Saturday, October 29, 2011

MRI's and athletic injuries

who am i to question a medical provider's advice and guidance?

i'll tell you who i am: a concerned citizen and health care patron. i use my docs and their skills and i pay my own insurance and deductibles, so i know the costs i incur. and if, as a reasonably intelligent and informed adjunct health care provider, i see the issues on my bills, i know there are way more out there who don't see them. and that leads to rising health care costs.

this news piece talks about the highly sensitive technology of non-invasive scanning - magnetic resonance imaging, or MRI. this allows, without radioactivity, for looking inside the body and seeing soft tissue, not just bone. hence, muscles, ligaments, tendons, organs - all are easy to see before going in to repair damage. at one time, these were so expensive, docs referred to the few hospitals that had them and only in cases where uncertainty about a diagnosis - and i'm going to keep this to orthopedic/sports med concerns - existed. in the old days, docs asked questions, palpated, manipulated and if need be, x-rayed to diagnose. today, they are quick to get an MRI, too. for one thing, many groups own their own unit. if you got it, use it, is the mantra. often times they are used instead of the traditional methods, whereupon things get 'seen' that may or may not be related to the problem at hand. several studies show that, while sensitive, MRI's are not that specific. that means, it shows a lot but not necessarily that what you see is what the problem is. in this piece, it talks about all the bad shoulders in pro pitchers who actually do NOT have pain or problems. hence, just because it's visible does not mean it needs repair. this has been found in spinal disks, too: about 33% of us without back pain have damaged disks. that means that not all back pain is caused by disk damage even if the disk is bad. it takes a good doc or therapist to ascertain the difference and the subsequent value of further treatment options.

when i went to get my hyaluronidase shots last summer for an obviously arthritic knee, my doc pulled out his cool new ultrasound machine. he could show me the joint and found exactly where to inject. as he did so, he noted that this is where he'd have injected anyway. by the third treatment, i had gotten a bill. that less than a minute ultrasound cost over $600!!! i was stunned and brought this to his attention. he subsequently stopped using it on me saving me, my insurer, and the health care system the next $2000. but how many other patients caught this; how many objected to its use; how many more dollars did this doc make doing a procedure he never had to use before to do the procedure he was tasked with?

now, i don't fault him; he's a friend and a conscientious doctor. but his group's business manager saw a cash cow here and suggested he use this new toy. and of course, as this becomes 'standard of care' the insurance industry is bound to reimburse, to the tune of 20-35% of charges, and lawsuits will evolve as some docs resist its use.

perhaps its the nature of the system - each group trying to make dollars while each group's nemesis trying to keep dollars. whatever it is, please be aware of the game, esp if you can do so before you get nailed for the procedure. ask if, indeed, an MRI is going to actually help with the diagnosis or the subsequent procedure. save your money....and mine.

Thursday, October 27, 2011

why it's so hard to lose weight

much has been written about dieting, exercising, or combining the two for effective weight loss. many a book, and many an author, have pretended to know the answer for the vast majority of those carrying excess weight. while some of these sources have gained wt in the process - made tons of moolah - few have offered the magic bullet that keeps people on task for the duration...of their entire lives. that's because nearly anything that reduces calories in or increases calories out will cause some wt loss. how much depends on many factors not the least of which is genetics. but ultimately, how much and for how long depends on how consistent, regular, and diligent one is with the program that helped you lose it in the first place. that said, here's another piece of the puzzle that is just now starting to enter the mainstream of discourse by pros and by the lay public.

a month ago, i presented a 90 minute lecture to a cadre of wt loss professionals from all around the country. the event was the Lifestyle Intervention conference, in las vegas, at the lovely Four Seasons Hotel. and while it sounds glamorous, due to circumstances, not the least of which is that i earn my living training clients one on one, i did a quick turn-around trip - got in wednesday nite, lectured at 330, got on a plane home and in at 2 a.m. so i saw nothing other than my room, the lobby, the restaurant, and the gym - yes, i made sure to get in a workout after i arrived that nite; it always helps me sleep better in strange places. the rest of the time, in the plane out and in my room, i was prepping for my talk: The Weighting Game: Why it's So Hard to Beat the "House". the house, of course, is our body, our physiology. and anyone who's ever tried to lose substantial amounts of wt understands from whence i come.

my challenge, in speaking to diet, exercise, and treatment-center professionals was to convey just how difficult - based on science and data - it is to lose substantial amounts of wt. now, you should understand by now that 'substantial' is the key word. it's easy to lose 3, 4, maybe even 10 lbs if you are carrying lots of excess fat. but that is not, in the minds of the overwt/obese, substantial. losing 10% of your body wt, tho, would be for some an ecstatic accomplishment...despite the odds stacked clearly against you maintaining it off. doing so was not difficult; there's tons of support for the almost miserable stats of long-term wt loss: many studies show that after 1-2 yrs, avg wt loss among participants in diet-based studies is about 3 kg, or 6.6 lbs. of course, most have lost more early on only to regain it back. and longer term studies show that by 5 yrs out, they've gained back their original losses PLUS added more wt. also, studies show that those who complied with the programs - be they wt watchers, zone, atkins, or whatnot - lose the most and keep it off the longest despite gaining some of it back from those first few months. but, medically speaking, substantial wt loss is different than clinically-useful wt loss; and while the latter may not achieve statistical significance, the long term stats rarely do. nonetheless, 3 kg is medically useful wt loss, esp if kept off.

where my talk deviated from the basic diet/exercise loop was in the discussion of hormones. this article hits it on the head. but, while it confirms my speech, it does have a major flaw that needs to be addressed here. that is, all the subjects were put on a very low calorie diet (VLCD) of 500-550 cals/day for the first 10 wks. they lost an average of 14% of their body wt. and subsequently added wt over the ensuing year.

for anyone who's been in this field long enough, or anyone who's dieted their whole lives, this is a DUH! conclusion. i refer to a 'duh' conclusion as one that we all know just by reading the results; of course, the way the study is designed, it almost never comes out saying anything other than what you'd expect. it's kind of like that famous 'golden goose' (a political title for wasted money by the fed gov) award for a study that showed cow manure in a dairy farm is slippery. DUH!

why this study lacks utility is that hormonal drivers to eat more are exacerbated by the extremes of the diet itself. these subjects were frickin' starved for 2.5 months! hell yes, they wanted to eat, and eat a lot. furthermore, as i learned in my prepping for the talk, not only does leptin decrease which stimulates appetite when you lose wt by dieting; your body's sensitivity to it - much like it's sensitivity to insulin when you've become type 2 diabetic - is diminished with obesity. that means that, as it goes down and stimulates greater appetites,and wt increases such that leptin increases to suppress appetite, the brain can't sense it. yes, you read right: the brain, on which the leptin acts, is less able to sense rises in leptin that tell you to stop eating as you regain wt. hence, you keep eating. and gaining.

can you guess what works to keep leptin resistance at bay? if you guessed the same thing that keeps insulin resistance at bay - EXERCISE - you are a genius. because those who lose wt with a substantial exercise program also see leptin drop, that drop that decrease is sensed at higher levels by the brain to minimize appetite surges. or, in easier to understand terms - which by the way was a real challenge in presenting to this audience - exercise-induced wt loss does not get as sabotaged by hormones as diet-induced wt loss. you can more readily resist appetite surges and more readily control or maintain wt loss. the why's have yet to be elucidated. but that exercise is absolutely so much more effective and essential in maintaining wt loss is indubitable.

so, diet - but not to extremes - to lose wt; diet plus exercise to lose a little more wt; but continue or increase your exercise to keep the wt off even if you stop being overly diligent with your dieting. it's the only way. and, it's the healthiest way.

Saturday, October 22, 2011

set point theory - not for weight but for activity

i'm sorry it's been so long since i've posted a blog. besides being busy at work and moving out of one house and into another, i also got slammed by a retinal detachment two weeks ago that required emergency repair. fortunately, despite being forced to lie on my right side for 10 days under threat of a failed surgery and potential blindness, i survived this sentence and now can type sitting upright.

there is lots to be written but it does not have to be done today. i did read a lot and found some very interesting fitness-related material i could share, but that'd be ex post facto now, so let's move on to today.

in the above link, the hypothesis is that we have an 'activitystat' much like a thermostat that keeps our bodies at a set level - of activity, in this case. studies have shown that kids in varying amounts of school-based p.e. are not stimulated to be more active as a result of their school behavior. that is, if you are in p.e. class x-hrs/wk, you are not apt to be more active outside of school than kids who are not given similar opportunities to be moving around. in fact, they find that most kids move about the same numbers of hours/wk regardless of how many hours of p.e. they have in school. as such, the hypothesis is we have a set point of hours of activity and, if we move a lot today, tomorrow we'll move less; and if we don't move in school, we'll be more inclined to move after school.

i don't buy it. and there is other literature that supports this counter-belief. i say belief because (1) i've not done nor read much research in this arena and (2) i think our activitystats are all screwed up by our environments. and my proof? ME! audacious, yes, but let me explain.

my life is pretty active. i train clients moving about the gym anywhere's from 5-13 sessions/day, or 5-12 hrs. (the days i do 13 i also have some half hr sessions.) when i get home, i don't sit around more or less depending on my sessions that day. in fact, as i've written before, i often get on the exercise bike or ski machine later in the evening before bedtime in order to get some activity that i'd call exercise. now, sure, i'm an exercise professional for whom it's a lifestyle. but if set point theory was right, i'd be more apt to chill on long days and more apt to exercise longer on short ones. again, a study of one is insufficient to argue one way or the other but i have more to tell you that may be more scientifically valid.

while laid low, i had no appetite. despite shopping with my girlfriend - cherrie - and staying at her house under her watchful eyes for those 10 days, i could not find any foods or junky foods that appealed to my tastes. not unusual here; illness and injury often disrupt normal taste for food. but i proceeded to lose 5# lying still allllll day long. most would gain wt. i lost - mostly muscle mass. this past monday, when the doc released me to resume work, even tho i didn't actually go work, i went to the office, i came home hungry. and the next day, even tho i only worked 50%, as per orders, i came home and ate big. in 4 days, i've nearly regained the wt i lost, tho surely not in the form of muscle since i've been restricted til next wk from any lifting - a..n...y! and i've been a good boy about it.

so what happened? why didn't i gain? and how is it i've regained? it's really quite simple.

as a lean, muscular person who's been this way my entire pre-adult and adult life, my body is 'set' to such a degree that it eats what it expends and vice versa. when i trained in martial arts 3-5 hrs/d, and did construction work, and a few miles of running, i ate like a horse. when i gave up the construction work and scaled the tae kwon do to teaching, i ate less. when i could not exercise as hard due to bad joints and had even stopped teaching, i ate even less. and when i was laid up and not able to do any activity, i hardly ate at all. the hormonal stimuli that otherwise told me to eat had scaled itself down to where it was telling me i hardly had to eat any more.

now this differs from the homeostatic mechanisms of most, esp the obese and sedentary. most folks, sentenced to supine-ness, would have eaten as normal and gained weight, mostly fat. we know, interestingly, that leptin, a brain hormone that's linked to appetite via fat stores and intake, is less effective in the obese than in normal wt people. in other words, they have leptin insensitivity. interestingly, when they diet and lose wt, leptin continues to stimulate appetite to a greater degree than when they exercise to lose wt. in both cases, leptin decreases but with exercise, due to the increased sensitivity to it, it actually requires less in order to be more effective at modulating appetite according to the new wt.

the message here is, as a lean, active person, i'm regulated toward leanness, even when inactive. it's a pretty tight setting under which i operate. the overwt/obese may not have such tight settings - we don't know which comes first tho genomics is looking hard at this - and so are apt to eat even when not burning calories, or even after eating. and i suspect the same is true for activity: lean, active people are active, more than their overwt/obese peers, even if they've been encouraged or forced to be active by outside or internal mechanisms, and it has little to do with how active they had been earlier. in other words, without assigning guilt - as it could be genetics for some - those who are carrying too much wt have set their thermostats to lower settings such that they may indeed reduce later activity if they had some earlier. but it may be that our culture and environment simply does not mandate enough activity to re-set their activitystats because, in days of yore, before electricity and other modern conveniences, if they didn't move, they didn't eat. it's the lifestyle, not the genetics, that determines movability!