I got a pedometer that actually works this holiday season. I discovered not only do I get well over half of my recommended 10,000 steps in a 90 minute Jazzercise workout (did that yesterday), but also that I don't sit still very long. This reminded me of a study I wrote about some time ago, so I thought I'd share it with you that you might consider the health benefits of racing around looking for your keys etc. as you consider your New Year's Resolution List (1. Fidget more, 2. Run upstairs to answer the phone instead of putting the handset on the table next to your recliner, etc.).
Consider inclinometers and triaxial accelerometers. Gizmos found in the instrument panel of a fighter jet that were sewn for this study into the high-tech underwear encasing the more or less active behinds of twenty Minnesotans. While all of the subjects were self-proclaimed 'couch potatoes,' half were lean and half were mildly obese. Dr. James Levine and colleagues then recorded 25 million underwear-generated data points on posture and movement from each subject over ten days. The Mayo Clinic investigators believe the results may explain why some persons tend to put on the pounds more easily than others.
Healthy adults gain weight when energy in (food) exceeds energy out (daily activity). While energy expenditure occurs during exercise, a large part of our daily calorie output is Non-Exercise Activity Thermogenesis or NEAT. Dr. Levine defines NEAT as "physical activities other than volitional exercise, such as the activities of daily living, fidgeting, spontaneous muscle contraction, and maintaining posture when not recumbent." The more you twitch, squirm, and generally fussbudget through your daily activities, the more calories you burn in this unexpected way. The researchers discovered that their obese volunteers were seated daily for 164 minutes more than were lean participants. In fact, if the heavier group had demonstrated the same NEAT behavior as their skinnier colleagues, they would've burned off an extra 350 calories per day or the equivalent of 7 pounds per year.
The Mayo endocrinologists had previously conducted research on the effects of overeating on NEAT. They stuffed an extra 1000 calories/day over 8 weeks into sixteen normal weight volunteers. During the two month feeding extravaganza, the subjects increased their energy output in subtle but significant ways, burning the majority of the extra calories as NEAT. Based on these studies, the researchers theorize that while obese individuals may "have a biologically determined posture allocation" (genetically inclined to hit the recliner), perhaps they can be taught to consciously overcome their torpid destiny with increased body busyness as part of a weight loss program.
Saturday, December 27, 2008
Saturday, December 20, 2008
"Studied calm"
I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.
Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "
Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.
I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.
Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"
Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.
Here's to studied calm.
Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "
Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.
I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.
Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"
Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.
Here's to studied calm.
Monday, December 15, 2008
Living through cancer
A friend and I are gathering material for a how-to guide for cancer patients. Last week's JAMA had an interesting essay on that subject by Deborah Lewis, a social worker and breast cancer survivor. Titled "Legacy," her comments address her cancer experience as it relates to her father's death from heart disease. In particular, she found herself "playing follow-the-leader behind my father's tough but frail, limping frame" because she discovered that parents teach their children how to handle illnesses, aging, and death. She notes:
Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.
But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:
Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.
Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.
But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:
Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.
Sunday, December 14, 2008
Social anxiety disorder
(aka generalized social phobia or GSP)
No one likes to be criticized, but criticism affects some more than others. I believe, for instance, that women who are unable to extract themselves from abusive relationships are more likely to react strongly and fearfully to criticism which further traps them in a toxic bond. Psychiatrists at the National Institute of Mental Health theorized that individuals with GSP who are fearful of social situations may demonstrate a stronger brain reaction to criticism than persons free of such anxieties.
They performed functional magnetic resonance imaging scans on subjects with GSP and controls. While under observation, the scanees read comments such as "You are ugly" "You are quite the looker" or "He'd look better with a paper bag over his head."
The GSP victims got all hot and oxygenated in their medial frontal cortices (brain area in charge of representation of self) and their amygdalae (brain area responsible for fear reactions) when they were slipped a slip with a personal insult. They had no such reaction to praise, nor did negative comments about others raise their amygdaloid activity.
Comments such as 'buck up honey, all those people are human just like you and they all go to the bathroom just like you' are unlikely, therefore to change the neural activity of those with GSP. Anti-anxiety agents that tone down the amygdala are helpful, and further research into changing neural circuitry is anticipated.
No one likes to be criticized, but criticism affects some more than others. I believe, for instance, that women who are unable to extract themselves from abusive relationships are more likely to react strongly and fearfully to criticism which further traps them in a toxic bond. Psychiatrists at the National Institute of Mental Health theorized that individuals with GSP who are fearful of social situations may demonstrate a stronger brain reaction to criticism than persons free of such anxieties.
They performed functional magnetic resonance imaging scans on subjects with GSP and controls. While under observation, the scanees read comments such as "You are ugly" "You are quite the looker" or "He'd look better with a paper bag over his head."
The GSP victims got all hot and oxygenated in their medial frontal cortices (brain area in charge of representation of self) and their amygdalae (brain area responsible for fear reactions) when they were slipped a slip with a personal insult. They had no such reaction to praise, nor did negative comments about others raise their amygdaloid activity.
Comments such as 'buck up honey, all those people are human just like you and they all go to the bathroom just like you' are unlikely, therefore to change the neural activity of those with GSP. Anti-anxiety agents that tone down the amygdala are helpful, and further research into changing neural circuitry is anticipated.
Early a.m. calls
Ordinarily I'm up by 6:30 a.m. I recognize, however, that patient problems don't follow my schedule, even my more leisurely Saturday morning agenda. I also know that nagging problems have a way of seeming more urgent through the wee hours of the morning, so that which is not an emergency (say the discomfort of a bladder infection) can move a patient to place a call to me at oh-dark thirty.
That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:
Pt: I've had an irregular heart beat on and off for two weeks now.
Me: Is it worse this morning? Are you having shortness of breath or chest pain?
Pt: No. It's just been on my mind and I thought I'd run it by someone.
Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.
Would I have been justified in schooling him on after-hours etiquette?
That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:
Pt: I've had an irregular heart beat on and off for two weeks now.
Me: Is it worse this morning? Are you having shortness of breath or chest pain?
Pt: No. It's just been on my mind and I thought I'd run it by someone.
Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.
Would I have been justified in schooling him on after-hours etiquette?
Saturday, December 06, 2008
Irritable bowel syndrome
Irritable bowel syndrome or IBS is a diagnosis of exclusion. In order to conclude that a patient suffers from IBS--a cluster of unpleasant abdominal symptoms including pain, bloating, gas, constipation, and/or diarrhea--we first must exclude other possible reasons that they may be suffering so.
There's a lot to be said about IBS and the many ways that it can seriously affect quality of life even if it does not result in serious illness. The pain can be quite debilitating and result in frequent absences from work or school. An article in last month's British Medical Journal discussed three simple strategies that significantly decrease the discomfort of IBS.
In a meta-analysis (a study of studies that combines results of multiple trials to amplify the significance of results) researchers found that fiber, anti-spasmodics, and peppermint oil all performed significantly better than placebo in relieving the pain and screwy bowel movements of IBS. They reported the number of patients needed to be treated for one to experience significant relief from the heartbreak of IBS were: 11 for fiber supplements (using psyllium compounds such as Metamucil) 5 for anti-spasmodics (hyoscyamine sold as Levsin, NuLev, Transderm Scop, and generically), and just 2 1/2 patients needed treatment with peppermint oil (187-225 mg. in water 2-4 times daily, available OTC) for 1 to feel better!
There's a lot to be said about IBS and the many ways that it can seriously affect quality of life even if it does not result in serious illness. The pain can be quite debilitating and result in frequent absences from work or school. An article in last month's British Medical Journal discussed three simple strategies that significantly decrease the discomfort of IBS.
In a meta-analysis (a study of studies that combines results of multiple trials to amplify the significance of results) researchers found that fiber, anti-spasmodics, and peppermint oil all performed significantly better than placebo in relieving the pain and screwy bowel movements of IBS. They reported the number of patients needed to be treated for one to experience significant relief from the heartbreak of IBS were: 11 for fiber supplements (using psyllium compounds such as Metamucil) 5 for anti-spasmodics (hyoscyamine sold as Levsin, NuLev, Transderm Scop, and generically), and just 2 1/2 patients needed treatment with peppermint oil (187-225 mg. in water 2-4 times daily, available OTC) for 1 to feel better!
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