The Future: A Pill To Prevent Cognitive Decline?
Why not exercise?

For many years scientists believed that the adult human brain was not able to make new cross connections. Neurons were thought to stop functioning and die at a high rate as one aged. Altman, in 1964, hypothesized that vertebrates could create new neurons, but this did not become a prevailing view until much later. Neural plasticity, the ability of

Andrew Pieper, M.D., Ph.D.

the brain to change and respond to conditions and experiences was believed to get worse and worse each year. This is not the case. A number of studies have shown that the brain continues to be active, nerves can “learn” and cross connect actively, and aging doesn’t inevitably lead to a severe cognitive decline. Dementia also, is not inevitable. And exercise makes it significantly less likely.

Science Friday recently interviewed researcher Steven McKnight and reported on a new study that came up with what may be the first pill to lessen cognitive decline. The study was performed on rats and looked at the impact of P7C3 on the dentate gyrus of the hippocampus. The authors conclusions were:

• P7C3 stabilizes mitochondrial membrane potential and inhibits newborn neuron apoptosis (programmed cell death)
• P7C3 corrects hippocampal deficits in mice devoid of adult neurogenesis
• P7C3 preserves cognitive capacity in aged rats

But, just as studies have shown that for many cases exercise can help with depression and sometimes be better than the “pills”, exercise has already been shown to be a good inhibitor in humans of both cognitive decline and dementia. The authors of the P7C3 study even noted that rats who perform voluntary exercise have a lower cognitive decline associated with aging. And social integration of the rats is another “environmental” factor associated with a decreased risk of cognitive decline.

While you are waiting for clinical trials and FDA approval of P7C3 and the “lose weight magic pill” you can take action today. Besides, the active ingredient of the pill already has a patent pending. So, get out there and exercise. Exercise should be a life long activity. If you find as you age that you can no longer do the same exercise you were doing before, it isn’t hard to find other activities to substitute. Run, walk, swim, bike, elliptical, rowing machine are all fine ways to get aerobic exercise. Body weight exercise, dumbbells, or machines all work well for strength training. The exercise recommendation is:

30 minutes of moderate aerobic exercise – 5 days per week
(or 20 minutes vigorous aerobic exercise – 3 days per week)
2 days of strength training each week

Related:

What Made The Brain Get Bigger: Exercise and Evolution

References:

Altman J. Are new neurons formed in the brains of adult mammals? Science. 1962 Mar 30;135:1127-8.

He XZ, Baker DW. Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age. Am J Public Health. 2

Laurin D, Verreault R, Lindsay J, MacPherson K, Rockwood K. Physical activity and risk of cognitive impairment and dementia in elderly persons. Arch Neurol. 2001;58(3):498-504

McKnight, S.L., Pieper, A.A., Ready, J.M., DeBrabander, J. July 2010. Proneurogenic compounds. U.S. patent 2010/020681.

Piepersend A, Xie S, Capota E, et. al. Discovery of a Proneurogenic, Neuroprotective Chemical. ell, Volume 142, Issue 1, 39-51, 9 July 2010 10.1016/j.cell.2010.06.018

Strawbridge WJ, Deleger S, Roberts RE, Kaplan GA. Physical activity reduces the risk of subsequent depression for older adults. Am J Epidemiol. 2002;156(4):328-334.

Smith et. al. Aerobic Exercise and Neurocognitive Performance: A Meta-Analytic Review of Randomized Controlled Trials. Psychosom. Med. 2010;72:239-252.

van Praag, H., Kempermann, G., and Gage, F.H. (1999). Running increases cell proliferation and neurogenesis in the adult mouse dentate gyrus. Nat. Neurosci. 2, 266–270.

Yaffe K, Barnes D, Nevitt M, Lui LY, Covinsky K. A prospective study of physical activity and cognitive decline in elderly women: women who walk. Arch Intern Med. 2001;161(14):1703-1708.

Blisters are a common sports injury caused by a combination of friction and moisture. Blisters normally

Blister

cause pain that limits your activity and resolve and go away. You should take good care of blisters to avoid infection. Running in pain with an altered gait can cause you to injure another body part. A couple of days off if needed can prevent a longer down time.

And no, you will not get gangrene from a friction blister. However, if you are diabetic with insensitive feet caused by diabetic peripheral neuropathy you will not have a normal response to pain. In that set of circumstances there is a higher danger of infection which can spread deeply and widely and cause serious problems. If you are diabetic please check your feet regularly and get professional care at the first sign of any problem.

More information on blisters can be found on my running injuries website.

PPE Coalition for Youth Sports and Safety
PPE Initiative Launch Event & Press Conference: May 13, 2010

Across the U.S. there is no formal standardization of the young athlete’s pre-participation medical evaluation (PPE or pre-participation evaluation). States have varying standards and requirements on what needs to be checked and who may perform the evaluation. These examinations are important since many disorders that can cause serious problems may be picked up during the evaluation.

The newly formed PPE Coalition for Youth Sports and Safety held a press conference at the National Press Club in Washington, DC this morning. This event launched an initiative to standardize and upgrade the pre-participation physical evaluation. This was done in conjunction with the publication of the fourth edition of the PPE Pre-participation Physical Evaluation, written with the collaboration of 6 medical societies, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

A standard and thorough pre-participation physical evaluation is vital for the health and safety of young athletes. The purpose of the Coalition is to encourage the use of a standard PPE. To provide a safer environment for the athletes, the coalition is pressing to create a specific standard.

A website has been established to promote the initiative. You may download the new standardized PPE H&P form

PPE 4th Edition

Information on the organization, the founding and participating organizations, and the newly published text is available at the new website: http://www.ppesportsevaluation.org/ .

The American Academy of Podiatric Sports Medicine is one of the founding members of the coalition and was recognized at the event along with the other founders. I attended this event as a representative of the AAPSM.

Among the speakers was Jim Ryun, was the first high school runner to run a mile in under 4 minutes. He set a high school record of  3:55.3 for the mile, which stood for 36 years.  Former Congressman Ryun also held the world record in the mile, 1500-meter, and 880 yard runs. He participated in three summer Olympic games in 1964, 1968, and 1972. He won the silver medal in the 1500 meter run in 1968. Recently ESPN declared him to be the best high school athlete ever, finishing ahead of Lew Alcindor (Kareem Abdul-Jabbar). Jim Ryun spoke of the importance of having physical education included within a revised “no child left behind” law. With the rise in childhood obesity there is no reason to have only one year of PE required in the 4 years of high school. To much amusement he told of not making the baseball or basketball team, but being able to join the cross country team. With a rapid increase from no running to up to 60 miles per week, he found that his first injury was an incredibly painful case of shin splints.

Also speaking was Congressman Mike McIntyre  of North Carolina. He is the founder of the Congressional Caucus on Youth Sports. As a member of the “Blue Dog Coalition” he attempts to forge a bipartisan agreement on health and fitness related issues. His feelings were strong on the importance of safely encouraging youth health and fitness. He spoke of how what we teach our children is our message to a far-off future that we will not be around to see.

Included in the initiative was recognition of the importance of serving children with special needs an including these special athletes in all of the initiatives that are now set in motion. The AAPSM has long supported initiatives along this line as evidenced by the Special Olympics “Fit Feet” project.

Many other initiatives were discussed including the fight against childhood obesity which has long been a goal of the American College of Sports Medicine, the American Academy of Podiatric Sports Medicine, the American Academy of Pediatrics and the President’s Council on Physical Fitness and Exercise along with all of the organizations which participate in the Joint Commission on Sports Medicine and Sports Science. The recently completed White House Task Force on Obesity and the newly created Let’s Move program were mentioned as hopeful programs to change the trend of increasing childhood obesity.

Encouraging healthy eating and regular exercise for everyone within the context of safe programs is all of our jobs.

PPE

This applies to young and old,  and for those who are slim and not so slim.  Everyone who can do so needs to move for optimal health and to keep both the mind and the body in good working order. The PPE initiative will help  young people as safe as possible and be an aid in detecting serious diseases which may put them at risk. For those who pass successfully through the PPE the greater risk will be in not participating.

Resources:

PPE H&P form (PDF)  http://www.ppesportsevaluation.org/evalform.pdf

Preparticipation Physical Evalution – 4th Edition and further information: http://www.ppesportsevaluation.org/body.html

You Got To Move!

Now that you’ve trained properly after having a medical exam and clearance to run, you are nearly ready for the big day. Prudence should keep you upright for the next 26.2 miles. Some have said “Start slow, and finish slower”. But that may not be your plan. Make sure you run within your means. Be certain to taper for 3 weeks. And let’s make another list:

• 3 training runs of 18 – 20 miles should have you set for your marathon.
• Taper and run much less for 3 weeks.
• You may gently carbo load. Don’t “deplete”. Don’t gorge. And don’t eat new or spicy foods for the 4 – 5 days before the marathon.
• Sleep well the nights before the marathon.
• Don’t drink too much the night before. Don’t use drugs. (In Woodstock the word was to avoid the brown acid.)
• Don’t take herbal diet or stimulant mixes. They are not checked by the FDA and may have unhealthy contents.
• Hydrate wisely. You may hydrate before the race. Don’t drink till you slosh. Don’t overhydrate. For the slow marathoner, hyponatremia (low blood sodium) from taking in too many fluids is a bigger danger than dehydration. Some races have scales for you to weigh yourself on. If you weigh more as the race goes on, you are drinking too much.
• Wear a medical condition and allergy bracelet or have the information attached to your shoe.
• Eat your regular long run breakfast.
• Warm up gently.
• Don’t start out too quickly.
• Pay attention to your body. Dizziness, faintness, chest, shoulder, jaw pain or tightness should be checked with the medical team immediately.
• Drink and eat foods you’ve used before on your training runs.
• Don’t sit down abruptly at the end of the race. Walk around a bit as a gentle cool down. If you sit, your muscles will likely tighten up and you may not get back up again easily.

General Tips

• Wear shoes that you’ve had good success with and shoes that are broken in.
• Make sure the rest of your clothes are also comfortable and broken in also including your sports bra or other sports underwear, shorts, singlet, sweats and socks.
• Use broken in Coolmax socks or another “wicking” fiber for all of your runs and  on race day.
• Try to get adequate sleep over the last month so your body can be as well recovered as possible from all the training you’ve been doing.
• Eat healthy throughout your training. Don’t overeat  or drink much alcohol  on the night before  your  race. Do eat a carbohydrate rich meal for a few evenings before the marathon.
• Wear outer layer clothes you can throw away as the race goes on and you warm up. If you are going to be at the race line early, dress warm for the morning chill, and be prepared to ditch your outer layers as the race draws near or as you go along and warm up.
• Use the same fluid replacement and  gel that you’ve practiced with on your long runs. Beware of under hydration and over hydration. If you are running for longer than 4 hours, consider using weighing stations if your marathon has them available to attempt to avoid hypernatremia.
• Remember to go out slower than you think you should so you can have a negative split and  not burn out somewhere before mile 20.
• Figure out where some of those cameras will be taking your photo so you can  look  good for your marathon portrait.
• Don’t forget after the race that you should rest about one week before running again and then “reverse” taper.

Things To Bring:

1. Race number  and safety pins. Pin this to your clothes two nights before the race.
2. Running Shoes and all your racing clothes
3. Clothes to toss, if it is cold. Long sleeve teeshirts, sweat clothes.
4. Change  of clothes for after the race.
5. Money for emergencies.
6. Body glide, if you’ve used it for areas  that rub on previous long runs.
7. Your own food for after the race  in case the race runs  low.
8. Plastic  container of water  or sports drink to drink before the race
9. Toilet paper to carry in your carry-along, in case of emergency.
10. Very light  weight, miniature camera if you don’t expect to win.
11. Throw away reading material for the  long  wait before the race.

For post marathon recovery, I have some tips on recovering from the marathon and a reverse taper program.

I just came across the following “tips” video performed by Toby Tanser via Mark Remey at RW

Last Minute Marathon Tips: shot with Nikon D90 from Mike Kobal on Vimeo.

Best quote of the day was by Chris Mcdougall in the New York Times:

“You know any sport has gone off the rails when you have to remove body parts to do it,” said Christopher McDougall, the author of a recent book about ultrarunning called “Born to Run.”

With it’s motto of “all the news that’s fit to print” the Times seems to have not had room to fit the rest of what I’m sure Chris said. First, “Born To Run” is about a quest to run, and Chris’s quest was answered by running barefoot or in minimalist shoes. What I’m sure Chris said was that it might be easier to remove your shoes than have your toenails removed at their roots.

The article highlighted ultramarathoners who had elected to have all of their toenails removed rather than suffer thick nails, ingrown toenails, and bleeding underneath the nails. This is not something that would be done often or by many. It is not something that should really be necessary to do. Many runners, tennis players, and other athletes have problems with “black toe” or bleeding underneath a toenail or two. The first thing to do is make sure there is enough room at the front of the shoe. Be certain you have a fingers width in front of the longest toe. Make sure your socks fit well and don’t pinch your toes. Your socks should be made of a wickable material. Cut your toes just at the end of your toes, not too long, and not too short.

If you’ve developed bleeding under your toenail and it has turned black, don’t panic. If you have Diabetes, or any other medical problem that could cause foot insensitivity or a neuropathy, get to your doctor or some place to be checked fairly quickly. If it hurts see your podiatrist for evaluation and advice. You may gradually have the nail fall off, but the new nail will reattach properly over 90% of the time. With repeated injury the toenail will usually thicken and in some cases it may not attach quite as well.

For toes that repeatedly grow in at the corners, having a portion of the ingrown part permanently removed might be the best option and a wise choice. For a toenail that has fallen off after bleeding underneath, and has a new toenail growing,  the new nail will usually reach the end with no problem. It moves forward slowly like a glacier and pushes the skin down in front of it. On occasion a corner won’t grow out and it will have to be removed. Only rarely does the entire front edge dig in and require removal of the whole nail. But, removing 10 toenails permanently? Sorry, I don’t expect to be doing that any time soon. I’d rather have you toss your shoes, and find a better fit. And Chris would get you out for a barefoot run.

Can Shoes Be “Tiny Coffins”. Yes, they can.

(Please read comment section below. Author Chris McDougall has posted an informative comment and added to the quotes seen in Born To Run.  I’ll extract from the quotes, but be sure to read the comment. (If it says “comments closed”, which the blog does automatically at a set time interval, please click on the blog title which will open this entry in full, with the comments visible.) The thrust of this blog entry will remain the same. For me the deadly shoes I’m speaking of point to the neuropathic foot which was a large part of Paul Brand’s professional life work. )

Paul Brand, M.D. (1914 – 2003) was quoted by Chris McDougall in Born To Run as essentially saying that if everyone stopped wearing shoes, his office would be less busy and most foot problems would disappear in a generation.

Paul Brand 2002

While many may think Paul Brand had an ordinary waiting room, he did not. Brand did not specialize in treating the usual foot problems. He was a brilliant innovator on the special problem of diseases which cause loss of pain sensation via neuropathy.  He worked for many years at the National Hansen’s Disease Center at Carville in Louisiana. He specialized in  the orthopedic treatment of Hansen’s Disease (leprosy). Among other innovations, his work led to contact casting to help heal ulcers in feet with neuropathy, such as diabetics and those with Hansen’s Disease.  He contributed a good deal to knowledge about the significance of neuropathy in the creation of ulcers and to the care of insensitive feet. (Brand also worked extensively on hands with problems related to neuorpathy and insensitivity.) These neuopathies also affected strength rations of opposing muscle groups which often led to significant foot problems including hammer toes and bunions. Insensitivity combined with altered biomechanics, physical deformity, create special problems in walking and wearing shoes, particularly ones that are not fit well and do not serve to balance areas that are overloaded by pressure (pressure points on toes, hallux valgus, or on the plantar surface (metatarsal area or any other part of the bottom of the foot).

Brand worked with patients whose shoes often did create significant and even life threatening problems. Lacking sensation, because of neuropathy, they couldn’t feel the blisters, ulcerations, and infections developing. Another one of his sayings was “Pain is god’s greatest gift”. A shocking statement, but he said that because those lacking normal sensation did terrible damage to themselves.

As tiny coffins in this case, the shoes which caused the problem could lead to an amputation of a foot or leg in a diabetic which would lead to a second amputation more than 50% of the time within 2 years. Amputation in diabetics also is known to have a high mortality rate over 5 years (up to 74%, note that bypass operations may help). Slow healing ulcers have a death from all causes mortality of up to 50% within 5 years. This is worse than many forms of cancer.

Chris McDougall has provided some direct quotes, ( I believe from one of Brand’s biographical works – which will is now added to my reading list.) I’ll add some of those here. For the remainder, please be sure to read the comment section.

“A high proportion of the world’s population walks barefoot most of the time, and the average person who walks barefoot has much healthier feet than the average person who wears shoes.”, said Dr. Brand. Speaking of his own personal experience he said that “The barefoot walker receives a continuous stream of information about the ground and about his own relationship to it, while a shod foot sleeps inside an unchanging environment. Sensations that are not used or listened to become decayed and atrophy. There is a sense of aliveness and joy which I experience walking barefoot that I never get in shoes.”

Chris reports that Dr. Brand said this of normal people in normal shoes. And adds that Dr. Brand was a proponent of barefoot walking and sports. We will accept that as Dr. Brand’s opinion and statement and warn people who do suffer from pain insensitivity to not take this as advice directed at them. They are usually given special advice to not go barefoot, and in many cases to have carefully designed shoes, often custom, with special insoles or diabetic orthotics designed to decrease pressure, and to lessen excessive pressures over areas at risk. In spite of this care problems may still develop and this is only a cursory and incomplete look at these problems and their causes.  Patients with pain insensitivity must perform a self-inspection daily.

I was lucky to meet Dr. Brand in 2002 at the American Podiatric Medical Association meeting in Seattle, Washington. Dr. Brand opened a special section on insensitive feet which included presentations by his former prodigies on their current work. While I spend more time working with athletes, all knowledge is helpful, and Dr. Brand was a true icon.

While I scoffed the other day at  the quote in the New York Times about shoes as tiny coffins that halted evolution, in cases like these they truly are tiny coffins. They could cause your loss of limb and ultimately put you at a much higher than normal risk of death. Seeing the New York Times quote calling them “tiny coffins” did immediately make me think of the neuropathic foot. We’ve previously discussed the cost of amputation. We also see that diabetic ulcers and amputation are also deadly problems.

Preventative care, helpful? Yes, of course.  Make sure it gets properly included in any health care reform. Medicare ( a government run system) includes special shoes, non-custom inserts, yearly foot checks, and some  insurance carriers include this also. Some policies cover custom orthotics for diabetics, but not for runners. The policies and medicare aren’t quite up to speed but they are improving. Make sure that encouraging healthy life habits and preventative care is incorporated in some fashion and included as a core feature in future health policy to assist in decreasing the overall cost of care and in particular the cost of chronic illness. If you are diabetic, get your feet checked regularly, check them yourself, and learn how to both check and care for them. Exercise as recommended by your physician, and make sure you eat correctly, and monitor and control your blood sugar appropriately. Follow advice from your podiatrist on what foot wear  and socks are best for you.

For the runners, I expect you should shortly find here some blogs on what bad can come to you from your shoe, and what steps to take.

References:

Diabetic foot ulcers: prevention, diagnosis and classification.
Armstrong DG, Lavery LA. Am Fam Physician. 1998 Mar 15;57(6):1325-32, 1337-8.

Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial. D. G. Armstrong, L. A. Lavery, S. Wu, and A. J.M. Boulton. Diabetes Care, March 1, 2005; 28(3): 551 – 554.

Revisiting the Total Contact Cast. Maximizing off-loading by wound isolation. Petre, M, Tokar, P, et. al. Diabetes Care  April 2005   vol. 28  no. 4  929-930

The total contact cast. A therapy for plantar ulceration on insensitive feet
WC Coleman, PW Brand, and JA Birke. J Am Podiatr Med Assoc, Vol. 74, Issue 11, 548-552, November 1, 1984

Mortality rates and diabetic foot ulcers. Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. J Am Podiatr Med Assoc. 2008 Nov-Dec;98(6):489-93.

What is the most effective way to reduce incidence of amputation in the diabetic foot? Apelqvist J, Larsson J. Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S75-83.

Diabetes Res Clin Pract. 1997 Jul;37(1):41-7. Mortality following lower extremity amputation in minorities with diabetes mellitus. Lavery LA, van Houtum WH, Armstrong DG, Harkless LB, Ashry HR, Walker SC.

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Moulik PK, Mtonga R, Gill GV. Diabetes Care. 2003 Feb;26(2):491-4.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Faglia E, Favales F, Morabito A. Diabetes Care. 2001 Jan;24(1):78-83.

While you wouldn’t think so, Time Magazine and Rush Limbaugh are on the same reality denying page. Neither the magazine nor Rush are looking at the facts and being fair and balanced on the topic of exercise. Rush, not

Time For Exercise

that long ago, implied that exercise was not necessary, didn’t add to your health, and increased the cost of health care since all those exercising were injured so frequently. Time magazine denigrates the value of exercise and espouses the twisted thought that exercise will not help with weight loss and may lead to weight gain because after you eat, the author felt, you’d be hungrier and would eat donuts and other junk food.

But we have some big problems that are too often overlooked. This is a society where a town, Elgin, is deemed the fattest in Illinois offers $1,000 grants to encourage exercise and fitness and no one applies. We have a county where a public health doctor  is fired who while working for a county agency feels that it is his duty to distribute healthy messages such as “Donuts = Diabetes” and “America Dies On Dunkin” since one of the county commissioners is part owner of a donut shop (and said 2 attorneys were threatening to sue). Dunkin’ Donuts declared themselves happy over the doc losing his job.  And it is the place where a respected weekly magazine hypes on its cover page an anti-exercise piece.  And here we are Rush and Time magazine agreeing strongly on the same wrong headed, mistaken issue and leading people down the path to increased sickness and disease, to osteoporosis, sarcopenia, dementia, colon cancer, congestive heart failure, diabetes, metabolic syndrome and an early death. Those are some of the health problems of which the risks are greatly decreased.

We  are lucky to have Mike Huckabee and President Obama talking about the benefits of  exercise and healthy life habits in lowering the cost of care and improving life quality. We are not lucky in how some of our media portray the importance of exercise, diet, healthy body weight and body composition in improving our health and our lives.

We are a nation with an obesity rate 3.5 times that of Sweden and 10 times that of Japan. Of all large industrialized nations we have the highest rates of overweight and obesity. 65% of our population are overweight or obese. How can we wonder why we spend more on health per individual than most other countries and don’t always have as much to show for it. Health reform seems to scare some of us. Are some scared that healthy habits will be encouraged? Is just feeling good about yourself enough? Or should you be working on healthy living so you can really feel good and reduce your risk of chronic disease?

Recent studies have made it quite clear how healthy life habits can have a major impact on our well being. Studies have also shown that only about 3% of Americans follow 4 simple healthy life habits. (Reeves and Rafferty 2005). Exercise is about more than losing weight. As far as losing weight goes it is considered so important that HHS and the American College of Sports Medicine came out with extensive documentation and guidelines within the last year. Recent research has been so clear I didn’t think anyone could be so foolish that they would deny clear and obvious evidence. But this seems to be a year in which many seem to look for whatever evidence supports the point of view they want to believe, even if the evidence is weak and their point of view doesn’t hold up to critical examination.

We evolved to move and I’m sure that we evolved because we moved and we are still meant to move and exercise. Without movement we become less healthy, get sick, and die short of what should be our full, healthy life span. A few recent studies  have demonstrated “Sitting Disease” and also found that excessive television watching was associated with serious illness and an increase in mobidity and mortality.

The “modern hunter-gatherer” who commutes to work by walking, running, or biking is far healthier than the bus taker, metro using, or car driving worker. The authors conclusions were that “Active commuting was positively associated with fitness in men and women and inversely associated with BMI, obesity, triglyceride levels, blood pressure, and insulin level in men” (Active Commuting and Cardiovascular Disease Risk: The CARDIA Study. Gordon-Larsen, Penny PhD; Boone-Heinonen, Janne PhD; Sidney, Steve MD, MPH; Sternfeld, Barbara PhD; Jacobs, David R. Jr PhD; Lewis, Cora E. MD. Arch Int Med Volume 169(13), 13 July 2009, p 1216–1223

On the podcast “Fitness Rocks”  Robert Salas, M.D., past president of  ACSM said “Our patients will take rat poison to live longer. Can’t we convince them that exercise is good for them?” The rat poison Salas referred to is Coumadin, a blood thinner.

Quick look at exercise, diet, and weight loss:

1)   calories in – calories out are what gives weight change. You should maintain a healthy body weight. And a good body composition too.

2)   Eat multi-colored servings of fruit and vegetables each day.

3)   Don’t smoke

4)   Exercise 30 – 45 minutes 5 days a week. Strength train 30 minutes 2 days a week. And stretch just a bit for good luck.

Facts without hype or hyperbole:

Looking at just a few recent studies we see:

Exercise and Fatness Gene: Amish who have the gene for FTO (one of many obesity genes) have the entire effect of the gene negated by adequate exercise. They don’t become overweight with enough exercise. Moderate exercise such as folding laundry counts, but it takes an incredible amount of exercise to work in this case; 4 -5 hours of moderate exercise per day.

Lifetime risk of heart failure reduced by 50%. (Relation Between Modifiable Lifestyle Factors and Lifetime Risk of Heart Failure Luc Djoussé, MD, ScD, MPH; Jane A. Driver, MD, MPH; J. Michael Gaziano, MD, MPH JAMA. 2009;302(4):394-400.)

Survival and exercise capacity

Those who followed healthy life habits had their risk of heart failure reduced from 50% going from a lifetime risk of about 20% to 10% by adhering to 4 healthy life habits.

Inability to exercise at a vigorous intensity compared to those who are fit is associated with a 260% decline in long term survivability. Or put another way 2.6 times  increase in chance of death. The study compared those only able to exercise or reach a maximum effort level of 5 Mets in comparison with those over 7.1 Mets and 10 Mets.  (Circulation. 2008;117:614-622. Exercise Capacity and Mortality in Black and White Men. Peter Kokkinos, PhD; Jonathan Myers, PhD; John Peter Kokkinos; Andreas Pittaras, MD; Puneet Narayan, MD; Athanasios Manolis, MD; Pamela Karasik, MD; Michael Greenberg, MD; Vasilios Papademetriou, MD; Steven Singh, MD)

There are many more examples of why exercise and healthy life habits are important and vital keys to your future health, well being, and life. Each week more studies are published demonstrating this. Earlier this month I gave a lecture at the annual American Podiatric Medical Association meeting in Toronto entitled “Exercise: Good For What Ails You”. References and links to resources are available at the previous hyperlink. If I sit still long enough, I may be convinced to voice over the lecture and post the slides online.

References:

Healthy Lifestyle Characteristics Among Adults in the United States, 2000 Mathew J. Reeves, PhD; Ann P. Rafferty, PhD. Arch Intern Med. 2005;165:854-857.

Active Commuting and Cardiovascular Disease Risk: The CARDIA Study. Gordon-Larsen, Penny PhD; Boone-Heinonen, Janne PhD; Sidney, Steve MD, MPH; Sternfeld, Barbara PhD; Jacobs, David R. Jr PhD; Lewis, Cora E. MD. Arch Int Med Volume 169(13), 13 July 2009, p 1216–1223

Circulation. 2008;117:614-622. Exercise Capacity and Mortality in Black and White Men. Peter Kokkinos, PhD; Jonathan Myers, PhD; John Peter Kokkinos; Andreas Pittaras, MD; Puneet Narayan, MD; Athanasios Manolis, MD; Pamela Karasik, MD; Michael Greenberg, MD; Vasilios Papademetriou, MD; Steven Singh, MD

Sitting Time and Mortality from All Causes, Cardiovascular Disease, and Cancer. Katzmarzyk PT, Church TS, Craig CL, Bouchard C Med Sci Sports Exerc 2009 Apr 3

Rampersaud, E., B. D. Mitchell, et al. (2008). “Physical activity and the association of common FTO gene variants with body mass index and obesity.” Arch Intern Med 168(16): 1791-7.

Outside Link:

Tom Venuto on Why Time Magazine Owes the Fitness Community a Big Fat Apology

Bonus Music:

Anime: Move Your Body

Old School Moving: Rolling Stones – You Got To Move

Audio Reference: Rush On Exercise

I had the opportunity to speak at the American Podiatric Medical Association’s Annual Scientific Seminar this weekend. The American College of Podiatric Sports Medicine also held it’s annual meeting here in Toronto. The meetings were excellent. And, as always, it gave me the opportunity to see many people who I cannot often visit with. Old friends, new friends, very old friends, and students from many years ago were all a pleasure to see. There were several people who because of time constraints all we could manage was a hello. The lecturers were excellent. And the ones I enjoyed the most were given by friends I’ve heard lecture many times. But, of course, I did enjoy some other lecturers who I had not heard speak before. Unfortunately, there is never enough time to really visit the city in which the conference takes place. But the people I met in Toronto were all great and friendly.

My lecture was titled “Exercise: Good For What Ails You”, but that was the take off point. I promised there would be resources online that I’d link to and the start of that is available. I plan to place large parts of the lecture including the text (minus some images) of the slides, along with a recording of it (minus some of the humor) online. Hopefully in an expanded version.

In the meantime, I’ve placed selected references and links to articles that cover some portions of the lecture. Many of those articles were here on the blog. More are in the making.

Supplemental materials for “Exercise: Good For What Ails You”

It just doesn’t add up when you mix and match numbers that aren’t meant to be simply added together. When you have numbers that represent things that can’t be merely added together and derive from different measuring systems, you can’t simply join them together. If you thoughtlessly and carelessly put the numbers together, you could crash a space landing craft, as happened when meters and feet were jumbled together by NASA and NASA’s private industry contractors some years back. In 1999, this resulted in the Mars Climate Orbiter plunging and crashing onto the surface of Mars. And that was “rocket science”.

The numbers I’m talking now  are health care cost numbers that have been bandied about both left and right. The latest bit of what I call the 3 D’s (dumb, deceptive, and dangerous) of thinking and posturing was seen in David Broder’s column today in which he quoted Democratic Senator Ron Wyden (D Oregon) as saying:

“As you look at what is being proposed [in two Senate committees] you don’t see savings in the 10-year budget. That’s why the discussion has shifted to finding new money to finance expanded coverage. But at home, when you tell people we’re already spending $2.5 trillion a year on health care and now we’re going to spend $1 trillion more, it just doesn’t add up.”

No, unfortunately that doesn’t add up at all. Nor should it. You can’t take a yearly figure, the $2.5 trillion dollars and then seemingly add $1 trillion more to it and now you don’t make any sense at all. And this comes from a democratic senator who 3 years ago proposed his very own healthcare and health insurance reform bill. His bill declared savings of over $1 trillion over 10 years. The savings was declared by having the cost not climb by the amount it would have been anticipated to climb over that period. This form of logic and calculation has been used by nearly everyone speaking about healthcare costs. We’ll let it be. But both Weyden and Broder should know better than to jumble these numbers up in such a deceptive manner.

You can’t take a yearly figure and then add to it a 10 year cost to it, pretending that the 10 year cost is an annual, yearly expenditure. That is deceptive and dangerous, and likely calculating rather than merely dumb. It is intended to mislead rather than enlighten. We shouldn’t expect that from elected officials, representatives to government, appointed officials, pundits, talk show hosts and participants. Nor should it be acceptable from columnists both noted and those of little renown, nor should it come from bloggers. Yet this sort of unexamined rhetoric and misleading numbers appears often. I have no explanation for this phenomena.

Certainly there are good features in Weyden’s program. Many of these I wrote about back under Bush 41. A more global amortization of costs and risks, elimination of prior existing condition clauses and more. And Wedyen specifically promised a plan as good as what those in the federal government have. And that is a very fair, and well administered system. But that was great 20 years ago. We do need something outside the current system to serve as a model, example, and fail safe system. And we do need it to be cost effective.

We need to cut health care costs. We need to lessen the risk of chronic disease. We need any addition to the system to be paid for in some manner by itself. We also need to look at the costs to the economy of chronic illness, absenteeism, lack of productivity caused by illness. We need to look at the costs to the economy of health related bankruptcy. We need to examine the health fairs, such as those in Tennessee where people come from several states away to sit and stand in lines of people, hundreds long, to receive treatment in groups inside tents giving the appearance of an American refugee camp. There is more, but you’ve seen it elsewhere and either related to what you’ve read or ignored it.

There are a few proposals that may help control costs. The first was a bill proposed in the senate that the premiums charged (yes, there will be and should be premiums charged) for a government system should be at acturarial prices. The other proposals include what may ultimately be cost savers such as shared electronic medical records, and incentives for healthy lifestyle. Of course in some camps the term “lifestyle” has other connotations. But here and where it is applied to heathy living choices it means:

1. No smoking.
2. Healthy body weight.
3. A healthy diet including a variety of vegetables eaten every day.
4. Meet the recommended exercise requirements:
5. 30 minutes of moderate exercise x 5 days per week or 20 minutes of vigorous exercise x 3 days per week (Not enough in my book. I think you should add 10 minute warm up and 5 minute cool down to high intensity training. But then you are actually exercising for 35 minutes.)

Exercise is one of the most important components of a cost reduction plan for health care. In combination these items would all help reduce the incredibly high 65% over weight and obese figures for the U.S. adult population. Childhood obesity also bodes poorly for the future. As we compare these numbers and our health care dollars spent with other nations, one could observe that we far “out weigh” the other nations. Along with obesity, an awful diet, and a loss of regular physical education in schools we are becoming sicker at earlier ages and less productive as individuals and a nation. The costs of chronic disease occurring earlier in life than they should if one adheres to the 4 healthy life habits are an incredible economic burden. A delay in onset of chronic disease, meaning it will occur later in life, and compression of illness, meaning it appears so late in life, that you don’t suffer for years and years with the chronic disorder, will dramatically reduce the cost of the chronic diseases to society.

According to the peer reviewed journal article by Reeves and Rafferty (2005), only 3% follow the healthy life habits mentioned above. So get a move on, shape up, and help reduce health care costs. And don’t forget that we do need a lean, efficient, and effective health care system. This means changes and reform. And perhaps a blog entry entitled the “7 Habits of Highly Effective and Healthy People”. We’ve got 4 above, and I have no problem suggesting another 3.

References on Fitness, Life Choices, Health, and Chronic Diseases

1. Reduced Disability and Mortality Among Aging Runners: A 21-Year Longitudinal Study. Chakravarty, Eliza F. MD, MS; Hubert, Helen B. PhD; Lingala, Vijaya B. PhD; Fries, James F. MD. Archives of Internal Medicine. Volume 168(15), 11/25 August 2008, p 1638–1646
2. Effects of Exercise Modality on Insulin Resistance and Functional Limitation in Older Adults: A Randomized Controlled Trial. Davidson, Lance E. PhD; Hudson, Robert MD, PhD; Kilpatrick, Katherine MD; Kuk, Jennifer L. PhD; McMillan, Kathleen MSc; Janiszewski, Peter M. MSc; Lee, SoJung PhD; Lam, Miu PhD; Ross, Robert PhD. Archives of Internal Medicine: Volume 169(2), 26 January 2009, p 122–131
3. Effect of a lifestyle intervention on change in cardiorespiratory fitness in adults with type 2 diabetes: results from the Look AHEAD Study . Jakicic, J.M., Jaramillo, S.A., Balasubramanyam, A., Bancroft, B., Curtis, J.M., Mathews, A., Pereira, M., (…), Ribisl, P.M.    2009    International Journal of Obesity
   Article in Press. 20 January 2009; doi:10.1038/ijo.2008.280.
4. Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Luft, A.R., Macko, R.F., Forrester, L.W., Villagra, F., Ivey, F., Sorkin, J.D., Whitall, J., (…), Hanley, D.F.    2008    Stroke; a journal of cerebral circulation 39 (12), pp. 3341-3350
5. Laukkanen JA, Kurl S, Salonen R, et al. The predictive value of
   cardiorespiratory fitness for cardiovascular events in men with
   various risk profiles: a prospective population-based cohort study.
   Eur Heart J. 2004;25:1428–37.
6. Katzmarzyk PT, Church TS, Blair SN. Cardiorespiratory fitness
   attenuates the effects of the metabolic syndrome on all-cause and
   cardiovascular disease mortality in men. Arch Intern Med. 2004;
   164:1092–7.
7. Physical Activity and Coronary Heart Disease in Men: The Harvard Alumni Health Study . Sesso, Howard D. ScD; Paffenbarger, Ralph S. Jr MD, DrPH; Lee, I-Min MBBS, ScD
   Circulation Volume 102(9), 29 August 2000, pp 975-980
8. Healthy Lifestyle Characteristics Among Adults in the United States, 2000. Mathew J. Reeves, PhD; Ann P. Rafferty, PhD.  Arch Intern Med. 2005;165:854-857.

Health care reform of some sort is in the making for this year. The shaping of it probably should not be a political issue, but should be instead an informed decision made with wisdom.

Before medical procedures are performed a consent form called “informed consent” is read, (mostly) understood, agreed to, and signed. All speakers at medical conferences and authors of articles appearning in medical journals are required to disclose conflicts of interest before speaking or publishing. These declarations are made in public, in clear and open view of all. The declaration appears on the first page of each journal article and in programs and from the podium prior to each lecture, by the lecturer.

Our discussion of these issues both in the media and among members of congress and others with specific axes to grind and political preferences are not obligated to make any disclosures. From the democratic congress person receiving mega bucks to the republican senator receiving similar funds for campaigns, there is no requirement before making a statement to announce how much financial support they have received. Former members of congress do not make these declarations nor do they state what boards they sit on or organizations they’ve founded.  The news media does not state what their interests and conflicts are.

Yet, this debate should be beyond conservative and liberal. It should be between sense and nonsense. It should be what will be the best possible system in all regards versus a system of appearances that serves only those with the most money to spend lobbying and the most money to make. The debate between single payer and traditional insurance is over. We do need to consider though including a public option within the reform we will be making.

The obvious necessities will be in this plan. Elimination of prior existing condition clauses, better control of health care savings programs, and a wider, geographically based,  more inclusive amortization of costs will likely be implemented. These could have been implemented years ago. The usual recent buzzing issues that will be included are electronic record keeping, decrease in over utilization of tests and radiology services, and decrease billing  and other fraud within the healthcare system. This year physicians are required to make sure that their patients do not appear to be committing identity theft. We’ll see what next year brings.

A public insurance option be made available would set a minimal standard and put some pressure on the insurance industry to conform to at least this minimal standard and  to do so without deception in all of their plans. Some have declared that a government plan will cost people little but provide bad care. People don’t want bad care, although they would like less expensive care. Many have learned that cheap and bad care are not worth much at all, and would  be happy with something that works, is trustworthy, and isn’t necessarily at a rock bottom price. Newt Gingrich is now a prominent spokesperson on health care reform. He is one who has often stated that a government run health care program will be too expensive to the nation and provide miserable care for patients. He has recently amended that to also declare that it would drive insurers out of the market place.

Appearing recently on MSNBC  Gingrich said, “I think when the average American looks at the idea that we’re going to have a government bureaucrat decide whether you get, or your daughter, or your granddaughter gets the treatment you need, if you look at the death rate from breast cancer in Great Britain and the death rate from breast cancer here, I don’t think that’s a model we’re going to accept.”

The reality is that there is no way that traditional insurers will be eliminated. There is much they can do to make their programs attractive and have sufficient value added service to make them desirable for many. I do have a fair number of ideas on what they can do to be more attractive than a government run system, and I’m sure they have others making suggestions. They also have considerable power to market and to lobby and to even join the organization the Newt Gingrich founded the “Center For Healthcare Transformation”. The corporate members and even the existence of this organization is not often mentioned, if ever, when Gingrich is quoted in the media or appearing on a news show. The corporate members are not an absolute secret. A list is available online.

There is no need for traditional insurers to fear for their existence. They will survive, live long and likely prosper.

But for many people another option is required and that option is a public health care option. It shouldn’t and won’t be free but some will feel more comfortable within that system than what they have experienced within the current traditional system. The next area of concern is how to pay for it. Certainly part of the cost, and perhaps much of it may be borne by those who buy in to the plan. And that is how it should be. Do we need to increase taxes elsewhere? Do we need to tax other peoples health care plans? To me taxing others health care plans does not make sense.

A public option for health care does not have to follow any other model precisely. It doesn’t need to follow Canada, Switzerland, Sweden or the U.K. We have a specific set of expectations from our health care system that are different from our friends and neighbors. And “Freedom of choice” is a resonant slogan. We can work in freedom of choice, carefully defined benefits, prescription drug coverage, and choice into a plan.

How else can we cut costs? One way is to decrease the cost involved in caring for chronic disease. But, let’s save that for an upcoming blog. And, I’ll bet fitness and healthy lifestyle choices come into play. In the meantime, ask not what your health insurance company can do for you, ask what it will take to get some more options.