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Postpartum Weight Loss- Say You’re Fit!

August 29, 2008 on 10:49 pm | In Uncategorized | Comments Off

The power of what we tell ourselves has a strong affect on how we feel.  Start telling yourself positive messages and you’ll start feeling better.  I encourage my clients to creat positive self-statements in the form of “I am” and repeat them out loud.  For example, every morning and every night repeat 10 times “I AM FIT!”  Soon you’ll notice that you feel more fit, and you’ll start taking the actions to become more fit.

Debate flares: Can obese patients be healthy?

August 25, 2008 on 9:52 am | In Uncategorized | Comments Off It's a frequent and challenging topic for exam room discussion -- do those extra pounds really undermine health and well-being? Now, a pair of studies in the Aug. 18/25 Archives of Internal Medicine has added to the discourse about whether someone can be fit and fat.

The studies upped the level of confusion and controversy by offering new evidence that some people who carry excess weight may have healthy cardiovascular and metabolic profiles while those considered at a normal weight may not have such rosy statistics. Nonetheless, experts still expressed caution about telling patients weight loss is unnecessary because it is unclear how the added bulk may affect these numbers over time. Also, the pounds often bring with them other health risks.

"Weight loss is important for all patients who are obese or overweight," said Lewis Landsberg, MD, who wrote an Archives editorial that accompanied these studies. He is director of the Northwestern University Comprehensive Center on Obesity in Chicago. "Even if one loses a small amount of weight, it definitely improves your risk factors and one's overall health, but not all obese people are at the same degree of risk."

One study, involving data from the 1999-2004 National Health and Nutrition Examination Surveys, found that almost 24% of those at a healthy weight had at least two metabolic abnormalities. These levels included low HDL cholesterol or high blood pressure, triglycerides, fasting plasma glucose or C-reactive protein. Approximately 51% of those who were overweight and 32% of those who were obese had healthy metabolic profiles.

"There's a large degree of heterogeneity in the metabolic consequences from the same amount of body fat," said Rachel P. Wildman, PhD, lead author and assistant professor of epidemiology and population health at New York's Albert Einstein College of Medicine. "And I think for a certain subset, the cardiovascular risks may not be as big as we thought."

The second study, this one by researchers at the University of Tübingen, Germany, reported the results of various tests on 314 patients. Those who were obese but insulin-sensitive had similar cardiovascular risk profiles to those who were of normal weight. Those who were obese and resistant to this hormone were at increased risk.

51% of overweight people and 32% of obese people have healthy metabolic profiles.

But experts say these studies do not exonerate excess weight as a health threat and should not change how physicians counsel patients. "From a practical standpoint, I don't think it changes our mantra at all," said Mott P. Blair IV, MD, a family physician in Wallace, N.C.

In both papers, a significant number of patients carrying excess weight still were at increased cardiovascular risk. In addition, these studies did not track outcomes. It's unknown how those with normal metabolic profiles but excess weight may fare over time. Wildman plans to investigate this issue in future projects.

"The idea that there are those who are obese and metabolically healthy appears to be true, but it's not a majority," said Dan Bessesen, MD, chief of endocrinology at Denver Health Medical Center. "And are these people really going to be healthy over the long haul? We're not sure."

These studies also did not track other health issues linked to extra weight, including an excess risk of cancer and joint problems. For example, another paper in the same issue of this journal found that being overweight increased the risk of recurrent venous thromboembolism by 27%.

"Even if there is not a cardiometabolic effect, obesity affects a person's life in so many ways," said Eric Westman, MD, associate professor of medicine at Duke University in North Carolina. He also is vice president of the American Society of Bariatric Physicians.

Watching the waist

Experts say the take-home message is that body fat is a more complicated issue than it appears, and the location of those pounds may be more important than the amount. The NHANES study found that those who were of normal weight but had a large waist circumference were more likely to have a poor metabolic profile. The German study found that those who were obese but had lower levels of fat in skeletal muscle or the liver were more likely to be heart healthy.

"It's not so much what we weigh. It's where we weigh," said Tim Church, MD, MPH, PhD, director of preventive medicine research at Pennington Biomedical Research Center in Baton Rouge, La.

24% of people at healthy weights have at least two metabolic abnormalities.

For this reason, medical societies and public health agencies are increasingly promoting the measurement of waist circumference. American Medical Association policy encourages physicians to incorporate this vital sign along with a BMI calculation into the routine adult physical. Experts say it can be particularly helpful to identify and monitor those whose total weight is normal but may not be distributed in a healthy way. But many say that although physicians generally support this practice, anecdotal evidence suggests that measuring a patient's waist has not become widespread.

"Patients feel a little funny about it," Dr. Bessesen said. "They're not used to a physician coming at them with a tape measure."

Experts said these studies highlighted the importance of healthy behaviors, such as eating well and being active, over numbers on a scale.

"There are people in my practice who have a BMI of 25 to 30 who are actually very active and very fit," said Randy Rice, MD, a family physician in Moose Lake, Minn. "They're quite healthy, and they just cannot get the weight down. It's fine to keep active and not to get to hung up on just the weight."

The NHANES study linked physical activity to greater metabolic health. Also, a study published in the Dec. 5, 2007, Journal of the American Medical Association associated physical fitness, as determined by a treadmill exercise test, with a low risk of death, regardless of body weight.

Long-term use of acid reflux drugs weighed

August 25, 2008 on 9:52 am | In Uncategorized | Comments Off Washington -- Two new studies on proton pump inhibitors are uncovering added benefits and risks associated with the popular prescription and over-the-counter medications used to treat acid reflux.

One study reinforced the drugs' cost-effectiveness when used to reduce the risk for upper gastrointestinal bleeding that may result from long-term aspirin therapy. The other found long-term use may heighten the risk of osteoporosis-related fractures.

A large observational study in the Aug. 12 Canadian Medical Assn. Journal determined that patients who used proton pump inhibitors for seven or more years had a significantly greater risk for fractures.

It mirrored findings published in the Dec. 27, 2006, Journal of the American Medical Association, which also showed long-term PPI use, particularly at higher doses, was associated with increased risk of hip fractures.

Osteoporosis and its accompanying fracture risk is a major health threat for an estimated 44 million Americans, or 55% of people 50 and older, according to the National Osteoporosis Foundation.

However, the evidence is not yet strong enough to change the current risk-benefit calculation that favors the use of the medications to treat acid reflux, said Laura Targownik, MD, the lead author of the Canadian study and an assistant professor of internal medicine at the University of Manitoba in Winnipeg.

Osteoporosis is a major health threat for 44 million Americans.

"What I advise my patients at this point is, if they are on [proton pump inhibitors] for a solid indication, like severe reflux that can't be managed in any other way, or they are on nonsteroidal anti-inflammatory drugs and have a risk of ulcer complications, I would probably keep them on PPIs."

However, as a precaution, Dr. Targownik noted, she also would ensure that patients take adequate calcium and vitamin D and have regular bone density scans.

The lead author of the 2006 JAMA study agreed the evidence tying the medication to osteoporosis is not yet solid enough to change prescribing habits.

Other variables may be at work, said Sameer Dev Saini, MD, a clinical lecturer at the University of Michigan Medical School in Ann Arbor. He noted that none of the studies was able to control for calcium intake or vitamin D intake. "We don't fully know if the effects we see in the papers are from the proton pump inhibitor or some other confounding factor."

But the advantages also should not be discounted. "On the flip side, we have very strong evidence that PPIs are very helpful for patients who have had ulcer bleeding in the past," he said. "In those patients there is a very strong protective effect of PPIs."

Medications for the long term

Although medical guidelines recommend that patients with cardiovascular disease take low-dose aspirin, long-term aspirin use poses a risk for upper gastrointestinal bleeding. "The stomach normally has a protective coating to prevent acid-related injury, but aspirin and other NSAIDs impair the stomach's ability to form this barrier coating, potentially leading to ulcer formation," said Dr. Saini. "Furthermore, these drugs may themselves cause injury directly to the stomach cells and can impair the ability of platelets to form a plug in the event of bleeding."

Dr. Saini and colleagues found that at OTC prices, PPIs are cost-effective for patients older than 65 who are taking low-dose aspirin and may be cost-effective for patients as young as 50. Their study is in the Aug. 11/25 Archives of Internal Medicine.

The fact the medications involved, aspirin and proton pump inhibitors, are recommended for long-term use also is raising concerns. "And it should," said Dr. Saini. "If there is a long term effect like bone loss, I think that will be very important to know."

Dr. Targownik and colleagues are continuing to explore that link. "We are looking prospectively to see if people develop osteoporosis over time." This time, dietary factors such as calcium and vitamin D will also be considered, she added.

Bruised and bleeding: Watching for von Willebrand disease

August 25, 2008 on 9:52 am | In Uncategorized | Comments Off The simplest of assaults -- a nick while shaving or a too-close encounter with the bread knife -- starts a coagulation cascade, sending help to the endothelial wound. A few seconds of pressure or a piece of wet tissue on the gash and the cut seems fine. It's often an automatic response, rarely triggering any thought of the complicated clot-forming process.

But even when this process consistently fails to happen, a bleeding disorder often is not considered.

When Mary DeArmond was 3 years old, she fell and sliced her gum. The seemingly mild injury required a blood transfusion. At 12, a chair fell on her leg and triggered a joint bleed. Four years later, a wisdom tooth extraction required repeated sutures before healing. "Nothing was ever done and I did not realize it was odd," says DeArmond.

She got used to constant warnings from her parents to be careful on the playground. "When I was growing up, I had lots of cut knees and there were unbelievable amounts of blood," she says. She was finally diagnosed with von Willebrand disease at age 22.

First reported by Erik von Willebrand in 1926, von Willebrand disease is caused by a deficiency or abnormality of von Willebrand factor, a glue-like blood protein necessary for normal clotting. The Finnish physician studied abnormal bleeding patterns in a Scandinavian family, recognizing autosomal inheritance patterns and the increased threat to women. His index patient bled to death while menstruating.

Understanding has increased significantly over the years. "It is inherited equally by men and women," says Peter Kouides, MD, a hematologist who is the medical director and research director at Mary M. Gooley Hemophilia Center in Rochester, N.Y. "It's just that women are far more likely to have symptoms during menstruation and childbirth."

2.6 million people have von Willebrand disease.

It's estimated that 2.6 million people -- as many as one in 100 -- are affected by vWD, the most common inherited bleeding disorder. But awareness remains low. The seemingly simple list of symptoms -- heavy or prolonged menstrual bleeding, easy bruising, frequent or prolonged nosebleeds, and prolonged bleeding following surgery, dental work, childbirth, or injury -- are often dismissed as normal. And it isn't until a crisis -- a boy hemorrhages following a tonsillectomy; a serious wound spontaneously bleeds days later; a woman hemorrhages postpartum -- that the patient is diagnosed.

"Mild defects may go undetected, and it isn't until the patient is challenged that it is recognized," says Andra James, MD, assistant professor of obstetrics and gynecology in the Division of Maternal and Fetal Health at Duke University School of Medicine in North Carolina. Dr. James recently served on the National Heart, Lung and Blood Institute vWD expert panel.

A 2004 study by the Centers for Disease Control and Prevention found, based on interviews with 75 women diagnosed with vWD, that the average time between symptom identification and actual diagnosis was 16 years. "The important thing is, in patients who have bleeding symptoms, pursue a diagnosis of an inherited bleeding disorder," says Barbara A. Konkle, MD, a hematologist and the regional director of the Penn Comprehensive Hemophilia and Thrombosis Program at the University of Pennsylvania Health System.

Sleuthing for a missing factor

A routine doctor visit finally set DeArmond on the right track. Noticing extensive bruising on her arms and legs, her physician began asking questions. "Once I convinced him it was not abuse, he sent me to a hematologist," she says. "I owe everything to that family physician. He was curious enough to ask."

DeArmond has type 3 vWD, the most serious form, which means her body does not produce any von Willebrand factor. Her father and her 13-year-old son Danny have type I, the most common and mild form, which produces a lowered amount of von Willebrand factor.

Von Willebrand disease is the most common inherited bleeding disorder.

While patients with type 2 produce the blood protein, it does not work properly. Additionally, vWF protects factor VIII, also important in the clotting chain, from being destroyed in circulation. When vWF is low or absent, so is factor VIII.

But clinical evaluation of bleeding symptoms is a challenge, according to NHLBI experts. For starters, some of the symptoms are relatively common in healthy populations, making detection of the vWD's mildest form tricky. Also, the use of aspirin or other nonsteroidal anti-inflammatory drugs exacerbates bleeding tendency, making it difficult to decipher vWD from such other variables. To further complicate the issue, vWD, in rare cases, can be acquired as the result of other conditions like hypothyroidism, or from medication, especially among elderly patients.

In its acquired form, vWD can be addressed by treating the underlying cause, says Margaret V. Ragni, MD, MPH, professor of medicine in the division of hematology and oncology at the University of Pittsburgh. She also is director of the Hemophilia Center of Western Pennsylvania. "[But] for anyone with a bleeding history, refer to a hematologist for evaluation to be sure you are not missing something."

Because of the disease's diagnostic and management subtleties, the NHLBI responded to a fiscal year 2004 appropriations conference committee recommendation, urging the development of treatment guidelines for vWD. "We had been waiting for years for guidelines to come out," says Val Bias, CEO of the National Hemophilia Foundation in New York. "The NHF advocated with Congress to allocate the funds to research."

This February, the first U.S. clinical guidelines for the diagnosis and management of the disease were released. "We are pleased to see the institute affirm the importance of vWD and the need for professional guidance and education around this disorder," Dr. Konkle says. "We are hoping with the guidelines that physicians will think about it and say, 'this is what I can do.' "

Multifaceted approach needed for diagnosis

There is no simple, single laboratory test to screen for the presence of vWD. "Unfortunately, our testing is not perfect," Dr. Konkle says.

And lab work sent significant distances is often compromised because of changes in temperature and humidity. "There's a 50% to 80% chance that [results] will come back falsely," says Dr. Kouides. "Insist that the lab work goes to a local lab that does the levels on site."

Several studies are under way internationally to determine better methods of screening, testing, diagnosis and treatment, and to build on the information contained in the recent guidelines. At the University of Pittsburgh, for instance, Dr. Ragni is heading a clinical study of three questions surgeons can ask to screen for the disorder in addition to several drug trials and novel approaches to evaluation and diagnosis. "The new NHLBI booklet is the most comprehensive we have," she says. "But it does not have all the answers."

It wasn't until one of Cindy Lampertz's twin daughters hemorrhaged after a routine tonsillectomy that she and her children were diagnosed with type 1 vWD. "In hindsight, it all makes sense. I had many things that pointed to it," says Lampertz, a registered nurse from Brentwood, Tenn. "I also hemorrhaged with my tonsils. I always have bruises. I had a hysterectomy at 32 because of bleeding." But she also says that, despite her health care background, she still didn't realize she had a problem.

For many women, diagnosis follows pregnancy or comes after a son or daughter has a bleeding crisis. Heavy periods, a key element in the symptom constellation, are rarely the catalyst. In 2004, CDC researchers, in collaboration with the Rollins School of Public Health of Emory University in Atlanta, surveyed members of the Georgia Chapter of the American College of Obstetricians and Gynecologists to determine their perceptions of and experiences with bleeding disorders, particularly vWD.

According to the survey, menorrhagia is reported by approximately 10% of patients annually, or about 3 million women. Fifty percent of the cases are of unexplained gynecological origin, yet only 3% of responding physicians consider vWD. Most respondents believed that menorrhagia is within normal limits. "Gynecologists don't frequently think of bleeding disorders [in this situation]," says Dr. Konkle, who also chairs the National Hemophilia Foundation's Women with Bleeding Disorders Task Force.

It's estimated that from 5% to 20% of women with heavy menses have underlying vWD, according to the CDC. The American College of Obstetricians and Gynecologists recommends screening adolescents with severe menorrhagia, adult women with significant menorrhagia not explained by other causes, and women who are considering hysterectomies because of excessive menstrual bleeding.

Interestingly, during pregnancy, vWD almost always improves because vWF rises to protect women during childbirth. The gravest worries are postpartum. "Within 12 hours to a week, the levels will fall and there is a risk of delayed hemorrhage," says Dr. Kouides.

According to the NHLBI guidelines, women who have any type of vWD, a history of severe bleeding, or blood test results showing very low levels of von Willebrand factor or factor VIII, should be referred for prenatal care and delivery to a high-risk obstetric center that has a hemophilia treatment center.

Reproductive cycles present women with vWD with more frequent bleeding challenges, but anyone with the condition -- male or female -- worries about the next fall or bump. Daily missteps can equal serious outcomes. And what's serious for one might not be for another.

DeArmond's 13-year-old son has frequent nosebleeds. "This summer, he's had gushers," she said. "He wears a MedicAlert bracelet and has a letter he takes with him" to explain the medicine he needs in an emergency.

Similarly, Lampertz worries about her daughters, recalling a tense ski trip. "We were on vacation in the mountains, there was a blizzard and my daughter got a nosebleed. I couldn't stop it," she says. "Now we travel with her medicine and my rule is: If I can't stop it in two hours, we go to the hospital."

Overall, vWD offers physicians and patients a quandary. For physicians, it is difficult to diagnose and manage. For patients, it can present stark risks every day. And overall, at its earliest point, the condition is a puzzle that requires looking at the whole picture. The vague bleeding symptoms add up. "This is a condition we should think more about in primary care settings," says Dr. Kouides. His advice: Follow the guidelines and keep the antennae up.

Link strengthened between sleep apnea and mortality risk

August 25, 2008 on 9:52 am | In Uncategorized | Comments Off Washington -- Evidence is building that sleep apnea poses an independent risk for dying, particularly from cardiovascular disease. Two studies in the Aug. 1 issue of the journal Sleep came to the same conclusion: Untreated obstructive sleep apnea can be lethal.

In addition, a joint statement from the American Heart Assn. and the American College of Cardiology, in recognition of this apparent connection between heart disease and sleep apnea, called for large-scale studies to determine possible mechanisms for this link.

The statement was published online July 28 in Circulation: The Journal of the American Heart Assn. and The Journal of the American College of Cardiology.

An estimated 12 million to 18 million Americans have moderate to severe sleep-disordered breathing, or sleep apnea, according to the National Heart Lung and Blood Institute. But since sleep apnea is strongly linked to obesity, the nation's collective weight gain may signal that even more people will be affected.

Obstructive sleep apnea involves a reduction in breathing, called hypopneas, or a complete halt in airflow, called apneas, during sleep. Most pauses last 10 to 30 seconds, but some may persist for one minute or longer, according to the American Academy of Sleep Medicine.

This condition can lead to abrupt reductions in blood oxygen saturation, with oxygen levels falling by 40% or more in severe cases.

12 million to 18 million Americans have moderate to severe sleep apnea.

In the larger of the two recent studies, people with severe sleep apnea had three times the risk of dying due to any cause compared with people who did not have sleep apnea. The researchers controlled for age, sex and body mass index. Additionally, when those who used continuous positive airway pressure therapy -- a first-line treatment for severe apnea -- were removed from the statistical analysis, the risk of dying was found to be four times greater among those with untreated apnea than for those without.

The study was part of an 18-year follow-up of 1,522 participants in the ongoing Wisconsin Sleep Cohort Study, which was established in 1988 and involved a random sample from the community. Participants were between the ages of 30 and 60 when the study began.

After spending one night at the University of Wisconsin's General Clinical Research Center in Milwaukee for assessment, participants were categorized by apnea-hypopnea index, or the average number of breathing pauses and reductions per hour of sleep. Sixty-three were found to have severe sleep apnea and about 1,157 had no apnea. The rest exhibited an intermediate range of apnea.

To follow up, state and national death records were reviewed to identify participants who had died and to note the cause of death on the death certificate. Eighty deaths were recorded, including 37 attributed to cancer and 25 attributed to cardiovascular disease. About 19% of participants with severe sleep apnea died, compared with about 4% of those with no sleep apnea.

Strong findings

"I was surprised by the strength of the risk," said lead researcher Terry Young, PhD, professor of epidemiology at the University of Wisconsin-Madison. "In epidemiology you rarely get such strong, robust findings. This strong association between sleep apnea and increased risk of all-cause mortality and cardiovascular risk was striking."

The second study in Sleep also found that moderate-to-severe sleep apnea was an independent risk factor for dying. Fourteen years after collecting initial data on sleep apnea for 380 men and women in the state of Western Australia, researchers found that about 33% of those with moderate to severe apnea had died, or six of 18 participants, compared with 7.7%, or 22 of the 285 without apnea.

People with severe sleep apnea have 3 times the mortality risk of people who do not have the disorder.

"The size of the increased mortality risk was surprisingly large," said Nathaniel Marshall, PhD, a postdoctoral fellow at Australia's Woolcock Institute of Medical Research. "In our particular study a six-fold increase means that having significant sleep apnea at age 40 gives you about the same mortality risk as somebody aged 57 who doesn't have sleep apnea."

Michael Twery, PhD, director of the NHLBI's National Center on Sleep Disorder Research, wasn't surprised by the high mortality rates. "When people have difficulty getting air into their lungs it has an impact on their physical well-being," he noted. "We know that the desaturation of blood oxygen levels is a stressor."

What is yet unclear is how sleep apnea contributes to heart disease, said Virend Somers, MD, PhD, professor of medicine and cardiovascular diseases at Mayo Clinic and Mayo Foundation in Rochester, Minn. Dr. Somers chaired the writing committee for the AHA/ACC joint statement.

But despite this missing information, the cardiovascular community is concerned enough to recommend that treating apnea may also help prevent and treat heart disease.

This first step toward effective treatment also is likely to be taken by primary care physicians.

"Primary care is clearly where the action is," said Dr. Twery. However, recognizing and diagnosing patients with sleep apnea may be difficult. Physicians may want to pay more attention to those who complain of excessive daytime sleepiness. Sleep apnea may impair daytime vigilance, he added.

Individualizing treatment is important, said Dr. Somers. Among those patients at the top of the list are heavy snorers and those who have been told they stop breathing at night.

Patients who have cardiovascular disease, high blood pressure, heart failure or atrial fibrillation, and those who are obese or snore may also have sleep apnea. And the disorder should be considered among patients with cardiovascular disease who don't respond well to standard therapy. "This suggests there is something going on in the disease process that we are not treating," Dr. Somers said.