrhea). Refinements of technique resulted in fewer symptoms, though patients require supplementary vitamins and minerals, and some dumping symptoms still occur.

Modern Procedures

Today, gastric “banding” with an adjustable silicone noose placed around the upper stomach and a procedure called vertical gastric banding are the least invasive and most reversible of the commonly done bariatric procedures. They are also the least effective in terms of amount, speed and persistence of weight loss. The best operation for treating obesity is the Roux-en -Y procedure, the type of surgery most commonly meant when the term gastric bypass is used.

Understanding the Roux-en-Y

Under normal circumstances, food travels from the mouth, through the esophagus and into the stomach, which is about the size of two fists. There, it sloshes around for about 20 minutes before passing through a valve to the first part of the small intestine (the duodenum), where it mixes with bile and pancreatic enzymes. After Roux-en-Y surgery, incoming food finds only a tiny pouch of stomach, 5% of its original size, opening directly into the second part of the intestine (the jejunum). Surgical rerouting has separated 95% of the stomach and the the entire length of the duodenum from the food stream and plugged the end of the duodenum back into the system farther down the jejunum. The small amount of food tolerated by the tiny stomach bypasses several feet of small intestine before it meets up with bile and digestive enzymes.

After Surgery

Under the best circumstances, weight loss following Roux en Y surgery is prompt and long-lasting. Initially patients can eat only an ounce or 2 at a time. They must schedule meals and plan content carefully in order to meet their protein and fluid needs and to avoid constipation. Over time they can begin to eat a little more at one sitting. Most patients lose 35-40% of their bodyweight over 12-15 months, and maintain that for at least 15 years. Diabetes is cured in over 80-95% of patients. Hypertension, sleep apnea, acid reflux, arthritis, infertility, stress incontinence, fatty liver, and leg infections also disappear or are significantly improved.

Candidates for Surgery
Given all of these positive results, why not offer this type of surgery to less than morbidly obese patients who struggle to lose weight? Currently weight loss surgery is limited to patients with BMIs (Body Mass Index) of 40, or 35 if the patient already suffers from obesity related diseases like hypertension or diabetes. BMI is a calculation of weight divided by height squared, with measurements expressed in kilograms and meters. A BMI of 30 qualifies a patient as obese; 19-24.9 corresponds to appropriate weight. Statistical analysis of risks and benefits of bariatric surgery set the acceptable range for surgery. Surgical candidates must also undergo extensive medical tests and psychiatric analysis, and have made serious attempts to lose weight. They must understand that gastric bypass is drastic and usually permanent, that complications can be bad, and that success is not guaranteed. Some patients manage to regain all their weight and then some.

Oversight

Bariatric surgery is regulated by American Society of Metabolic and Bariatric Surgery, which sets professional standards for hospitals and surgeons, establishes centers of excellence, and promotes research and data collection about the procedures. In 2007, surgeons performed over 200,000 surgeries for obesity, up from around 16,000 in 1992. Advances in laparoscopic surgery have made recovery faster and less uncomfortable. The best surgical mortality rates are 1% and peri-operative complication rates 10% – acceptable numbers given the worse risks of morbid obesity.

Complications and Long Term Results

Possible complications of bariatric surgery include blood clots travelling to the lungs, heart attack, respiratory compromise, suture line leaks, hernias, ulcers, GI bleeding, bowel obstruction, and gallstones. Calcium iron and some vitamins are not well absorbed and they require life-long monitoring and supplementation. All bariatric surgeons emphasize that long term success depends on patient cooperation with major eating and lifestyle changes forever. This is especially important when the choice of procedure involves only change in stomach size, as is the case with the gastric banding procedures.

Clues about metabolism and diabetes

Sheer calorie restriction accounts for some of the success of all types of bariatric surgery. When the surgery also bypasses a segment of small intestine, more is at work than meets the eye. The rapid disappearance of diabetes before significant weight loss occurs and the remarkable loss of previous cravings are clues to unappreciated biochemical and hormonal complexity of the intestines. The surgical assault on obesity appears to have much to teach us about energy metabolism and diabetes. One day, hopefully, such strange surgery will be unnecessary.

Resources:
American Society of Metabolic and Bariatric Surgery (http://www.asmbs.org/): Access to readable, professional information regarding bariatric surgery.
http://www.obesityhelp.com/: Support group website for patients contemplating surgery or looking for related information

Posted by medical plaintalk

Physician turned medical writer.

The Obesity Epidemic: Blame it on Science Too

When I was a child I thought my grandfather and Jackie Gleason were two of the fattest men in the world. Last year I happened on a rerun of The Honeymooners and was taken aback by Mr. Gleason’s modest girth. And an old movie of my grandfather shows, at most, a size 40 waist – practically svelte these days. What’s happened to us? We’ve become accustomed to widespread obesity in men, women and children. Is this one of the prices we pay for our market-driven, entertainment-loving culture? Look at all the factors conspiring to load the scales: escalating inactivity, a vast snack and soft drink industry, supersizing, frenetic lives, fast food restaurants, the demise of the family-centered, home-cooked meal and its replacement with eating anywhere and everywhere, all the time. There is blame aplenty to go around, but this is a medical column, so we’ll stick to the role of science. Why pick on the medical science? Because we need to know how the expert advice we rely on plays out over time and if well-intentioned advances lead us astray.
Taking fat out of the diet
In the 1950s, medical researchers took on the epidemic of heart disease that had begun around 1900. Fatty streaks in the aortas of young soldiers dead in the Korean War made pathologists think that heart disease actually began early in life. They created an animal model for study, feeding rabbits cholesterol dissolved in vegetable oil instead of lettuce and carrots. When fat showed up in the rabbit arteries, the dietary theory of heart disease came to life. Some scientists quibbled, claiming that the problem was more complex, that other dietary factors like sugar might be equally to blame, but they lost the debate. Dietary cholesterol became the enemy, and over the next half-century the public learned to view the egg as a toxic substance, despite its near perfect protein and yolk full of valuable vitamins.

Along came the observation that Mediterranean populations had little heart disease compared to Americans. They also walked more, ate regular meals in family settings, didn’t snack, doused all but breakfast in olive oil, and scoffed at tasteless, pre-packaged food. But what we saw was lots of pasta, with not an ounce of cholesterol in it. Pasta was the ideal candidate to replace fat. We embraced the carbohydrate age, and turned a blind eye to the fact that, for years, we had managed to turn cattle fat by feeding them carbohydrates.

The national waistline ballooned, but can we at least say that the dietary agenda paid off in terms of heart disease? The answer is murky, because there were other, simultaneous prongs of attack: a fruitful campaign against tobacco use; drug treatment of high blood pressure; drugs that keep the body from absorbing or making cholesterol and drugs that calm the heart. Galloping technological advances allowed doctors to ream out plugged coronary arteries, prop them open with metal struts, or bypass them altogether. Nevertheless, cardiovascular disease remains our leading cause of death and the total number of patients with the disease has increased. Only the death rate from heart attacks has fallen and that statistic is attributable to the interventions and drugs and declines in smoking. The effect of the officially sanctioned diet on the epidemiology of heart disease, if any, is hard to discern. Now we face even more cardiovascular disease as epidemic abdominal obesity brings with it more diabetes, high blood pressure, and inhibition of physical activity.

A contribution from chemistry: artificial sweeteners

Science contributes to the obesity epidemic in other, more subtle ways. Through chemistry, we possess the magic of intense sweetness without a caloric price. An enormous rise in artificial sweetener use parallels the obesity epidemic. Well, is that a surprise? Everyone’s trying to lose weight. But what if, in addition to failing to stem the tide of weight gain, non-nutritive sweeteners are contributing to it? A few studies raise this unsettling possibility, and no study shows any significant effect of these chemicals on the process of weight loss, unless they are used in conjunction with a disciplined program of eating and exercise.

How could something with no caloric value contribute to obesity? Perhaps by raising levels of insulin, hormone which promotes fat storage. At least one artificial sugar (Xylitol) stimulates enough insulin release in dogs (who ate the stuff accidentally) to cause profound hypoglycemia and death. Do “non-nutritive” sweeteners cause release of insulin in people as well? This hasn’t been studied well. Artificial sweeteners were developed for Type I diabetics, who lack insulin altogether, so there wasn’t any point in measuring the hormone. But there is an insulin burst from the pancreas within thirty seconds of sweetness arriving in the mouth (the cephalic insulin response), and most people who use non-nutritive sweeteners do make insulin, which efficiently converts any extra calories in the meal accompanying the drink to fat. Some studies do suggest that insulin levels are higher in regular artificial sweetener users than non-users.

Tipping the scales while fixing the mood?

Chemistry also gives us the drugs that make people happy – or at least less unhappy. Over the last 30 years, antidepressant use for life’s inevitable miseries has skyrocketed. We are engaged in the very new practice of using these drugs in children. One side effect, perhaps more common than advertised, is difficulty withdrawing from the drugs. Another is weight gain. Some depression requires drugs, and antidepressants or antipsychotic agents don’t always cause weight gain. But the drugs are in such widespread use that you probably know someone who has packed on 20 pounds in the course of a divorce or other life stress that prompted antidepressant use and someone else who accepts the weight gains because they can’t stop the drugs.

Will science solve the obesity epidemic?

Should we look to medical science or to the mega-million dollar diet industry to reverse our big obesity problem? To the development of new surgical procedures, more appetite suppressing drugs, sterner diet and exercise prescriptions, or new versions of deprivation diets (which rarely lead to permanent weight loss)? I think not. And who knows what unexpected consequences might come along for the ride. For a significant statistical improvement in the obesity problem, the answers will have to come from all of us and from our choices about how we act and what we value – from the culture, not from science. For too long we have treated food as an enemy, taking the joy and taste out of eating, without much to show for our efforts. Heart disease is still the number one killer, obesity is epidemic, and diabetes is hot on its heels. Extra weight comes off for good in the same slow, sneaky way it crept on – a few hundred calories a day out of balance with caloric needs. That’s just one dessert, or a beverage or two. Or a brisk walk instead of an hour of television. Every day we make the choices that determine our energy balance – elevator or stairs? TV or a walk? Coke or water? Vote for the guy who wants to put PE back in school or the one who doesn’t care? Yes, extra weight takes a very long time to lose, but next year will come around before you know it, no matter what you do. The choices will have added up, one way or the other. Every choice counts. In an epidemic, every person counts.

Posted by medical plaintalk

Physician turned medical writer.

Mind Games

The arrival of the baby boom generation at the threshold of old age coincides with a technology boom that marries the appeal of computer and video games to updated views on the brain’s neuroplasticity– its capacity to rewire itself even in adulthood. This union has spawned mind game businesses in which clients exercise their brains with computerized games, quizzes and tests. Lumosity and other cognitive training companies (see a sampling below) claim success in improving clients’ mental flexibility, speed, focus, concentration and memory. Well over 60 million subscribers hope their brains benefit from mental workouts in virtual gyms. Is their money well spent?

What is neuroplasticity?

Neuroplasticity refers to the dynamic process of physical change in and between brain cells that occurs in response to experience. When an infant is born, there is ample space between the cells in the outer layer of his brain, where higher functions like seeing, thinking, speaking, planning and remembering will develop. By the time he is two years old, this space between brain cells is tangled with nerve fibers connecting them to each other and to new cells which have migrated in from deeper areas. These changes continue in response to experience and are accompanied by pruning away of some of the initial connections to maximize efficiency and conserve energy.

For years the dogma taught in medical school was that neural circuitry was complete by the early twenties, a concept that was hard to understand because learning is possible at all ages and learning must have some kind of physical basis. But new evidence gradually emerged to prove that the brain continues to rewire itself throughout life. Neuroplasticity persists. The developers of the tools used by the companies like Lumosity seized upon this concept and added to it a wealth of data obtained from cognitive testing by psychologists and neuroscientists about how people think, remember, organize, plan and act. The brain games they devised for mental workouts in virtual gyms call upon these functions in hope of strengthening the brain circuits they use.

Use the circuits or lose them

Unused brain circuits lose connections just like unused muscle loses size. Hard learned algebra disappears once there are no more tests to call it into use. But there are apparently some traces of initial learning left, because relearning is easier than first time learning. Rusty skills can be brushed up with less effort than their first development required. Brushing up a skill presumably involves a physical process within the networks of nerve cells called upon for the task. It is this process that the virtual brain gyms seek to stimulate and apparently succeed in doing according to at least some measures of improvement.

Virtual mental gyms vs. real life mental exercise

The mental skills exercised by cognitive training programs include memory, attention, mental speed and flexibility, mathematical skills and visual-spatial processing. There is no doubt that exercising these brain functions is beneficial and that, with enough time spent and effort expended, the exercise improves the ability to do the tasks involved. The question is whether or not the improvement in these tasks carries over into real-life reasoning, planning and problem solving abilities. Here the data are murky indeed. It appears that the positive effects of exercising in mental gyms, if measurable, are confined to the types of tasks involved in the exercise and are not sustained for long after the practice ends. Lifetime habits of mental activity have much more persistent influence as people age.

Most people know elderly individuals who have maintained robust minds. They are usually curious about life, resilient, adaptable and habitual seekers of information. These traits inform all of their interactions and activities. They spend their lives in mental gyms of their own construction and prefer active use of their minds over passive entertainment. Very often, they have also remained physically active long into older years.

The brain training programs popular today aim to provide a similar pattern of mental activity in an entertaining way, but the challenges are intermittent and short. If the participant has been on a lifelong course of high mental engagement with the world, and if he happens to enjoy the games and tests he is involved in and is committed to them, his test results after participation are likely to be better than those of someone who has been less active mentally in the past and who does not particularly enjoy the program.

Does mental exercise prevent Alzheimer’s disease?

Does an active, flexible and resilient mind resist Alzheimer’s disease? Since we do not know the cause of this devastating disorder, it is hard to speculate about what might make a brain resistant to the pathology that characterizes the disease – the amyloid plaques and neurofibrillary tangles that scar the brain. But it has long been known that the degree of mental deterioration in life in does not necessarily reflect the amount of scarring seen in the brain at autopsy of the patient with Alzheimer’s disease. Of two people with virtually identical diseased brains at autopsy, the one who had higher levels of mental activity over life – more reading, writing, educational achievement- will have suffered fewer and less severe disease symptoms. But even if this observation is coincidental and mental exercise has nothing to do with protection against the symptoms of Alzheimer’s disease, an actively lived life of the brain has its own rewards beyond preservation of health. And it does not require a virtual gym.

Other options

Though mind games don’t necessarily improve mental functions in daily life, there are no negative effects from engaging in brain training, except, perhaps, on the budget and on time better spent in physical and social activity. Regular modest aerobic activity like walking (preferably outdoors), resistance training such as weight lifting and Pilates exercises, adequate sleep and a supportive and enjoyable social network have all been correlated with better mental functioning in old age. For no fees there are always books, board games, crossword puzzles, jigsaw puzzles, hobbies, crafts, conversations and devotion to others’ needs.

A Sampling of Reputable Brain Training Programs

Lumosity, http://www.lumosity.com

Rosetta Stone Fit Brains www.fitbrains.com

Brain Fitness by MindSparke www.mindsparke.com

Brain Gymmer http://www.braingymmer.com

Posted by medical plaintalk

Physician turned medical writer.

The Master Gland and its Tumors

“When you hear hoof beats think of horses before zebras.”
Adage familiar to most doctors, reminding them that most symptoms come from common problems. Author unknown.

Pituitary gland tumors are common, often found as unsuspected abnormalities in brain scans and in autopsies, and counted as the most common “brain tumors” removed by neurosurgeons. Technically though, the most common pituitary tumors – the horses – are not brain tumors, but gland tumors called adenomas, usually benign and eminently treatable. While more dangerous tumors arising from nearby parts of the brain or skull may closely mimic pituitary adenomas, they are rare – the zebras of pituitary problems. This column is about the horses and for simplicity will refer to pituitary adenomas as pituitary tumors.

What and where is the pituitary gland?

The pituitary gland hangs like a little globe from the base of the brain. The back half of the gland is neural tissue, connected to the deepest regions of the brain above. The front half is glandular tissue, which, like other glands, makes hormones, secretes them directly into the blood, sends them out to perform many functions in other parts of the body and is prone to adenoma formation as life goes on.

Types of pituitary tumors

Pituitary tumors which are “non-functioning,” i.e. producing no hormones, may never cause symptoms. Larger tumors or those that produce hormones typically come to attention in midlife, more often in women than men because female reproductive cycles is exquisitely sensitive to hormonal variations. Small, unsuspected tumors turn up in about 10% of MRI scans of the head done for unrelated reasons like sinus disease or head trauma, and in 20-25% of autopsies.

The factors which determine whether or not a pituitary tumor produces symptoms and requires treatment include its size, its ability to produce hormones of its own, and the degree to which it compresses and damages normal pituitary gland tissue and other surrounding structures. Damage to the normal parts of the gland that diminishes production of pituitary hormones is a condition called pituitary insufficiency. Production of a hormone by a pituitary tumor is called pituitary hypersecretion, which causes predictable signs and symptoms related to the effects of hormonal overdose on the given hormone’s target organs and tissues. Pressure on nearby brain structures by a large pituitary tumor is a phenomenon called tumor mass effect.

Pituitary insufficiency

Some pituitary hormones such as thyroid stimulating hormone (TSH) prompt other glands to produce their hormones. Other pituitary hormones work directly on many body tissues. Growth hormone, for instance, affects all tissues in the body, controlling growth in early life and many aspects of tissue repair later. Still others control menstrual function, ovulation, and production of sperm, testosterone and breast milk. The rear half of the pituitary gland, which arises from the brain, makes one hormone that helps concentrate urine and another, called oxytocin which stimulates uterine contraction during labor, and has recently been suspected to play a role in some moods and behaviors.

When insufficiency becomes failure

If a pituitary tumor compresses the normal parts of the gland, causing it to fail, wide-ranging symptoms such as fatigue, headache, weakness, abnormal menstrual cycles, decreased libido, decreasing muscle mass and body hair, weight loss or weight gain and mood alterations may appear long in advance of a correct diagnosis. These are all symptoms which might easily be passed off as lifestyle problems, nutritional deficiencies and aging.

Pituitary Hypersecretion

If pituitary tumors are functional, i.e. producing hormones, symptoms come from excessive hormonal effects on the body. For instance, growth hormone (GH) and the adrenal gland stimulating hormone ACTH are the most common tumor-produced hormones. In someone still growing, too much growth hormone produces a giant – someone whose proportions are normal, but who far exceeds the normal range of sizes. Think Andre the Giant. Once growth ceases, overabundant growth hormone still causes overgrowth in certain bones and tissues, especially the jaw, hands and feet, the nose, heart and tongue, and the heel pads. This condition is called acromegaly.

ACTH overproduction produces Cushing’s disease, named after Harvey Cushing, the father of neurosurgery in the US, one of the first to try surgically removing a pituitary tumor. Weight increases around the trunk and in the face and neck; muscles and tendons weaken and atrophy. Bones lose calcium. Eyes bulge. Skin bruises and thins. Blood pressure goes up.

Tumor Mass Effect

A large tumor in the pituitary may compress not only the normal gland around it but also the surrounding structures in the brain and skull. The gland sits right below the junction of the optic nerves carrying visual information from the eyes to the brain, and in between the bones where the nerves that control eye movements enter the orbits. In addition, the large veins which drain blood from the brain travel beside the pituitary on their way out of the skull. The optic nerves fibers that carry vision from the sides of the visual field are most vulnerable to pressure, which impairs sight on both sides of the patient’s field of vision. Pressure on the nerves to the eye muscles causes double vision. Headache, eye pain, or eye redness comes from mass effect on the large veins coursing beside an enlarged pituitary. Very large tumors may affect the deep brain structures above, resulting in a host of emotional symptoms or seizures.

Diagnosis

Symptoms which suggest pituitary gland insufficiency, hypersecretion or tumor mass effect warrant hormonal testing, an ophthalmologist’s examination of the visual fields, and imaging studies of the base of the brain. Tumors found incidentally on scans done for other reasons should prompt a good medical history and physical examination, and possibly some hormonal testing to evaluate the functional status of the tumor.

Treatment

Surgical removal of the pituitary tumor is the treatment for functional tumors or those that damage surrounding structures. After surgery, patients might require either temporary or permanent supplementation with pituitary hormones. On rare occasion, abrupt pituitary failure called pituitary apoplexy is the result of a pituitary tumor bleeding. this is a medical emergency, requiring emergency surgery with meticulous attention to fluid balance and blood pressure because of failure of the hormones that modulate those functions. Non-functioning, small pituitary tumors call for regular follow-up imaging to monitor the tumor size – and should not carry the fearsome designation of brain tumor. They are horses, not zebras.

Posted by medical plaintalk

Physician turned medical writer.

Walking or Running For Fitness? Both.

Karl is a friend who hikes a local trail almost every day. The trail is not easy, ascending 300 feet in the first quarter mile alone. Uphill stretches push the pulse and breathing rates up; downhill stretches require strength, flexibility and balance. Karl is 83 and he has maintained his physical fitness with functional activities like hiking and skiing. His old friends in the valley no longer hike with him. “It is sad,” he says, shaking his head. “They didn’t need to stop and now they can’t do it anymore.” He is right – fitness requires doing.

Why bother staying fit?

Physical fitness is worth preserving. It makes aging easier and more enjoyable, prolongs independent living and accessibility to many pleasurable activities, and lessens dementia risk. It raises insulin sensitivity, reduces blood pressure, cuts weight and improves cardiovascular risk factors. You needn’t be an athlete to be fit and, as Karl demonstrates, fitness does not require gym memberships, classes or travel to and from a sports facility. And as many researchers have demonstrated, simple activities such as walking and running have positive effects on body and mind.

What does running do for you?

Much information about the beneficial effects of running comes from studies done in high level athletes. This sports oriented literature can be bewildering, leading into a thicket of terms like periodization and lactate thresholds and specialized measurements like aerobic capacity and heart rate variability. But buried in the details of these studies are useful facts that, when simplified, provide guidance that will improve the fitness of beginners and people who already have a stable exercise habit.

Why walk too?

While running promotes faster weight loss than walking, both lower blood pressure and improve heart and lung function. Walking requires more of the shin muscles and running more of the gluteals and quadriceps. Both are worth incorporating into a fitness program because of these different patterns of leg muscle use. Balancing the strength of lower and upper leg muscles and improving flexibility of all of them lessens strain on knees.

How much of each?

The balance between walking and running in an exercise plan depends on beginning fitness level and on goals. For a sedentary individual unaccustomed to exercise, regular walks will be enough to increase fitness, at least in the beginning. For someone who has run in the past but not recently, a combination of walking and running is a good way to start. And for someone who has a good level of fitness and a long running history but is getting older and accumulating aches and pains, the addition of walking balances leg muscle groups.

Short periods of intense effort pay off

For all groups, the introduction of short bouts of more intense walking or running into a regular exercise program is perhaps the most important aspect of maintaining and improving fitness. These “intervals” provide the challenge that the heart and lungs need to stimulate their capacity to provide blood to working muscle more efficiently. A recent study from Denmark provides good evidence that a very small amount of time spent running faster improves fitness. It also decreases blood pressure and makes routine running more efficient. In the study, the addition of an interval program of faster activity, performed twice a week, was not only well tolerated but study subjects stuck with it and benefited more than they did from other seemingly more difficult programs.

In the Danish program, a short warmup is followed by two five minute segments separated by a 2 minute rest, and followed by a short cool-down walk or run. The five minute segments consist of running comfortably for 30 seconds, harder for another 20 and as fast as possible for another 10 seconds, and repeating this pattern 4 more times. A walker could try the same pattern, with effort judged by breathing rate and difficulty and by the ability to complete the 5 minute segments. As improvement occurs the segments cover more distance.

Change the terrain

Other ways to increase effort include walking or hiking uphill and climbing stairs. The important thing is to build in some segments of exercise that require more effort and cause faster breathing into at least two periods of exercise a week. In addition, going “off-road” on dirt and rock and sand requires use of little balancing muscles and improves strength and balance.

How much is enough?

How much weekly exercise is necessary? One figure quoted frequently is 150 minutes – less than half an hour a day. The payoffs though, depend on demanding more of the heart and lungs during those times than during routine life. Ambling up the street at the same pace as you walk between the couch and the TV will have less effect than but walking briskly, to the point of feeling slightly short of breath.

Can people who have arthritis walk and run for exercise? For the most part stiff joints feel better with movement. If walking or running gets easier as the joint is “warmed up,” the joint stiffness and discomfort are most likely related to shortened muscles and tension on their tendons, not to joint pathology that will get worse with activity.

Make sure you remain able to get up and down from the ground

For overall fitness, some time also needs to be devoted to strength and flexibility exercises. Pilates exercises, yoga practices, weight lifting and core muscle strengthening exercises like the TRX programs all improve muscle strength and flexibility, enhance walking and running ability and contribute to improving balance. The ability to get up and down from the ground indicates a lot about these non-cardiovascular aspects of fitness, and every effort should be made to make certain this ability is preserved over time.

Mind over matter

The most difficult part of beginning or sticking to an exercise plan is often in the mind rather than the muscles. When Karl says his friends didn’t need to stop hiking, he means that they stopped pushing themselves before there were any compelling physical reasons to stop, and then one day they no longer had the ability which he has so far maintained. His example is inspiring.

Posted by medical plaintalk

Physician turned medical writer.

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