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A Mathematical Formula for Explaining Obesity

A New York Times article interviews mathematician Dr. Carson C. Chow about the formula he created to figure out the obesity epidemic. His answer is based upon the increase in the American food supply since 1970. If more food is available, we'll eat it.

Other gems his model reveals is how the body changes as we lose or gain weight. Cutting 3500 calories does not equal one pound of weight loss. A horrifying revelation: An extra 10 calories a day puts more weight onto an obese person than on a thinner one.

For those dieters out there, it takes about a year for your body to reach equilibrium following weight loss. This explains, in part, why so many people put weight back on after they've reached their target goal. It actually takes about three years for a dieter to reach their new “steady state.”

To see the model in action, Chow and company have developed the body-weight simulator. People can plug in their information and learn how much they’ll need to reduce their intake and increase their activity to lose. It will also give them a rough sense of how much time it will take to reach the goal.

The take-home message: cut calories and be vigilant about your intake for the rest of your life.

Let Food Be Your Medicine

According to a study published in the Archives of Internal Medicine, purified fish oil supplements may not offer health protection against heart disease.

The new report, a large meta-analysis that pooled and then analyzed data from various clinical trials involving thousands of patients, found that taking omega-3 fatty acids did not reduce the risk of further cardiovascular problems in patients who already had heart disease.

This study examined people who already have heart disease, so researchers don't know if fish oil acts to protect people who don't already have heart disease. Also, these studies don't show long-term effects of taking fish oil.

So, here's my beef with the whole issue: People hear that the omega-3 oils found in fish offers anti-inflammatory protection to the body that also helps reduce heart disease. Science has a way of looking at the big picture benefits with a magnifying glass to see what is happening at the molecular level, identifies the molecule, and throws the rest of the fish out with the bathwater.

Good health comes from lifestyle choices. Eat fish. Taking a pill will not cure all that ails us. Wouldn't our money be better spent buying actual fish twice a week? Don't like fish? Suck it up and learn to like it; we're adults here, right? Try this salmon recipe and see if it doesn't help change your mind.

The lead author has this to say about eating actual fish rather than fish oil supplements:

By eating fish, you end up replacing other less healthy protein sources, like processed foods and red meat.

Amen to that.

When a Patient Dies

Every once in a while, I lose a patient. Thankfully, it hasn't happened on my watch, but it can be someone who is "on program" for physical therapy, that I've treated or evaluated. Often, the death is expected, the patient is being care for by hospice, or is unconscious and unresponsive when PT goes to visit them. Sometimes, their passing is a shock, such as a patient who is alert and oriented, talking and walking, and something goes bad over night like an uncontrollable liver bleed. Sometimes their passing is really upsetting.

I discovered during one of my internships that there is a tendency among health care workers to share in the loss of a patient. After the discovery of a patient's passing we huddle together, voices hushed, to discuss what happened. At various times, each will withdraw into themselves, a personal moment in a group to process the passing. Stories will be exchanged, a funny anecdote, a poignant moment, a characteristic that we admired, the challenges that the patient faced. It's a ritual as old as mankind, a miniature wake. It is part of the experience of being a healthcare worker, and helps us move forward into our day to continue to help the people who need us.

So what is it about the one patient we carry with us on the rounds, whose loss we cannot proceed forward from so readily? For me, it is a patient who was young, only 52 years old. He was admitted to the hospital because of abdominal pain. He's in an isolation room; it is messy and the smell off-putting. He's a big, strapping guy, strong as an ox, legs like tree trunks. He cannot move around well, not because weakness or a coordination problem, but because he hurts so much. His bowels have not moved for days. The x-rays show nothing. We chat a bit on one of the days that he's feeling better. He tells me that he grew up locally, had a happy childhood. He wanted a big family ever since he was young. His kids are in their 30s now and he has many grandchildren.

I left work for the weekend, and on Monday I saw where he had been discharged from the hospital. I figured his abdominal distress had resolved itself; I was glad for him. Then the news came that he died and it was a shock. Nobody knows what happened. Maybe that is the most disturbing part - that medicine was not able to solve the mystery. The doctors have their theories, but nobody will know for sure unless and autopsy is performed. Maybe the loss is more disturbing because he was so young, close to my age. Maybe it was the personal connection I felt we had formed - he had a happy childhood - that pulls at my heart. I take comfort where I can, despite how young he was, he had the big family he always wanted. He had a good life.

Pet Ownership Good For Your Health?

For years there has been a belief that pet ownership is good for your health. Studies in the past report that having a pet boosts mental health in the elderly by offsetting feelings of loneliness and improving self-esteem. In younger populations, as well, dog ownership correlates with increased exercise from taking the dog for a walk.

Harold Herzog, professor of psychology at Western Carolina University (my alma mater!), has recently publish a report in the journal Current Directions in Psychological Science, that refutes the claim that animal ownership is always beneficial. Herzog has authored the book Some We Love, Some We Hate, Some We Eat: Why It's So Hard to Think Straight About Animals.

However, some evidence is emerging to refute the claim that pet ownership is good for your health. In the elderly, owning a pet increases the risk of falls, which could lead to broken bones, a devastating event for the elderly. Taking care of a pet on a limited income, especially veterinarian bills, could increase stress in the elderly. And then there is the inevitable loss of our companion animals, which can lead to a very real sense of loss and depression, no matter the age of the pet owner.

Herzog, a cat owner himself, admits that the benefit or deficit of pet ownership depends a great deal on the strengths and weaknesses of the owner. “I’m not a Grinch,” said Dr. Herzog, “but the science is not as clear as most people think.”

I share my household with 3 pet companions, all of whom are rescues (I'm polishing my halo right now). For the most part, this is not something I regret. However, I will admit to feeling overwhelmed at times, by the zaniness and laundry and annoyances of pet ownership. Right now, we are enduring a period of nocturnal hyperactivity from our black feline, which seems to come in spells, and deprives us of quality sleep. Lack of sleep makes their human companions cranky and argumentative. The other feline has a habit of sleeping on my pillow during the winter, which prevents me from finding a comfortable position and results in neck cricks. The dog, it seems, almost always needs to go out just when I've sat down to relax, letting out that first sigh, following a long day at work. She more than the others, insults my olfactory senses. All of them contribute to an increase in animal hair, and therefore housework, in my home.

Despite these complaint, they are my family and I love them.

Talking About Weight Control

I've recently attended a continuing education course and read a book regarding habit formation. In simplest terms, habits require a cue that encourages people to act a certain way that results in some sort of reward. Technically, habits are neither good nor bad, they simply are a loop system of cue, routine, reward.

However, when we begin applying habits to healthcare, we define habits as "bad" when they result in long-term harm. Drug abuse, whether illegal or prescribed, comes to mind. But in a health atmosphere where obesity is epidemic, eating habits must also be address by health care professionals. And this is where conversations with patients can get dicey.

Feelings around obesity, especially regarding children obesity, is fraught with uncomfortable emotions that can range from guilt to shame to outrage. Researcher have actually taken a survey to determine which terms are more or less desirable when having a conversation about weight. Obviously, terms that were more neutral and less stigmatizing, such as "weight," "unhealthy weight" and "high BMI" were deemed least offensive.

And here's where physical therapists and massage therapists may be able to play a role. Food is something everybody needs, so when encouraging people to change their eating habits, the idea of cutting back how much we eat becomes unproductive for long-term change. However, changing behavior patterns so that people become more physically active tends to change other habits, such as food choices. The idea is that once someone is doing one healthy thing for themselves, they make several changes toward healthy habits.

From experience, I find that assigning exercises as homework can have varying results. Too many exercises (more than 3 at a time) will likely not get done at all. Assigning a patient one exercise per office visit, to help decrease low back pain, for example, is more likely to result in compliance. And once a patient does an exercise that helps reduce their pain, chances are they will be willing to with the next exercise you assign them.

The trick to changing a habit to a healthy habit is to help the patient/client determine goals that align with their lifestyle. As professionals, we can play a supportive role as coaches or cheerleaders to motivate them toward those goals. Choosing the right way to frame the conversation can make the difference between success or never seeing them again.

Statins and Exercise

Statin drugs are known to help lower cholesterol. But a new study shows that statins also increase oxidative stress, a measure of cell damage, in muscle cells, making exercise more difficult. And in elite athletes, that oxidative stress is exponentially greater.

Also found while taking statins, glycogens or stored carbohydrates, which are processed in the liver, are less available to muscle cells. And mitochondria, the power generators for the cells, are dysfunctional, creating 25% less power than in unmedicated individuals.

“It seems possible that statins increase muscle damage” during and after exercise “and also interfere somewhat with the body’s ability to repair that damage,” says Dr. Paul Thompson, the chief of cardiology at Hartford Hospital in Connecticut and senior author of the study.

If you take a statins, consult with your doctor before engaging in an exercise program, or before terminating any medications.

Quote of the Day

I heard this while passing a curly, red-headed three-year-old talking to another three-year-old on my walk home . . .

"Yeah well, my Mom's purple sneakers taste like watermelon. I'm serious!"

Working WIth Children

I was forced way out of my comfort zone this week when I was required to get a child out of bed following spinal surgery. The bandage traveled all the way down the back: spinal fusion surgery starting at the 4th thoracic vertebra that ended at the 2nd lumbar vertebra. Poor kid.

Family was everywhere. Everybody was nervous and on edge, including me, because I have no experience working with children. So I took the approach I take with frightened adults - I explained everything we were going to do and how we would do it. Getting the patient rolled into side-lying went fairly well, and then the child's fear kicked in. And this is where my lack of pediatric experience made me panic. The patient wanted Dad to sit them up, and frankly, he was in the way. Trying to teach him to drop the legs off the edge of the bed and raise the trunk simultaneously requires practice and would likely have created pain for the patient.

The saying goes "never let them see you sweat." Well, I hate that mentality. Why can't we be human with uncertainties? Why can't we let people know that those of us in the caring professions don't know everything? Maybe there would be fewer lawsuits if we did. It is these things that make the job hard and it's why they pay well. So, out of my mouth, before I could stop it, in the face of my patient's fear, came my own fear that I was not a pediatric specialist (and where, by the way, did the patient's nurse go when I showed up?? Lunch, of course). It was not my greatest moment, and it was all caught on camera thanks to "auntie Booboo's" cell phone, thanks "auntie Booboo." Dad, understandably, became upset and asked the obvious question, "Why didn't they send a pediatric specialist??" My response wasn't a bad one, and it was honest: "I can do the PT, it's the emotional part that I'm not good with."

My patient is 10 years old. And behind those eyes is an understanding of the situation and what needs to be done. Again, a clear, short explanation, a count to three, and in one coordinated movement, they're up and sitting. We did it. A cheer goes up. The patient, perfectly healthy before the operation, stands and moves to the chair with steadying assistance. Pain, a squeeze of the pain pump, the inevitable nausea, vomit, vomit again, and we're done. Dad shakes my hand, a firm thank you. And I apologize for our dicey moment back there. The certainty that we need as health care professionals is not for ourselves, but to reassure the patient and their family, I get that.

But it was my patient's courage, the sentience behind their eyes, that allowed me to do what needed to be done. Every person is different, no matter their age, in what they can handle. I saw the patient the next day and told them that they did better than most of my adult patients under similar circumstances. And I thanked them for what they taught me about courage.

Food As Medicine

Below is a link to a nice little slide show that outlines foods that help stave off neurological and mental illnesses. The most common neurological illness mentioned in the aricle, of course, is stroke or cerebral vascular accident (CVA). The most common mental illness mentioned is depression, but ADHD and pshyochoses are mentioned as well.

A feast for the eyes as well as the mind. Enjoy. See the slide show.

Part of the Problem With Our Health Care System

When I walked into the room, I was immediately struck that I had seen this patient before. In fact, it turned out I had seen him just two weeks ago and he was back in the hospital. So, following protocol, I examined him as I have been taught to do.

Just before I assisted him to standing, his daughter said she had a question, "This is too much. Why are you doing this to him?" The doctor wanted me to evaluate the patient for strength and function before he could send him home. "But why?" she asked, pointing out that he already had a rolling walker and that was feeling better and would be going home soon. We want to make sure that once patients are medically stable, they have not lost functional ability and strength. If they have, they may need to get rehab.

"But he's already getting rehabilitation across the street at the out-patient facility for a knee replacement surgery that he had in November." This hospitalization was a different incident, he may need a higher level of care. "But clearly he is feeling better and is just fine. So why does physical therapy need to examine him?" She is clearly annoyed. We are trying to make sure that he has remained strong through this hospitalization and that he hasn't lost any function. If family does not want him to receive therapy, then they need to speak to his doctor and tell him not to order physical therapy.

I got the name of the doctor off of the consult form. She wasn't interested in seeing it. At this point, I'm confused about why she is angry. "He came into the hospital because he was sick. I don't see how physical therapy is helping to make him better. He doesn't need it, he can already walk." But we don't know that. "You can see that he's fine!" I'm at a loss for how to respond, and so I respond incorrectly: An order was put in for physical therapy by the doctor. I'm just here to do my job." This was followed by a diatribe about abuse of the patient's insurance.

Now, I'm a sentient being, and I see her point. Oftentimes, there is a system in place, especially in the health care system, and especially in a hospital system, that forces hospital staff to follow certain protocols. These protocols are set up for the benefit of the patient, but they are not always appropriate for every patient. Someone higher up in the system than myself (unfortunately) has the authority to say "no" to a protocol and relieve the 8-10 people further down the chain from having to take action. That person is often the doctor. Doctors are human. They want to be thorough in caring for their patients, not only for the good of the patient, but to prevent something from going wrong, God forbid. Following my examination, the ball gets passed to social workers, home health agencies, durable medical equipment vendors, nursing staff and so on.

So it is tough for a person in my position to flaunt the system and decide when a patient is not appropriate to evaluate. I can evaluate a patient and THEN decide that they are inappropriate for therapy. Or I can consult with a physician when I believe a patient has been over or under-prescribed physical therapy, engendering a re-evaluation (which is more expensive than a treatment - spending money to save money). So what am I to do? I entered physical therapy in order to help people. But what I have joined is a system of bloat, a health care system that is cumbersome, expensive, and somewhat broken. And now it appears, I have become part of the problem.

A Poignant Moment in Neuro Rehab

Sometimes brain injuries are difficult to understand. A patient can be up and walking aand talking and laughing with family, and the next minute they can be throwing furniture. I've had such a patient recently. He experienced a stroke, and thankfully, is a survivor.

He seems fine. He can carry on a conversation. He can walk, and walk quickly, with only slight imbalance. He's plenty strong and he is impulsive. When the sun goes down, he undergoes a personality change. He becomes hostile. He is clearly confused. Even during the day, he cannot tell you what the date is. And he wants to go home really badly. When asked how he feels, he say "I'm fine, fine. When can I go home."

His family is afraid of him. They don't think they can handle him at home. They want to get him into rehab. Walking with him one day, we were talking, and he became frustrated because he was having word-finding troubles. When we turned a corner, he lost his balance. I pointed out these things to him, and he admits, these things didn't happen to him before he came to the hospital. He became teary. It was the first time he expressed an understanding of his deficits since his stroke.

I reassured him that his noticing these things meant that he was getting better. And while his walking was improving, the reason he had not been released to go home is because we were looking for consistency in his steadiness. I told him that we had people at the hospital who could help him with his speech and memory problems. In a nutshell, he is in an environment that is safe, with a staff of people here to help him until these rough patches in his abilities are polished smooth again.

Returning to his room, his nurse asked him, "what is today, sir?" His reply, "I can't answer that right now." He lay face down in his bed and cried.

An Interview With Jillian Michaels

You may know her from the weight loss show "The Biggest Loser." Jillian Michaels is a personal trainer known for whipping people into shape. Personally, her hard-core style is not for me - I recognize that many clients with obesity have complicated medical conditions. For this reason, I would be inclined to proceed with caution, introducing people to exercise and diet changes gently.

However, her own story as an overweight teenager makes Michaels deserve a second look. She used physical fitness as an entry point to self-confidence, a characteristic she sees as lacking in many of her more challenging clients:

Lazy doesn't exist. Lazy is a symptom of something else. The person who can't get up off their butt is just a person who's depressed. It's usually a pervasive lack of self-worth, or a feeling of helplessness.

Her other tips for finding health and happiness: eat right and get adequate sleep.

Letting Go

Into every life, a little rain must fall. Without rain, flowers would never bloom. I must be getting ready to bloom because I've had a very rainy week. Disappointment, frustration, loss, and general irritation with everything around me has ruled the day - in short, I've felt depressed. And when I get depressed, I feel GROUCHY! Are you curious if you may be depressed? Take this self-assessment.

Short spells of depression are normal in every life - it only becomes a problem if it lasts longer than a couple of weeks and interferes with daily functioning. Luckily, I've had several instances where I've felt pretty darn good. Working with patients and making them laugh makes me happy. Getting a compliment about my clinical thoroughness or patient interactions from doctors, nurses, or other clinicians helps buoy my spirits. A good meal or the satisfaction of accomplishing something at home has helped me feel happy.

So what could be going on? 1) one of my favorite co-workers moved on to another job; 2) my boss (who I absolutely love) and I have had a disagreement; 3) it's February - the longest month of the year if you tend toward SAD; 4) I haven't been sleeping well thanks to my cat disrupting my sleep in the night; 5) could it be menopause barreling down upon me like a Mack truck on I-95? Throw in a dash of bickering, perfectionism, and a heaping helping of "I can't let it go," and you have a recipe for GROUCHY!

I'm lucky to feel the way I do. HA! But this is truly a gift, because I know there is a problem and I have an opportunity to do something about it. So I trolled the internet looking for insight about what it means to hang onto internal baggage. And for people like me, who fall into bad habits once in a while, how do we let go when we realize we're mentally constipated.

For those who subscribe to religious guidance, advice similar to a 12-step program may offer profound insight into relinquishing control to a higher power. For those who are more secular, this advice might not be so helpful. These folks may find pursuit of a psychological explanation more helpful (or both, if you want to be thorough). It may also be helpful to realize the benefits of letting go, not only for mental well-being, but for physical health, as well.

This is all fine and good, but the big question becomes HOW do I let go? I found an entire section on a website called Tiny Buddha - simple wisdom for complex lives about letting go. I found the article "40 Ways to Let Go and Feel Less Pain" helpful for me. Another article that offered me insight and a way to process my emotions is titled How to Release and Prevent Resentment in Your Relationships, also on Tiny Buddha.

Sometimes it is helpful to know that we are not alone with our difficulties. Given the abundance of websites, books, articles, and even a TV show titled the "Psychology of Letting Go," it is clear that other people struggle with similar emotions. I hope that my search for peace through forgiveness can be helpful to others.

Research Support Healing Benefits of Massage.

Finally, there is evidence that the massage industry can sink its teeth into regarding the efficacy of massage reported in the Feb 1, 2012 journal Science Translational Medicine. Antecdotally, massage has been said to help reduce muscle soreness, improve blood flow, and speed recovery of muscles following exercise. And now there is finally proof about what everybody has been saying all along.

The key is cytokines, a cellular substance present in the inflammatory process. Massage therapy has been found to inhibit cytokine production and increase the production of mitochondria in muscle cells. This is a huge finding involving the link between massage and pain reduction.

An Awakening

A pretty neat thing happened at work last week. I was writing up notes at lunch time in the rehab gym while eating my lunch. Out in the hallway, a young man was playing the piano brought out from the solarium and several patients and staff were listening to him play. Inside the gym, a gentleman was working at the upper body ergometer.

Having music in the gym is not untypical; often a gym will have a system playing music from the radio. But what we heard this day was classical music played live and rich, resonating throughout the rehab floor. This is a good thing, because music is found to have a calming effect. Not only that, music, unlike speech, is a whole brain activity. This will become important in a moment.

As I'm writing up my notes, I hear the gentleman at the ergometer say, "I've had a stroke!" I look over at him, he pedaling away, in no apparent distress. I see no new symptoms of a stroke, in fact, the initiation of speech is new for this man. "oh wow! I've had a stroke!" I slide over to him, "you want to talk about it?" He exhibits word finding problems, stuttering and perseverating on one of the words he can grasp but I can tell it's not quite adequate to express what he really means.

A cerebral vascular accident (CVA or stroke) is a type of traumatic brain injury where blood supply is cut off from a portion of the brain, either due to a burst or blocked blood vessel. It is strongly related to heart disease. Following a CVA, affected tissue areas of the brain, like any part of the body that is injured, exhibit swelling. As that inflammation goes down, patients often begin to get function back that they had lost. Forcing the engagement of this process too early is found to have more detrimental effect upon recovery than if we allow the brain to rest 3-4 days.

For my friend in the gym, what I was likely witnessing was post-ischemic recovery of brain tissue. With music playing in the background, more areas of the brain were stimulated, which would increase blood supply to the cortex (or outer covering of the brain). This would allow alternate blood flow to reach affected areas of the brain, and with it memories, words, and capabilities that the brain may have lost.

I can only imagine for someone like this, what his recent experiences must be like. He's in the hospital and may not understand why? Amnesia of the event may lift like a veil, and memories of the precipitating event may flood in, along with the emotions surrounding the event. A realization of the extent of the loss of prior function or the gratefulness to realize that they have survived such a dangerous experience may be overwhelming. With it may come relief and a clearer insight as to the why people have been pushing, pulling, prodding, moving him from one place to another, along with a sense of purpose that these things will help with recovery.

It was a big moment and really neat to see. I informed the attending physician and the speech therapist regarding their patient's breakthrough. I think he'll be alright now. Rather than floating through his therapy as though he is lost, he will likely engage his therapy with vigor and purpose, speeding his recovery.