Wednesday, August 29, 2012

Care of the Diabetic Foot


By Rodney Snow, MD
Diabetes is a major problem that we deal with in the United States and Alabama is certainly one of the states near the top of the list with a large percent of the adult population that are diabetics. In the U.S. it is estimated that up to 17% or more of the adults are diabetics. Close to 14% of all US health care expenditures are related to diabetes and its complications with about half of the cost related to complications such as heart attacks, strokes, kidney failure including dialysis, degrees of blindness (diabetic retinopathy) and diabetic foot ulcers (DFU) with various levels of amputation.
Human nature is such that most do not even think about their feet unless an issue developed that causes pain or some other issue that gets our attention. We just take our feet for granted and move along. Any diabetic that develops a foot ulcer (DFU), no matter how small or simple can result in that person losing their leg. It is estimated that the lifetime risk of the diabetic getting diabetic foot ulcers or other foot complication is up to 25%; therefore 25 out of 100 diabetics are going to get a foot ulcer that can lead to loss of their limb.
Diabetic peripheral neuropathy is the main factor that leads to diabetic foot issues with risk of ulceration and then possible limb loss along with peripheral arterial disease. To prevent peripheral neuropathy controlling of one’s blood sugar is vital. Elevated blood sugar leads to the development of neuropathy in various ways, which causes damage to the nerves. It usually develops first in the feet, distally in the toes progressing up into the legs and later into the hands. However, all nerves in the body can and will be damaged over time. The neuropathy leads to damage of the sensory nerve function so there is gradual loss of sensation or feeling in the foot that’s why it’s is so important in protecting the foot from injury. We all learn to not do something when it causes us pain, such as touching a hot stove in which we learn not to repeat that behavior. The loss of protective sensation in the foot from the diabetic neuropathy allows trauma and injury to occur. In addition, the motor nerve function is also damaged so there is weakness in the muscles and the muscles get smaller especially in the foot. This allows deformities in the foot such as hammer toes or claw toe deformity to have more pressure in one location over another on the bottom of the foot allowing callus formation. In addition, neuropathy affects the nerves that regulate the sweat glands and regulates the micro blood flow in the skin. The diabetic foot becomes dry leading to cracks and scaling of the outer layer of skin. With the deformities, shoes will not fit properly leading to areas of pressure and or friction that leads to blisters and calluses. The blister can open, getting infection and or causing an ulcer to develop.  A crack can occur in the callus which can get infected leading to an ulcer. Without protective sensation, even minor trauma can lead to issues because with no pain the trauma is overlooked until it is noticed from bleeding or infection.
When the diabetic patient sees his primary care provider he should go ahead and take his shoes and socks off at each visit for foot inspection.  At least once each year a complete examination of the feet should be done. The diabetic patient should ask for the foot exam each year. In addition, blood flow to both feet should be assessed. When sensory function is altered, different foot ware should be considered.  Shoes should be wide and deep enough to allow for custom inserts, to distribute the pressure on the bottom of the foot more evenly. With the mechanical wear and continuous changes that occur in the foot, shoes and inserts need reevaluation at least every six months.
The diabetic patient should be educated and understand their responsibility to check their feet daily and take proper care of them, if the individual wishes to keep them over time, along with blood sugar control, diet, and not smoking, which accelerates artery damage. One should avoid activities that can injure the feet such as walking barefoot or even in sock feet, using a heating pad, hot water bottle, or putting ones feet on a furnace vent or near a space heater. Do not step into a bathtub or soak ones feet without testing the water temperature. Do not spend extra time on ones feet looking for other ways to ambulate or exercise. Trimming nails and other bathroom surgery that leads to breaks in the skin on the feet should be avoided, allowing Podiatry or other healthcare providers to do even the minor procedure. Feet need to be washed daily in lukewarm water with a mild soap (such a Dove®) and apply generously moisturizing lotion or cream. Because of the dryness it will require application of the lotion or cream more than once daily. The diabetic must check the entire surface of both feet for skin breaks, blisters, swelling, or redness, including between and underneath the toes where damage may be hidden. Use a mirror, if it is difficult to see all parts of the feet or ask a family member or caregiver to help. Select cotton socks that fit loosely, and change the socks every day. Select shoes that are snug but not tight, and break all new shoes in slowly to prevent any blisters. When blisters develop, do not open them and get pressure off that area to allow the blister to heal.  The top layer of skin comes off on its own. Keeping calluses soft as possible and filed down, prevents the build of additional callus and development of a blister underneath or cracking. Most diabetic foot ulcers develop from blister or calluses.
If an ulcer develops, the time to get it healed is when it is first noticed. Seek medical attention and keep in mind antibiotics alone will not heal the ulcer. Remember that one should not be able to walk without pain with an ulcer on their foot. This is the problem, the lack of the pain from the neuropathy. For the ulcer to heal, the pressure must be taken off of the ulcer so the patient must not walk on the ulcer or some method must be provided to relieve that pressure.  If not, the ulcer will not heal and will get larger and deeper, with infection developing at some point. The price for healing must be paid and with the lack of pain, our mind must guide us to accomplish the appropriate things needed for healing, to prevent a greater price that could be prevented.
 

Thursday, August 23, 2012

Single Site Robotic Gallbladder Surgery

By John Touliatos, MD with Advanced Surgeons, P.C.


Surgery to remove the gallbladder is one of the most common operations performed in this country by general surgeons with over 4,000 being done in Alabama alone. Patients typically present  with pain in the right upper abdomen after eating a fatty meal. This pain can be quite intense, often sending patients to the emergency room for evaluation. Food (especially fatty foods) stimulates the gallbladder to contract to aid in digestion. When a patient has gallstones, intermittently these stones will block the outlet to the gallbladder causing pain which can last from several hours to all day. The only treatment for this is to remove the gallbladder along with the stones it contains.
This procedure was first accomplished with the laparoscope in 1989, which changed the course of history as it relates to general surgery. This advance in technology leads to decreased pain, decreased recovery time, and an improvement in cosmesis over traditional open surgery. It wasn't long before more and more procedures were being done with this new technology with similar results for a myriad of diagnosis and surgical diseases.
The Da Vinci Robot has taken that a step further with its introduction of the single site platform for gallbladder surgery. Trinity Medical Center was the first in Alabama to apply this technology and at the time of this writing have done over 30 of these cases. The technology allows us to perform the same operation, with the same safety profile as in traditional laparoscopy, but it does this with improved cosmesis. The incision is nearly completely contained within the umbilicus (belly button) and is virtually invisible when healing is complete. In my opinion, there is no other technology that allows for this approach in virtually every patient that desires it. I also believe that this is the tip of the iceberg as many other procedures will be performed using this single site (incision) technology and we are happy to be on the leading edge offering this to our patients.

Monday, August 20, 2012

Multi-modality Approach to Knee Pain Workup


By Jonathan Davis D.O.
Board Certified Radiologist
Birmingham Radiological Group P.C.

Your at the gym enjoying the treadmill and have been progressing nicely with your workout routine and you start noticing a slight pain in your knee. You work through it and finish your work out. Over time the twinge in your knee starts to worsen and starts to affect your life style. How common is the above scenario? For quite a few of us this is common place.  65% of Americans age 18-34 are dealing with knee pain and decrease in function secondary to knee injuries. How does your primary care physician or Orthopedic surgeon work up your knee pain? First and foremost they will perform a physical exam and allow a focused diagnostic work up leading to the proper diagnosis.
            The diagnostic work up for knee pain from an imaging standpoint is varied and certain imaging modalities are useful for certain structures and not necessarily other structures of the knee therefore there will be a multi-modality approach to your symptoms. One misconception of imaging is MRI will be able to diagnose all of the problems of a joint. While MRI is a key imaging component X- Ray also plays an important roll. Why you may ask. MRI ( Magnetic resonance Imaging) uses the water that is naturally in our bodies to generate the images in conjunction with Radio frequencies. Now, this allows the ligaments and tendons to be evaluated as well as the cartilage and the bone marrow. Well, that sounds like the majority of the joint for imaging one would say. We are however leaving out a very important component, the actual cortex of the bone. The hardened bony structures do not have enough water to be imaged well on MRI. To image this important portion of the joint Plain X-ray, or Computed Tomography comes into play.  Finally Ultrasound can be used as well in a limited fashion to evaluate certain tendons.
            Now to review a few basic and common knee injuries and problems that affect us and how we work them up from a diagnostic standpoint. First and most common is osteoarthritis. This is one the most common findings. As we age this is something we all will encounter to one degree to another. From an imaging standpoint the cartilage which acts as a “bumper” between the femur and tibia begins to wear out and thin which in turn allows the concussive force of walking or running to transfer to the adjacent bone. This causes edema (bone bruising) and pain. Now the body responds by laying down more bone in these regions caused osteophytes (bone spurs) which compounds the problem. The knee will also respond by producing more fluid in the joint due to the irritation. As one can see this is cyclical and trying to interrupt the natural body's response to the chronic changes is one way your physician will try to treat this problem. At some point your Orthopedic surgeon may recommend a joint replacement if the arthritis has progressed to the more extreme case. Plain film x ray can be used to effectively diagnose this problem.
             Next we will discuss injuries to the  knee. One of the more common injuries are tears of the meniscus which are small “cups” on the periphery of the tibia that the femur nestles into. These injuries can cause pain, limited range of motion and clicking/locking of the knee based on the type of tear and location. To image this portion of the knee MRI is used quite effectively. Anterior cruciate ligament tear ( ACL tear) is the next common injury seen in the knee. The anterior cruciate ligament sits in the mid portion of the knee and does not allow the tibia to translate (slide) anterior. This injury can cause pain and loss of stability of the knee and based on you activity level your orthopedic surgeon may repair this injury. Next there are collateral ligaments of the knee which can be strained or torn. These structures reside along  the medial (inside) and lateral ( outside ) of the knee and stabilize the knee from abduction/ adduction motion of the lower extremity. MRI is well suited for diagnosing these injuries.  Stress fractures from repetitive micro trauma can cause pain and limited range of motion. This can be diagnosed with MRI as well. There multiple tendons that insert at the knee from the proximal thigh and tendons that arise from the knee extending to the lower extremity. The tendons can be torn or strained and MRI can pick up changes in these tendons allowing your physician to tailor a treatment plan to your injury.
            So as you can see the multi-modality approach of the work up of knee pain is used to quickly and accurately diagnose the problem and to structure a treatment plan using first and foremost the physical exam augmented with plain film and MRI.  The diagnostic imaging used by your physician will be tailored to your symptoms and physical exam findings to get you back in the game and enjoying life.

Thursday, August 16, 2012

Neuropsychology: Understanding Cognition

By DeLisa A. West, Ph.D., ABPP (CN), West Neuropsychology, LLC 205-453-9888


How often do you walk into a room and completely forget why you went into the room? Or do you struggle with remembering someone’s name a few seconds after they introduce themselves to you? It seems that these “senior moments” occur more frequently as we all get older. As a clinical neuropsychologist, I am often asked if this is normal aging or if it is a sign of a bigger problem such as Alzheimer’s disease.  The field of neuropsychology is uniquely skilled to answer this very question. Clinical neuropsychology is a sub-field of psychology which examines the relationship between the brain and behavior. It uses neuroscience, neuroanatomy, cognitive psychology, cognitive science and clinical psychology to understand the structure and function of the brain in relation to behavior and the information processing aspects of the mind. Neuropsychologists help to assess, diagnosis and treat individuals with neurological, medical, developmental or psychiatric conditions across the lifespan. Neuropsychological testing can aid in understanding how different areas of the brain are working. Neuropsychologists use various standardized tests to objectively examine a person’s strengths and weaknesses in all areas of thinking or cognition. Tests may be paper-and-pencil, answering questions, computer-based or task oriented. Areas of cognitive impairment or deficit can be identified and placed within the context of the individual’s medical and psychological history in order to determine what condition may be impacting a person’s functioning and thinking. 
Typically testing is requested if symptoms or complaints involving memory or thinking are noticed by individuals, their family members or healthcare professionals.  A person’s performance on each test is compared to those who are similar (e.g. same age, level of education, etc.) to decipher whether there are areas of thinking that are poorer than would be expected as compared to the person’s healthy peer group. The pattern of performance can show whether there has been a change in thinking in certain areas. A neuropsychological evaluation assesses all areas of our thinking including but not limited to:
·         General Intellect
·         Attention and Concentration
·         Language Skills (e.g. language comprehension, etc.)
·         Visual-spatial Abilities (e.g. perception)
·         Motor and Sensory Skills (e.g. fine motor skills, etc.)
·         Learning and Memory (e.g. ability to learn, retain and retrieve information)
·         Executive Functioning (e.g. reasoning, problem solving, organizing, etc.)
·         Mood and Personality (e.g. depression, anxiety, etc.)
Neuropsychological testing is sensitive to mild changes in thinking that might not be obvious in casual situations or conversations. Testing can identify whether changes are normal age-related changes or if they are related to a medical or psychiatric condition. Different conditions or illnesses can manifest themselves in different patterns of cognitive strengths and weaknesses on testing that can then aid in determining the most appropriate course of treatment. For example, testing can demonstrate different patterns among Alzheimer’s disease, stroke or depression. Once the cause of the deficit is identified then specific treatments can be chosen by the healthcare team. Neuropsychologists also assist with the management and rehabilitation of those who are suffering illness or brain injury which has caused cognitive difficulties. Additionally, they can provide helpful compensatory cognitive strategies as well as emotional support for adjustment to illness.
Current trends in the field involve neuropsychologists focusing on individuals with specific conditions. For example, neuropsychologists assist athletes with identifying whether they have experienced substantial cognitive problems secondary to sports-related concussions and whether they should return to sports given any cognitive difficulties identified. Attention difficulties can be examined to determine whether they are consistent with Attention Deficit/Hyperactivity Disorder (AD/HD) or other conditions such as depression, anxiety, etc. Neuropsychologists who work with older adults can answer whether cognitive problems are secondary to normal aging or various dementias such as Alzheimer’s disease. Approximately, one in eight older Americans has Alzheimer’s disease and memory and cognitive changes are the most prominent early symptoms. Neuropsychological testing can provide concrete data as to the severity and progression of cognitive impairment caused by Alzheimer’s disease. In addition, neuropsychologists provide recommendations to individuals and their families in regards to planning for future cognitive decline and the need for assistance with daily tasks. Neuropsychologists play a vital role on rehabilitation teams who work with individuals with traumatic brain injury (TBI) as questions as to the person’s cognitive ability to return to independent living or work are raised.  Different types of stroke or brain tumors can negatively impact a person’s thinking abilities and neuropsychological testing can aid in identifying any areas of cognitive impairment which may hinder a person’s ability to independently function (e.g. driving, manage finances, etc.). Psychiatric disorders such as Major Depression can cause changes in thinking which differ in pattern from other neurological conditions and neuropsychologists can help decipher what impact emotional conditions have had on a person’s thinking. They also can focus on working with children and adolescents to determine whether developmental disorders are affecting learning and thinking.
Often individuals are not sure what is causing their problems yet they know that something is not going well with their thinking.  Neuropsychological testing can help with determining:
·         Does cognitive impairment exist?
·         Does the pattern of impairment in the context of the person’s history suggest a diagnosis?
·         What are the real-life consequences of this impairment (e.g. need for assistance, medication, etc.)?
Neuropsychology: a specialty discipline that provides detailed cognitive data to guide healthcare treatment.  






Monday, August 13, 2012

Concussions in Young Athletes



By Dr. James Johnston, MD, Assistant Professor of Neurosurgery, University of Alabama at Birmingham and Children’s of Alabama.

Concussion has been in the news a lot lately, with stories detailing chronic traumatic encephalopathy and early dementia in retired NFL players and concerns about cognitive development in younger children.  Given its newly recognized prevalence and possible connection to long term neurological sequelae, prevention and recognition have become major priorities in the sports and medical communities. It is important that parents, coaches and athletic trainers know the symptoms of concussion and seek medical attention when concussion is suspected.  The most common symptoms of concussion are headache, nausea, dizziness, blurry vision and confusion.

Fewer than 10 percent of athletes who suffer from a concussion lose consciousness, and these other symptoms are often overlooked. While most people heal quickly and fully after minor head injuries, new research published in a recent issue of The American Journal of Sports Medicine http://ajs.sagepub.com/content/early/2012/04/26/0363546512444554.abstract?sid=17882163-1d9c-4b64-8b60-05865a378d18  suggests that young athletes may be particularly susceptible to the damaging effects of concussion, such as memory and attention problems, and may require more recovery time than adults. If left untreated, concussions or repeated head injuries can lead to more serious problems.

Concerns over the long-term effects of head injuries in professional athletes have prompted many states to take a more aggressive approach to ensure the safety of young players. Last year, Alabama joined more than 20 other states in passing a law that that requires removal of a player from the field of play if a concussion is suspected until he or she is examined by a licensed physician and receives written clearance for return to play.

As a result, many physicians in the community have seen more young athletes this year with suspected concussion. At Children’s of Alabama, as an example, the number of unique patients we treated for concussion increased from 51 between August 2007-July 2008 to 319 between August 2011-July 2012.

Evaluation of the concussed athlete should include a formal neurological exam and updated concussion assessment form like the Acute Concussion Evaluation (ACE) or Sports Concussion Assessment Tool (SCAT 2). Return to play should then follow a supervised incremental increase in activity without recurrence of symptoms before full return to impact sports.

In support of this effort, Children’s and UAB have established the Concussion Clinic to provide specialized medical care for young athletes, to educate parents, coaches and athletic trainers about the symptoms and management of concussion, and conduct research to better understand mild traumatic brain injury.

For more information and to obtain concussion assessment materials and return to play guidelines for young athletes, go to our website: http://www.childrensal.org/concussion. The Concussion Clinic is located at UAB Sports Medicine at Children’s of Alabama, 1600 7th Ave. S., Birmingham. Appointments can be made by calling 205-934-1041. 

Thursday, August 9, 2012

‘All in' the Family Medicine Paradigm


By Micah Howard M.D., UASOM Class of 2010

Those of us lucky to don the long white wardrobe have many to thank; our families, our mentors and the lineage of trailblazing physicians that came before us. The profession has always been one of service, and that is what I want to remind us of. We are in service to those needing assistance with the ills of life, and we assist in dissolving impediments to the powerful healing process that is intrinsic to human-kind. 

“A clinician is not someone whose prime function is to diagnose or to cure illness, for in many cases he is not able to accomplish either of these. A clinician is more accurately defined as one whose prime function is to manage a sick person with the purpose of alleviating, most effectively, the total impact of illness upon that person” - Nicholas J. Pisacano M.D.

Who was Nick Pisacano, MD? 
He was the man who through fierce devotion and perseverance founded the American Board of Family Practice and served as its Executive Director from 1969 until 1990. He believed in striving for an excellence that would be ultimately measured by the impact of the specialty on the health of the patients. He was well-read and even more well-spoken. His words remind me of a greater good I promised to give such a short time ago. When my job is dealing with the increasing complexities of health insurance litigation and the endless bombardment of pharmacologic marketing, I lose track of those ideals. So here I am, before your eyes, reuniting myself with the better part of my work, and in hopefulness inspiring others to join in their promise.

"The time has come when we must act to save medicine as a profession. We not only owe it to ourselves and to the youngsters who follow us, but we owe it primarily to the public, who needs a revered profession. Physicians as a group must reconsecrate ourselves to those ancient and cherished values of caring and giving. We must enforce continuing competence and proficiency, but, above all, we must rededicate ourselves to public service. We should embrace super-specialism and high technology only as they contribute to the welfare of human beings. We welcome and support scientific inquiry and new technology, but we must maintain a healthy balance between those advances and humanism. Let us not be drawn into mediocrity. Let us show the people that we hold high the staff of Aesculapius and that we can, and will, care for all who enter the health system with equal concern and caritas. These proposals are not foolish dreams. If we act to reconsecrate ourselves as physicians, think of the good that would be accomplished; think of what the public's image of us would be -- but most important, think of how you would feel -- Doctor!"  - Nicholas J. Pisacano M.D.

Family Medicine is now is more broadly distributed across the U.S. than any other specialty, with over 450 residency programs and over 120 academic departments. It is respected, well defined, and teaches the skills that allow a physician to confront large numbers of unselected patients with unselected conditions, and to carry on therapeutic relationships over time.

I am part of a group of specialized physicians that proudly focuses on:
–  Complaints which are obscure, vague, or undifferentiated 
–  Complaints which arise from potentially life threatening disease that has not yet been diagnosed 
–  Complaints which are out of proportion to physical or laboratory findings 
–  Complaints which are unusual, bizarre, non-physiologic, or non-anatomical 
–  Complaints which are persistent and disabling 
–  Complaints associated with marked anxiety or mood change 
–  Complaints which result from life change, conflict, or other family or social change 
–  Conditions which are incurable 
–  Conditions involving habits and the lifestyle of the patient 

I give my thanks to those that paved the way, and pledge my service to the intellectual and compassionate ideals that they held in highest regard. Our revered profession is one of grand sympathy and eternal conquest for deeper understanding of humanity. We all took the oath, and to our patients we must be true.

“Today we cure this patient, then her family, then the community, then the country, then the world” - Nicholas J. Pisacano M.D.

Micah Howard M.D.
@micah_howard

Monday, August 6, 2012

Social Media in the Workplace: the Good, the Bad, and the Very Ugly

By Daniel J. Burnick of Sirote & Permutt, PC


When I tell people that I am an attorney at Sirote, they usually ask what type of law I practice.  My response is Sex, Drugs and Rock and Roll.  After a little chuckle, I add that I do employment law, defending employers on claims of harassment, discrimination, retaliatory discharge and other employment related cases.  I also counsel clients on policies and procedures that I believe are necessary in today's workplace.  The use of Social Media (SM) is one of those areas that is often overlooked, and can lead to results that are good, bad or very ugly. 

Medical professionals may be asking what does SM have to do with me?  The following are two good examples of the bad and the very ugly. 

The Bad.  In Rhode Island, a Doctor was disciplined after she posted information about a patient on Facebook.  Although she did not identify the patient by name, she recounted enough of her ER experience that the patient could identify himself.  The Doctor had her privileges terminated at the hospital.  In England, EDP24, a regional newspaper, recently ran an article detailing numerous instances of hospital staff making inappropriate comments on SM sites, including congratulating a patient on her pregnancy after seeing her chart, and an employee "friending" a patient after obtaining information from the patient's records.   The Alabama State Nursing Association published an article in it's Fall, 2011 Newsletter about the problems nurses can face when using SM.   This is a must read for all medical professionals, in that it lists common problems that have occurred in real life.

The Very Ugly.  In California, a resident at a nursing home was attacked by a fellow resident.  His throat was slashed so severely that he was nearly decapitated.  When he arrived at the local hospital, staff took pictures of this mortally wounded man and posted them on Facebook.   4 staff members were fired and 3 others disciplined.  The LA Times story goes on to address numerous instances of hospital employees taking photographs of patients and/or medical records (such as x-rays) and posting them on SM sites or texting them to other employees. 

The GOOD.  SM has many positive benefits in the professional world.  These include the ability to market your practice, maintain or improve your reputation by publishing on blogs or professional sites such as BirminghamMedicalNews.com,   and the ability to keep up to date on recent news and innovations in the medical community.  There are also internet sites that rate businesses, including doctors.  These should be monitored on a regular basis to see what, if anything is being said about you or your practice.  Disgruntled/dissatisfied patients may post defamatory comments or false ratings.  Also, there have been some instances when lawyers have had made up positive postings made about them.  They did not do it, and did not know who was posting the comments.  The article also states that the same reviewers were also posting positive reviews about medical providers. 

The Dangers of Social Media in the Medical Profession.  There are numerous dangers that can be associated with SM in the medical profession, including:

                1.  The loss of one's license.   By improperly posting information on SM sites, Doctors and Nurses may be subject to disciplinary action by the licensing boards, including fines, suspensions or revocation.
                     2.  Claims by patients for invasion of privacy or HIPAA violations.
                     3.  Embarrassment.  No one wants to see their name on the front page of the newspaper as the result of a lawsuit or disciplinary action.
                  4.  Loss of reputation.  It takes a lifetime to build up one's reputation, and in the digital world, one click to ruin it.

How to Minimize the Dangers of Social Media.  There are many ways to attempt to minimize the dangers of SM.  These include:

                1.  Having a SM policy that outlines what is acceptable and what is not acceptable conduct when using SM.
              2.  Training, training and more training.  Training can include in person training, reminders during office meetings, via email, or in writing.
                3.  If an employee is posting on a SM site on behalf the employer via Twitter, Facebook, LinkedIn etc., the employer should be sure that they own the site.       
                4.  Monitoring of employees' SM sites.
                5.  Think before you post.
                6.  If it is something you cannot tell or show to your mother, it should not be posted on a SM site.
                7.  Google yourself on a regular basis to see what is out there.  Also, sign up for Google Alerts or other similar program.

The use of SM in the workplace presents very complex legal issues, and the issues change on a  regular basis due to developments in technology.  The law struggles to timely keep up with technology since it changes so quickly. You should consult your legal advisor to ensure compliance with the numerous laws and regulations that govern SM, as well as the medical profession. 



Thursday, August 2, 2012

Healthy Weight Maintenance


By Keehn Hosier, MD

Somewhat lost in all of the furor over the recent Supreme Court ruling on health care legislation is one simple fact: we can dramatically reduce health care costs if more Americans attain a healthy weight.  But attaining such a goal has been more easily discussed than accomplished, often due to poor understanding of what actually constitutes a healthy diet and exercise regime.  Fortunately, with the proliferation of smart phones, we have educational tools at our disposal that make life much easier when we are trying to help patients (and ourselves!) reach our weight goals.

One of the critical components for anyone trying to reach a healthy weight is an understanding of how many calories are needed vs. how many are actually consumed.  Physicians have often advocated keeping food journals as a means of maintaining accountability, but there are several outstanding applications that make this chore easier.  Two that I have found work well are mynetdiary and myfitnesspal.  Both of these smart phone food journals will calculate the necessary daily caloric intake necessary to reach a desired weight.  Many foods are pre-loaded in the journals so that patients can simply type in something like “grilled chicken, 4 oz, hamburger bun, 14 oz sweet tea” and have an instant reading of how many calories may be consumed the rest of the day.  These applications will also calculate break down food into component parts: fat, protein, carbohydrate, cholesterol and sodium amounts.  These tools are very useful for helping patients maintain cardiac or diabetic diets.  As an added bonus, patients can also see how exercise affects net daily calories.  This often inspires people to exercise just a bit harder or longer to help accomplish their goals.  One trick that I have found useful is to slightly underestimate caloric expenditure, i.e. record 25 minutes of exercise rather than the actual 30 minutes that was performed, and slightly overestimate caloric intake, i.e when in doubt if that piece of chicken is 4 or 5 oz, record the higher value.  This gives the user a margin for error that helps reduce plateaus.  Both of these applications are available on both Apple and Droid platforms. 

Strength training is an often underappreciated component of healthy weight maintenance.  However many people approach strength training with trepidation, either out of fear of looking out of place in a gym or out of concerns about injury.  As a result, I frequently advocated short term personal training packages for those patients completely na├»ve to strength training.  A new application, Jefit, serves as a portable personal trainer.  Jefit is by far the best weight training tool I have encountered.  For each body part, there is a lengthy list of exercises that a person can try; some of the exercises require nothing more than body weight, a small hand weight, or a resistance band.  As a result, people can perform these exercises at home, eliminating the “I don’t have time to go to the gym” excuse.  Each exercise has a cartoon illustrating proper form with written instructions to prevent injury below each animation.  Users can construct their own workout routines or they can enroll, without cost or obligation, on the jefit.com website where there are user and trainer submitted routines that anyone can copy.  The days of pen and paper charting a workout routine are over, as the application keeps track of your workouts, your performance improvement, and your theoretical one rep maximum weight for each exercise. 

Anyone who has watched The Biggest Loser is familiar with the ubiquitous BodyBugg that the contestants wear.  The BodyBugg is a fairly complicated device worn on the upper arm that measures daily caloric expenditure.  There is an internal accelerometer, a skin conductivity sensor, as well as heat sensors, all of which combine to provide a fairly accurate measurement of a person’s basal metabolic rate and exercise expenditure.  I have found this device to be useful for people who grossly overestimate their daily activities then wonder why they can’t lose weight.  The BodyBugg is not for the timid or for those who are pinching pennies.  As a result, I more frequently recommend pedometers to keep track of daily walking.  These simple devices easily attach to any lace up shoe and generally come with rough formulas to help people estimate caloric expenditure. 

Perhaps the biggest benefit the new technological tools offer is the pure accountability that keeping track of the numbers provides.  When caloric intake visibly exceeds expenditure, it forces the honest user to make healthy lifestyle changes.  That, after all, is our ultimate goal.