Archive for the ‘Uncategorized’ Category

Obesity as we all know is an epidemic in this country and childhood obesity may be one emerging root cause. New research from the University of California-Davis studied the types of food advertisements seen by children watching English- and Spanish-language American television programs on Saturday mornings and weekday afternoons, on the most highly rated children’s cable channels.

20% of commercials were food related and of those a shocking 70% of the 5724 commercials examined were food commercials. Almost all of the commercials were for high sugar, cereals, snacks and beverages. In addition 91.2% were in English and the remaining commercials were in Spanish.

When compared to general audience commercials, children were exposed to 76% more food commercials. In fact, there were 5.2 food commercials per hour on children stations. Sadly this trend continued into typically teen-aged stations like MTV or BET.

The study’s authors state that, “health educators need to develop and evaluate comprehensive nutrition programs that augment nutritional education with media use reduction strategies to lessen exposure to ads…and efforts should also be made to introduce media literacy training into nutrition programs. Such literacy training can help children and adolescents understand both the economic motivations behind food advertising and the strategies used by industry to increase desire for their products. Greater awareness of the potential influence of industry may immunize young people from food advertising’s deleterious effects.”

We know that there is a phenomenon of social obesity whereby if your friends are obese, you are more likely to be obese. The last thing we need is to add media brainwashing of children into thinking it’s desirable to eat high sugar cereals and fast food.

Reference via Medical News Today:

1) Robert A. Bell, PhD; Diana Cassady, DrPH; Jennifer Culp, MPH, RD; and Rina Alcalay, PhD. “Frequency and Types of Foods Advertised on Saturday Morning and Weekday Afternoon English- and Spanish-Language American Television Programs.” Journal of Nutrition Education and Behavior, Volume 41, Issue 6, Published by Elsevier.

Many athletes present to me with groin pain almost all saying they, “pulled [my] groin” and it’s not getting better. What are common causes of groin pain, when should you see a doctor and how is it treated?

Groin pain, that is pain where the abdomen meets the legs, can be cause by acute injury or wear and tear over time. Acute injury happens with direct blows, fall, sudden directional change or acceleration or some other kind of trauma.

More chronic overuse injuries happen with repeated day to day activity that puts stress on the anatomical structures in the groin area.

Groin Pain can also be referred from other parts of the body like the kidneys or intestines or reproductive system, so it is essential that if there is no obvious mechanism for your pain, you have to see your physician.

Ice Hockey, soccer, basketball and cross country skiing are common sports that put you at risk. Many groin injuries are also caused in work or home related injuries or motor vehicle accidents.

Pulled muscles, ligaments and tendons in this area can result of sporting or other causes of injury. Commonly, Injury is to the adductor group which stretches from your pubic bone to the femur. This group that helps pull your leg back in to your side from an outstretched position or from side to side.

If the injury is mild, localized aching pain in the inner thigh and groin can occur. If it’s a severe injury, sudden pain, swelling and bruising may occur as well.

Treatment is dependent on severity and cause. For this post, I’ll focus on the adductor group strain which is the most common. More so that other types of injury, rest is very important for groin strains. Many patients say they start to feel better, go back to the activity that caused it, but they reinjure it, putting them back weeks to months in terms of recovery.

Avoiding these exacerbating activities even when the pain goes away is critical. Icing and heat may also help for swelling and pain relief though heat should not be applied until the acute swelling phase of 48-72 hours is past. Physical therapy to incorporate various treatment modalities (ice massage, electrical stimulation and various exercises) can also help symptomatically in this early stage.

Further out, usually a least a week or two later, once pain free at rest, very gentle stretching exercises can help regain range of motion and flexibility though any pain is a bad sign and stretching should be discontinued.

Groin injuries to the adductor group can be recurrent so preventative hip adductor and abductor stretches and core and pelvic stabilization can help prevent future injuries.

If pain is persistent past a week or two, or if it is a child, it is very important to see a sports physician to rule out a sports hernia or other cause of groin pain.

References:

1) www.Uptodate.com
2) Lacroix V, Kinnear DG, Mulder DS, et al. Lower abdominal pain syndrome in National Hockey League players. A report of 11 cases. Clin J Sport Med. 1998;8:5–9.
3) Fan LJ, Spence RAS. Sportsman hernia. Br J Surg. 2000;87:545–552.

Health Reform Needed

Physicians and health activists like me have been trying to raise awareness for the fight against the obesity epidemic.  Health policy is obviously a hot topic, especially after Obama’s address to congress yesterday.  Not surprisingly, now leading health policy makers are taking up the charge. Below are excerpts from the STOP Obesity Alliance press release. Read the official release at the bottom of this post.

The two most recent Surgeons General of the United States, David Satcher, M.D., Ph.D., FAAFP, FACPM, FACP and Richard H. Carmona, M.D., M.P.H., FACS, today led the Strategies to Overcome and Prevent (STOP) Obesity Alliance in urging policymakers to take direct action in health reform to address obesity and the chronic diseases associated with it.

Dr. Richard H. Carmona, 17th U.S. Surgeon General, Health and Wellness Chairperson of the STOP Obesity Alliance and President of Canyon Ranch Institute says, “Obesity now impacts every aspect of our lives, including the future of our health care system. Health reform that directly addresses obesity will save lives, save money, and improve the health and well-being of every American.”

Dr. David Satcher, 16th U.S. Surgeon General says, that due to the complexity of the obesity epidemic, “Until we collaborate to address obesity through meaningful, population-based policies and programs, our nation will continue to be crippled by obesity and the chronic diseases it causes.”

The STOP Obesity Alliance released four targeted recommendations designed to improve the dialogue and interventions around obesity. The following elements should be included in health reform:

•    Standardized and effective clinical interventions, flowing from evidence-based guidelines, such as those approved by the National Heart, Lung and Blood Institute (NHLBI), that include acknowledging the health benefits of five to ten percent sustained weight loss to aid and support those individuals who are currently overweight or obese achieve improved health.

•    Enhanced use of clinical preventive services to monitor health status and help prevent weight gain, especially for individuals who are already overweight and are at risk of becoming obese.

•    Effective, evidence-based community programs and policies that encourage and support healthy lifestyles, focus on health literacy, address health disparities, and represent a significant investment in population-based prevention of obesity.

•    Coordinated research efforts to build the evidence for all three of the above elements, continuously improving quality of care, bolstering our understanding of what does and does not work in various settings, and helping to translate the scientific research into practice recommendations for real-world clinical settings and communities.

“Clearly, America cannot successfully reform the health system without addressing obesity,” said Christine Ferguson, director of the STOP Obesity Alliance. “While the situation is grave, the goal is attainable. The STOP Obesity Alliance recommendations provide a needed focus and a successful plan for health reform.”

See the full press release at:
http://www.stopobesityalliance.org/newsroom/press-releases/16th-and-17th-u-s-surgeons-general-stop-obesity-alliance-announce-america-has-reached-tipping-point-on-obesity-call-for-direct-action/

Yet another reason to lose weight if you are obese: obese women are more likely to have children with asthma.

A study from the Netherlands following 4,000 children from before birth to eight years of age. In the children with a least one parent with asthma, an obese mother increased the risk of asthma by 65 percent by age eight!

What is the link?  Obesity is a metabolic state with increased inflammation throughout the body. Excess fat produces inflammatory compounds called cytokines and reduces the effectiveness of natural anti-inflammatory cytokines.  In previous studies, cytokines have been proven to have a role in asthma development.

Obesity in pregnancy is also known to increase the risk for birth defects such as spina bifida, cardiovascular defects, cleft lip and palate, limb deformities, and hydrocephaly (abnormal build up of the fluid around the brain.)

So if you are of child bearing age, it essential to maintain a healthy weight as determined by your physician or health care provider. If you are pregnant already, talk with your physician about what healthy weight range should be maintained as losing weight during pregnancy is not advised in most cases.

References:

1) Presented at the International Conference of the American Thoracic Society, May 19, 2009 via www.healthcentral.com

2) Stothard, KJ. Journal of the American Medical Association, Feb. 11, 2009, vol 301: pp 636-650.

I will attempt to distill the complicated clinical decision of when to surgically repair your rotator cuff tear into a short post based on current knowledge.

The rotator cuff is a group of 4 muscles and tendons in your shoulder that helps to stabilize the shoulder and to internally and externally rotate as well as abduct and the shoulder. It can be injured with many types of trauma to the area, as well as overuse and degeneration of the cuff muscles and tendons and/or surrounding structures over time.

The indications for surgery include:  1) Acute loss of strength due to rotator cuff tear with healthy muscle bellies. 2) After failure of non-operative rehabilitation treatment and modalities for a chronic tear for 3-6 months.

What are the contraindications to getting the shoulder repaired? Tears causing no pain or decrease in function, frozen shoulder, or chronic “massive” irreparable tears should not be surgically repaired.  In addition, a surgeon may be unwilling to repair it if it is a chronic tear with little pain, longstanding weakness, or if the chief complaint is poor function.

With younger patients with rotator cuff pathology, the inherent quality of the muscle and tendon complex can be better, thus prompting many surgeons to surgically repair a tear in young people earlier.

The highly simplified goals of surgery are to cut out the tear margins, especially if it is frayed and degenerative, free up the cuff tear from any scar tissue that has formed, reattach the tendon to bone if necessary, and repair the tendon itself. The eventual goal is increased function and strength of the shoulder, decreased or resolved pain, and maintenance of as much safe range of motion as possible.

The surgeon may decide to operate with an arthroscopic approach using tiny cameras and instruments through tiny holes to repair the tear, or he/she may opt for a mini-open or a full open procedure. The approach varies depending on the tear, patient and surgeon. You must talk with the surgeon about which will be best for you.

The exact timing can be tricky. You should balance your personal life and obligations with when is optimal to give the cuff the best chance for healing. Typically, after the surgery, you will asked to not lift anything heavier than a cup of coffee for about 3 months although early passive range of motion and rehabilitation exercises will be incorporated.  As a result, most people need someone at home to help them with their activities of daily living, driving, and shopping.

The bottom line is that if you think you have torn your rotator cuff, immediately see a sports medicine physician or orthopaedist to determine if you have indeed torn your cuff and if non-operative rehabilitation or surgery is the best option for you.

Science is starting to focus on the determining the underlying causes of certain cancers and especially how metabolic problems like obesity and weight gain may potentially contribute.  While we know that obesity increases ones risk of colorectal cancer, kidney, esophagus, endometrial and breast cancer, there is new evidence from the University of Hawaii that shows middle age weight gain can confer an increased risk of prostate cancer in men.

Lead researcher Brenda Y. Hernandez, Ph.D., M.P.H., assistant professor at the Cancer Research Center of Hawaii studied a group of 83,879 men who were Hispanics, Japanese, white, Native American and blacks in a prospective study from 1993-1996.

Their data, recently analyzed suggests that excessive weight gain between younger and older adulthood increased the risk of advanced and high-grade prostate cancers in white men and increased the risk of localized and low-grade disease in black men, but decreased the risk of localized prostate cancer in Japanese men.

30 percent of prostate cancer cases occurred among Japanese men, 25 percent among white men, 27 percent among Hispanic men, 13 percent among black men, and 7 percent among Native Hawaiian men.

This difference in incidence of prostate cancer between men of different ethnic groups may be attributed to different proportions of fat to lean mass and where that fat is placed.

While it is difficult to jump to a conclusion that young adulthood weight gain causes prostate cancer, this study definitively shows that at the very least there is a strong correlation. Men at this age are undergoing much change after finishing school, entering new jobs, which may cause changes in eating habits, potential decreases in regular physical activity that results in weight gain.

I usually advise my college patients, especially those that are “retiring” from formal college athletics, that they have spent their lives forming poor eating habits that haven’t manifested in weight gain simply because they have been burning an extreme amount of calories doing sports. When they leave college, all of a sudden they aren’t burning as many calories, and metabolisms slow down yet they continue to eat similar quantities, so rapid weight gain ensues.

This new study is one more reason to encourage healthy eating habits BEFORE finishing college and some argue even before.

References:
1)    Cancer Epidemiology, Biomarkers & Prevention, September 1, 2009
2)    http://www.cancer.gov/cancertopics/factsheet/risk/obesity

I am currently travelling in Japan, the country of tremendous beauty but also one where the prevalence of osteoporosis is quite high due to the genetically thinner bone of the people here as a whole. I figured, I’d write about osteoporosis in North America as it is actually very prevalent there as well.

What is osteoporosis? According to the 1991 Consensus Development Conference it is, ““A loss of bone mass and micro-architectural deterioration of the skeleton leading to increased risk of fracture.” There are 1.5 million fragility fractures every year, half with diagnosis of osteopenia which is a milder version of osteoporosis in the spectrum of bone density deterioration. It costs the U.S. more than 18 million dollars per year in health care costs and its incidence is increasing with our aging population.

Why is it important to you?  The development of osteopenia and osteoporosis puts you at higher risk for fractures, many of which prevent you from doing the things you love.  In fact, if you develop a hip fracture, you are at higher risk of death itself, due to complications from the fracture. This risk increases with the age at the time of the hip fracture.  To understand why even children and young adults should be thinking about preventing osteoporosis, you have to understand how bone develops.

As we grow and age as children and young adults, our bone density and micro-architecture goes up, giving us stronger bones to allow our skeleton to carry more weight.  Unfortunately, we achieve peak bone mass when we are around 30 years old. I usually tell patients that our bones are a reservoir for calcium. We have 30 years to most effectively fill that reservoir and after that we are able to focus merely on reducing the rate of bone density loss.  Both women and men lose 0.4% of peak bone mass per year after age thirty. 70% of this process is genetic, 30% we can actually control.

What are the key risk factors?  In order of the relative risk for hip fractures, the most dangerous type of fracture, they are: 1) parental history of hip fracture, 2) history of systemic steroid use like prednisone, 3) rheumatoid arthritis, 4) drinking more than 2 glasses of alcohol per day, 5) prior fracture after age 50, 6) current smoking, and 7) having a lower body mass index of 20 versus 25.

How is it measured? Bone density is usually measured with a machine called “Dual bean x-ray absorptimoetry (DEXA)” or rarely with a specific kind of quantitative computed tomography (qCT) machine. All post menopausal women and/or greater than age 60, as well as pre-menopausal women and men with risk factors should be screened. See your primary care physician or health care provider to discuss if this is appropriate for you.

My hope is to convince everyone to actively prevent osteoporosis and the resultant fractures.  To do this we have to 1) maximize bone density if you are younger than 30, 2) prevent bone loss, and 3) prevent fractures. To maximize bone density, young adults and children should consume 1300mg of calcium and 200-800mg of calcium per day depending on age. Adequate vitamin D and weight bearing physical activity like running, walking or weight lifting are required as well to help stick the consumed calcium onto the bones.

To prevent bone loss, adults should consume 800 IU of Vitamin D and 1500 mg of Calcium per day as well as weight bearing physical activity. Everyone should avoid the risk factors that I listed above, especially systemic steroid use, excessive alcohol intake and smokers should aim to quit as soon as possible.  Women who have irregular or missed menstrual periods need to discuss this with their primary care physician because it could be a sign of poor bone health as well.

To prevent fractures, those who have been diagnosed with osteopenia or osteoporosis should undergo formal or informal training for gait stability, use appropriate gait assistance like canes if needed, and make active fall precautions like reducing the number of stairs or landings in the home, avoid clutter on the floor and reduce the step over height in the shower or bath. Regular physical activity is critical, especially weight bearing exercises as listed above. Talk to your health care provider to see if screening is appropriate for you.

If you are diagnosed with osteopenia or osteoporosis, treatment is critically important to prevent fractures and death. Again, see your physician or health care provider to discuss treatment options.

References:
1) Bauer DC,  Garnero P, Bilezikian JP, Greenspan SL, et al. Short-term changes in bone turnover markers and bone mineral density response to parathyroid hormone in postmenopausal women with osteoporosis. J Clin Endocrinol Metab 2006;91(4):1370-5.
2) Black D, et al. Once-yearly zolendronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 2007;356:1809-22.
3) Consensus Development Conference: prophylaxis and treatment of osteoporosis. Am J Med 1991;90:107-10.

Many runners have had this and those that have dread it. Typically, runners complain of a sharp or aching pain on the outside/lateral part of the knee just above the joint line of the knee and sometimes just below the knee.  Most runners complain of pain initiation around the same point in or at the end of a run that will not get better unless you rest.   Sometime it is associated with downhill running or with the heel strike phase of gait.

What is Iliotibial band syndrome (ITB), how do we treat it and more importantly how to we prevent it?

First the anatomy.  The iliotibial band is a thick band of connective tissue on the outside of the thigh, which stretches from the outside of the pelvis (iliac crest), over the hip and knee and inserts just below the knee. The ITB is contiguous with a muscle group called the tensor fascia lata near the pelvis whose job it is to  abduct or extend the hip and leg outwards.

The ITB functions to stabilize the knee from internally rotating during the heel strike and knee bending phase.   If you have abnormal gait mechanics, the ITB can rubs back and forth against the lateral femoral condyle and become inflamed.  There are some athletes where the pain gets so bad, they have to drop out of competition until it is adequately treated. Unfortunately rest, ice, compression and elevation alone will not help this problem in the long run.

Typically weak hip abductors are the culprit. They fatigue with time, thus allowing the femur to internally rotate, which explains why it happens in the middle or end of the run. Sometime the multifidi muscle groups in your low back aren’t firing properly.

Having sacroiliac joint dysfunction can be the underlying problem. This causes an anatomic asymmetry in the pelvis and sacrum which can subtly cause a gait discrepancy, which forces the hip abductors to work harder, fatiguing them prematurely causing ITB pain. Other anatomical asymmetries can contribute like high or low arches, over-pronation, leg length discrepancies, or if you are bow legged or have a tight ITB.

How do we treat this problem? In the acute phase of inflammation, if you’re an athlete training for a competition, you might have to decrease the amount of hill running or do more slight (1-2% grade) uphill or treadmill running only. Others should avoid running, deep squats, excessive stairs, bowling, tennis or wrestling that will stress the hip abductors and put more friction on the ITB.

After every run or exacerbating activity, the athlete should ice and elevate the outside of the knee to help with pain and inflammation.  A foam roller to help massage and stretch the ITB can help as well and can be picked up at your local sports store. A 7 day course of an anti-inflammatory medication can help as well but as usual, talk to your doctor or health care provider before starting this.

In order to truly treat and prevent recurrences however, you have to strengthen your hip abductor muscles and correct any underlying asymmetry or SI joint dysfunction. Picture those 1980’s exercise videos of Jane Fonda on her side, doing side leg lifts (4 x 15 reps) and that’s the mainstay of strengthening. Another exercise is to drop your leg down off a step slowly while firing your butt muscles (4 x 15 reps). A more advanced exercise is to do one legged squats.

A well trained musculo-skeletal sports medicine physician, physical therapist or chiropractor can help correct SI joint dysfunction. Talk to your sports medicine physician about how to correcting arch, knee, or leg length asymmetries.

If a solid regimen at home doesn’t work, see your doctor about maybe trying a round of formal physical therapy. Occasionally for athletes that fail this, I have done a cortisone injection or other type of injection. If all else fails, surgery to release the back 2cm of the ITB where it is rubbing against the femoral condyle can help but this should be the last option.

Here is a nice instructional video of an easy to do hip abductor strengthening regimen on Youtube. Thanks to Kristie La Tray, the fitness trainer in the video!

References:
1. Panni AS, Biedert RM, Maffulli N, Tartarone M, Romanini E. Overuse injuries of the extensor mechanism in athletes. Clin Sports Med 2002;21:483-98.
2. Ekman EF, Pope T, Martin DF, Curl WW. Magnetic resonance imaging of iliotibial band syndrome. Am J Sports Med 1994;22:851-4.
3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36:95-101.
4. Messier SP, Edwards DG, Martin DF, Lowery RB, Cannon DW, James MK, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc 1995;27:951-60.

Is a meniscal tear in either knee the start of that dreaded spiral of aging that eventually results in osteoarthritis of the knee?  The answer is a qualified yes. Some of the factors relate directly to your age at the time of injury, the treatment, where the tear is and the fact that after about 35 years of age the blood supply to the meniscus and its ability to heal itself goes down tremendously. There are at least 3 known studies that point to this being the case, each telling a slightly different story.

We know from a study in France that if you tear your meniscus at an age less than 35 and have that torn section removed at that time, you may need some sort of surgery for resultant osteoarthritis in the same knee on average 26 years later. If you are older than 35 however, that number of years to surgery dramatically changes to only about 10 years.1

Another study done on people who underwent menisectomy (removal of torn section) showed that the knee that had the torn meniscus was much more likely to develop osteoarthritis compared to the uninjured side.2

Yet another study looked at the associations between meniscus tears and osteoarthritis, symptoms of knee pain and radiographic signs of arthritis. The study showed that meniscal tears were indeed associated with osteoarthritis on Xrays as well as knee pain. Further, they saw increased osteoarthritis in the medial and lateral (middle and side) compartments of the knee after injury. They concluded that meniscal tears were likely an early event in the process towards developing osteoarthritis.3

So if you’re young and spry and get a meniscal tear, you may get arthritis in your knees down the road but it will likely take decades. If you are older, and a little more creaky however, and get a meniscectomy,  you may be at higher risk for developing arthritis. There are still other factors like obesity, amount of high impact activity level, genetics, and stability of the knee ligaments that may also contribute to this process.

The bottom line is that If you get a knee injury that causes the knee to swell, lock, catch or buckle, this may be a sign of meniscal tear and I encourage you to get your knee checked out by a sports medicine physician or health care provider that is comfortable dealing with this kind of problem.

References:
1)    Neyret, P, Donell, ST, Dejour. Osteoarthritis of the knee following meniscectomy. Br J Rheumatol 1994; 33:267.
2)    Boszotta, H, Helperstorfer, W, Kolndorfer, G, et al. Long-term results of arthroscopic meniscectomy. Aktuelle Traumatol 1994; 24:30
3)    Ding C, Martel-Pelletier, J etal. Meniscal tear as an osteoarthritis risk factor in a largely non-osteoarthritic cohort: a cross-sectional study. J Rheumatol 2007; 34(4):776-84

I have many patients of all BMI’s, and many with osteoarthritis. I have noticed a connection between obesity and osteoarthritis, especially in the knees. Normally osteoarthritis is slowly progressive with time, age and activity but a small percentage of people exhibit particularly rapid deterioration of cartilage. Many clinicians and researchers suspect that obesity may increase the RATE of cartilage loss that leads to osteoarthritis. Now a new study confirms these suspicions.

Frank Roemer, M.D. and his team from Boston University’s department of radiology have identified several MRI and demographic based risk factors for rapidly progressive cartilage loss. The study looked at 347 knees in 336 patient’s. Their average BMI was 29.5 which is considered overweight. Cartilage loss was identified and defined by MRI findings. They followed the subjects over 30 months.

The top risk factors for rapidly deteriorating cartilage included obesity, the only demographic factor.  Age, gender, ethnicity were not found to be risk factors.  All the other risk factors were MRI findings so I won’t go into too much detail but they can be found here.

Even a one point drop in BMI is significant. The study found that a gain of one unit of BMI was associated with an 11% increased risk for rapidly deteriorating cartilage and thus arthritis. So logic says that a drop of one unit will significantly decrease that risk. So the goal is weight loss of any kind, not necessarily a huge drop.

So why do we care? It’s yet another confirmation that obesity leads to health problems. More importantly however is that since obesity is a BASELINE risk factor, everyone who is obese should take steps early, BEFORE the onset of cartilage loss and eventually osteoarthritis. Most important is to see your physician or health care provider to discuss getting on a sustainable weight loss regimen.

As a sports medicine and family medicine physician, I urge parents to go one step further. Parents should take preventive steps to ward off obesity in their kids, even if they are only ages 2 or older. Again, talk with your health care provider to find out how and/or look at this very helpful tip sheet, courtesy of the state department of New York.

See the original study here via Medical News Today