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10 Tips How to get online products Without paying a buck

2008-03-29T19:51:00.001-07:00

NOTE : This tutorial is for Educational Purposes Only.

Before you start Please make sure you will Hide your IP and dowload firefox. DO NOT DO ANY OF THE METHODS before getting the tools.
I assume you will be using Firefox. I am not a fan of Internet Explorer. So if you do use
I E, please get Firefox as I am not sure if these tools work with IE or not.
Hide My IP 2007
You will need this software because you do not want to leave your IP behind and you
want to stay behind the proxy and Hide My IP 2007 is the best one available to be honest.
Download Hide My IP 2007 here

After downloading, Install the Hide My IP 2007 and change your IP address. Now we
must check if our IP changed go to
http://cmyip.com
and see if your IP has changed.
Once done you may proceed to do the tactics below.

* TACTIC 1
Rather easy method, but still this works for most of the sites. Its good to have an arsenal
of all the methods so that you can try all of them to get an ebook.
Well the first method is basically the old “site” synxtax used in search engines. So say
you want a product from a site
Code:
www.mysite.com
and they have a pdf or something, you will just head over to Google, and type
Code:
Site: www.mysite.com
now if the site is indexed you will have the url for the pdf file or the zip or whatever it is.
You can do this on Google, Yahoo and Alexa, I have used AltaVista in the past also, so
you can try all of them. This method rather easy works on some sites thare are har d to get
even with advance methods. So here is the fir st method the “site” command in Google
and other sites.. REMEMBER TRY ALL THE SEARCH SITES I TOLD. SOMETIMES
YAHOO SHOWS more results than Google. And vice versa.
* TACTIC 2
Another easy method, this one requires a guess work of the pdf or zip or exe file. For
example say you were looking for a book on
Code:
www.contentpro.com
now you gotta guess the pdf file if the site is selling a pdf file just give the pdf file a guess
in this case I might go for contentpro.pdf on Google and do a search and all other sites,
and see what is the r esult. If I dont get anything I will do conpro.pdf or contpro.pdf or
procontent.pdf, you get the idea. Now in some cases this method alone can find you the
ebook or product you are looking for, it has some limitaton but in most cases it wor ks like
a magic. Again try it on all sites, try it with dashes, underscores and few other add ons.
* TACTIC 3

This method requires you to have some knowledge of p2p sites and softwares. My
favourite ones happen to be IRC->DC++->Emule–>Torrent–>Limewir e. What you can
do is look around these places for the pdf file. You can find some on IRC and sometimes
on DC++ or emule or Tor rent, I have yet to find some stuff on Limewire but you can
always check it out.
* TACTIC 4

SEARCH TACTI CS
In this tactic we will try to get a ver y popular Keyword Searching Tool “Keyword Elite”.
First step is go to
http://www.filez.com
or
http://rapidshare-search- engine.com
then
search a keyword for the product that we want.
So now I will search for the keyword “keyword elite” and walla… check the rapidshare
links below and the download it.
Easy Right? :)
If you are not lucky enough to find the product then here’s something that will help you.
Go to
http://alexa.com
and search for “thank you for your purchase [keyword] ” without
the quotes(”)
example: thank you for your pur chase [adsense]
* TACTIC 5

just go to the victim : www.example- domain.com
put in robots.txt
example : www.example-domain.com/robots.txt
you will see
# robots.txt for http://www.example-domain.com/
User-agent: *
Disallow: /downld/downld.html
Disallow: /downld/a-nbsd
Disallow: /downld/b-34v8
Disallow: /downld/c-ksajfk
then you try below links, you might find goodies there
http://www.example- domain.com/downld/downld.html
http://www.example-domain.com/downld/a- nbsd
http://www.example-domain.com/downld/b-34v8
http://www.example- domain.com/downld/c-ksajfk
But it is based on luck!
* TACTIC 6

(Google / Yahoo / MSN and Other Search Engine)
:Try Following terms in the various Search Engine-
inur l:”cbreceipt”
inurl:thankyou
site:domain.com
domain.com.robots.txt
Thank you for your order + download
Congratulations on your investment
Topic filetype: pdf (where topic is what you are searching for & no space in front of pdf)
“this order button requires a javascr ipt enabled br owser”
thank you “Clk*Bank.com”
thank you “ClkBank.com”
“A syntax error has occurred” filetype:ihtml
(password|passcode)(username|userid|user) filetype:csv
intitle:index-of last-modified pr ivate
intitle:index.of ws_ftp.ini
To find weak servers try search for: intitle:”the page cannot be found” inetmgr
for chat logs sear ch for: something “has quit” “has joined” filetype:txt
Replace something with the thing you are looking for.
On Yahoo search for: link:domain.com
intitle:nameproduct intext:http://rapidshare This gives links from warez sites.

(Alexa.com)
Try Following Terms in Alexa-
Thank You for Your Purchase!
Thank you for your purchase
Your credit card statement will show a charge
Thank you for your order
Thanks for your order
Thanks for your purchase
Thanks for purchasing…….
Order Confir mation
Order Confirmed
Your credit card or bank statement will show a charge from CLKBANK*com
A charge from CLKBANK
A Charge from paypal
Paypal payment or paypal payment confirmed
Paypal Statement
CLKBANK Download instructions
CLKBANK*com
cbreceipt or cbreceipt click
CLKBANK r ight click eller CLKBANK click
Download the latest version of adobe acrobat reader
right click save target as

r ight click save file as
Click here to download
Save target as
Save file as
recieve future updates
username is password is
username: password:
Members eller Members area
charge on your statement will show as “Clickbank”
Tips:
Go to Alexa.com and type in search bar something like this:
site:www.xxxxxxxxxxxxxxxxxx.com yyyyyyy
where xxxxxxxxxxxxxxxxxx is the site you have your eye on and yyyyyyy is something
that would limit found pages (for example if you put pdf instead of yyyyyyy you’ll get
only pages where word pdf mentioned, or you put mp3 or something similar)
I f you have time and energy you may type just:
site:www.xxxxxxxxxxxxxxxxxx.com
and you”ll get everything that Alexa has indexed on that site. Than you sur f through all of
the pages and bingo. You’ll eventually find what you are looking for . You may try also
typing link without www.
Instead of words pdf or mp3 , you may type thanks, thank you, clickbank or whatever
you think could write on thankyou page…
* TACTIC 7

(GOOGLEBOT)
Be a googlebot to bypass membership sites and show the contents of the site without
registering.
Download this firefox plugin
http://chrispederick.com/work/user-agent-switcher/
Once the plugin is installed go to Tools tab on firefox the choose User Agent Switcher
then Options. A new window will popup. Click User Agents and click the add button.
Use this details to fill the for m.
Description: googlebot
User Agent: Mozilla/5.0 (compatible; Googlebot/2.1; +http://www.google.com/bot.html)
App Name: firefox
App Version: 4.8 [en] (Googlebot/2.1; U)
Platfor m: Win32
Leave Vendor and Vendor Sub blank
* TACTIC 8
( I Use this Most of the time)
My very best tool GOOGLE
Go here
http://www.google.com/help/features.html
you will understand google better.
Also Using Alter native query methods go here to know about this.
http://www.google.com/help/operators.html
I usually use the cache operator.
And lastly use the product search here
http://www.google.com/help/features.html#definitions
* TACTIC 9
If you are a hacker you can crack pay-pal code ;)
* TACTIC 10

Well, if any tactic that i dont suppose to know , if you know one Please let me know it too ;)

My Friends

2008-03-17T05:29:00.000-07:00

TItle: Buy Vaporizer
URL: http://www.vapornation.com/
Description: Buy Vaporizer products & accessories at discount prices from VaporNation.

TItle: Drug Rehab
URL: http://www.careflorida.com
Description: CareFlorida - Drug Rehabilitation - Intensive Treatment and Relapse Prevention.

TItle: Drug Rehab
URL: http://www.ambrosiatreatmentcenter.com
Description: Drug rehab and substance abuse treatment at Ambrosia Treatment Center.

TItle: Eating Disorder Treatment
URL: http://www.edtreatmentcenters.com
Description: Eating disorder treatment by EDTreatment Centers.

TItle: Dual Diagnosis
URL: http://www.dual-diagnosis-treatment-center.com
Description: Dual diagnosis & co-occurring disorder treatment center.

TItle: Drug Detox
URL: http://www.gay-rehab.com
Description: Gay friendly drug rehab, drug detox & drug addiction treatment center at Freedom Rings.

URL:http://www.synergytreatment.com/
California Drug Rehabilitation Center
Description:
Treatment is the first drug and alcohol recovery center in the United States to offer the NTR detoxification Drug Rehab with residential treatment in a 30 day package.

Url: http://www.thehumanbody.in
Title: The human body
Description: Site totally dedicated to the human body, human body illness and health, Mental health. In short words the site is a complete summary of the human body anatomy.

The Stress of Cancer: Seeking Support

2007-12-28T05:29:00.001-08:00

The Stress of Cancer: Seeking Support

Learning that you have a diagnosis of cancer is usually a traumatic experience. And following the shock of diagnosis, people have to face treatment decisions and side effects, changing personal relationships and uncertainty about their future.

"Stress can appear at every stage of the disease, at diagnosis, during treatment and after treatment," says Josée Savard, PhD, a professor of psychiatry at Université Laval in Quebec, Canada. While some stress is expected to accompany a diagnosis of cancer, Dr. Savard and other experts say that people with cancer should monitor their stress levels to make sure they are not crossing the line into depression and anxiety, which are conditions that can interfere with someone's quality of life and even their health status.

Stress vs. Anxiety and Depression
Most of the research on the psychological impact of cancer has been conducted in women with breast cancer. It's estimated that between 22 and 50 percent of women with breast cancer are depressed, while 33 percent have acute stress disorder and 3 to 19 percent have post-traumatic stress disorder (PTSD), a condition seen in people who have experienced traumatic events such as natural disasters or military combat.

A Canadian study published June 14th in the British Journal of Cancer found that almost 38 percent of its 3,095 participants—who included people with breast, prostate, colorectal and lung cancer—met the criteria for distress levels that should be treated. But almost half of these patients had not sought psychosocial support, primarily because they weren't aware of support services or because they didn't think they needed them.

According to study author Linda Carlson, PhD, a clinical psychiatrist with the University of Calgary/Tom Baker Cancer Centre in Alberta, Canada, not getting help can have major repercussions. "If people don't feel like they can talk to anyone, their distress just snowballs over time," she says, adding that people with untreated depression and anxiety often end up visiting doctors more often.

That snowball effect may be one of several reasons patients find the post-treatment period stressful. "Some patients find it most difficult when treatments end because they feel they're not fighting anymore and they don't have the support of their medical team," Dr. Savard says.

Getting Support
Sometimes people with cancer find that the friends and family they thought they could rely on aren't offering them the support they need. In fact, cancer can sometimes expose existing cracks in relationships, particularly in couples. "For couples who were functioning well before cancer, the cancer will usually have a minimal impact on their relationship, or even improve it. In couples who had difficulties before cancer, it will generally create more problems," Dr. Savard explains.

Other times, Dr. Carlson says, people don't want to overburden their friends and family with their worries and may feel pressure to stay upbeat. And those friends and family members don't always know what to say or how to be helpful, especially if they haven't faced a life-threatening illness themselves.

Many people with cancer find the support they need in psychotherapy. Depending upon someone's personality and preferences, they may choose one-on-one psychotherapy or a support group of their peers that is led by a mental health professional, such as an oncology social worker. A study published in May 2001 in The Archives of General Psychiatry found that support groups helped reduce distress in people with metastatic cancer, primarily by helping them face their advanced disease on an emotional level. (Because the concerns of people with early stage and advanced cancer are so different, separate support groups are often found to be helpful for participants.)

"Supportive treatment, whether it's individual or group therapy, allows people to express their concerns and fears," Dr. Carlson says. "There's this myth that you have to be positive all the time when what's really important is that people are able to express their feelings, whatever they are."

Support groups and psychotherapy are also available to the family and friends of people with cancer. People with cancer and their families can find psychosocial support though their hospital or cancer center, or though support and advocacy organizations such as the American Cancer Society and The Wellness Community and CancerCare, which offer online support groups led by health professionals.

Other options available to people with cancer include hypnosis and guided imagery, where you relax by focusing on a positive mental image. Biofeedback, a technique that helps people learn how to relax, works with bodily functions such as breathing and muscle tension. If it's feasible, mild aerobic exercise can also provide energy and a mood lift. Some people, especially those who have had anxiety disorder or depression in the past, may need antidepressants or anti-anxiety medications to help them cope.

Cancer is an isolating experience, Dr. Carlson says, but reaching out for support can help people living with the discomfort and uncertainties of cancer gain reassurance and a better quality of life.

National Cancer Institute's Symptoms of Depression Having a depressed mood for most of the day and on most days:

Loss of pleasure and interest in most activities
Changes in eating and sleeping habits
Nervousness or sluggishness
Tiredness
Feeling of worthlessness or inappropriate guilt
Poor concentration
Thoughts of death or suicide

More Than Mood Swings: Bipolar Disorder in Teens

2007-12-28T05:28:00.002-08:00

More Than Mood Swings: Bipolar Disorder in Teens

Parents are often exasperated by their moody teenage children. After all, teenagers are known to be irritable, to sleep a lot and to resist authority figures. So how can a concerned parent determine when a teenager is just being a typical teenager and when their child has a mental illness such as bipolar disorder?

In teenagers, symptoms of bipolar disorder can include dramatic mood changes within a single day and may have different symptoms than adults. Below, Barbara Geller, MD, a professor of psychiatry at Washington University in St. Louis, discusses how to recognize and treat bipolar disorder in adolescents.

What is bipolar disorder?
It's defined like other psychiatric disorders across the age span in a manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The specific definition for what we now call bipolar disorder, but used to be called "manic-depressive" illness includes certain symptoms that patients must have to make a diagnosis.

People have to experience both depressed and manic episodes. For example, to fit the depressed part, they would need to be sad, to lose enjoyment in usual activities, to have trouble sleeping and eating, to be guilt-ridden, suicidal. To fit the manic part, they'd have to have elation: a mood of being happy as if the most wonderful thing in your life is happening except it's on a day that's like any other day. Families often describe it as Jim Carrey—like behaviors: silly, giddy, joking without an apparent reason.

People with bipolar disorder also get very grandiose. In adults, it may be developing business schemes that are unlikely to work so they wind up maxing-out credit cards. They have very active personal lives and may have multiple marriages. They seem to be able to go without sleep and are very social.

When does bipolar disorder usually first appear?
It's really only been in the last decade that people have started to pay attention to diagnosing bipolar disorder in young children and early adolescents. So many adults looking back can describe that they had the illness, but it may not have been recognized at that time. It's estimated from current studies that maybe as many as half of adults who have bipolar disorder had their onset before age 17.

How is the bipolar disorder different in younger children?
In adults, what people are used to thinking is that there will be a discrete episode with a clear onset and a clear offset. You generally have mostly a high or a low, and people function somewhat better between episodes.

What we see in the younger population is they have continuous illness for years, but on a daily basis, they can be both high and low. So they may spend four hours of the day high and giddy and silly, and it's very infectious and amusing, and maybe another four hours of the day morose, gloomy, not wanting to be with friends and thinking of hurting themselves. You see these very rapid cycles shifting from extreme high to extreme low on a daily basis, day in and day out, year after year.

And in children, the high manifests a little differently because children are not likely to max-out credit cards or have had four marriages by the time they're seven or eight. So what we look for in children is being super happy, as if it were Christmas morning or the day you're going to Disneyland, except it's the average day in school.

What are some of the risk factors for bipolar disorder?
The biggest factor is that it seems to run in some families. Bipolar symptoms also can occur with use of certain prescription medications such as steroids, with some illicit drugs such as cocaine and with various brain diseases such as stroke, tumors and trauma.

What are some of the warning signs in teenagers?
What families may notice is an exaggeration of all the stereotypes of what we say teenagers do. So we think of teenagers as being irresponsible and being irritable, but the child with bipolar disorder may suddenly decide, "I'm not going to school. They're not teaching me anything. I'm going to be President of the United States anyway, why do I have to go to school?" They have very grandiose behaviors that are out of keeping with reality.

They can also get very hypersexual. We think of adolescents getting very interested in the opposite sex, but bipolar adolescents will feel an urgent need to have multiple partners. They'll begin using very sexy language in inappropriate places. At school, they may write it on the blackboard.

How can parents distinguish between a moody teenager and someone who might have a mood disorder?

It's extremely important for parents to get a professional evaluation if they have any suspicion. The worst that will happen, if it's unfounded, is they will have spent a little time and money. But if it is not evaluated, and you let it go on, it can devastate a child's life. There will be multiple suspensions from school. They can get sexually transmitted diseases because they have unsafe sex. They can very rapidly go into a depression and get very suicidal and act on it. So it's very important, especially in families where a family member has bipolar disorder or has depression, for parents to get consultations at the first sign of any suspicion.

Are teenagers with bipolar disorder more likely to have drug and alcohol problems?
There is a very high rate among people with bipolar disorder of using alcohol and drugs across the age span. Parents have to be very suspicious because a child who's using drugs may seem like they're just having "the normal moodiness of adolescence."

There are some common things to look for. For example, drugs cost money and the family may find that items are disappearing from the house. A child may ask to borrow Mom's jewelry, and it somehow gets lost. Or they borrow electronic equipment, and what they're doing is selling it so they can afford their drugs.

What treatment is recommended to teenagers with bipolar disorder?
There are three classes of medication that are used for bipolar illness across the age span. The antimania drug lithium is the mainstay, and lithium is especially good if somebody else in the family with bipolar disorder has responded to it. The second class of drugs is called anticonvulsants because they were originally developed to treat epilepsy. And the third class of drugs is called neuroleptics.

It's very important to educate the family about the illness and to let them grieve. The last thing they want is for one of their children to have the illness. Then you can help them adapt and take part in the child's treatment. You also have to educate personnel at the school so that the expectation about the amount of work that the child can do is geared toward what the child can manage.

How well does medication control the disease?
Some kids do very well and become indistinguishable from other children as long as they take their medication regularly. The medication essentially has to be taken indefinitely, as it is in adults. Most who take it regularly will have fewer hospitalizations and suicide attempts, and they will be able to hold jobs better and have more stable personal relationships. For others, bipolar disorder is very difficult to treat, and it can be months of trying to find the right combination of treatments.

Are there strategies for helping teenagers stay on their medication?
Strategies have really not been formally researched and developed. This is a very important area for future research. For example, will there be Web-based programs the patients can go to? One thing that we find very helpful to do with adolescents is to grieve with them. The way parents have to mourn the loss of a child who's well, the children themselves have to mourn the loss of their former well self.

But grief hurts a millimeter less every day, so we usually can tell them that six months from now, it'll be more automatic just to take the medication and go about your other business.

More Than Mood Swings: Bipolar Disorder in Teens

2007-12-28T05:28:00.001-08:00

What The Most Dangerous Job In The World Taught Me About Coping With Stress

2007-12-28T05:27:00.000-08:00

What The Most Dangerous Job In The World Taught Me About Coping With Stress
By: Kevin Thompson

I just got through reading some troubling news in the New York Times this morning.

62% of employees now say that work-related stress leaves them overwhelmed and overtired.

And for many of us, who bring work home from the office, the problem is even worse.

So what’s going on?

Why are most of us so stressed?

I’ll tell you what a major part of the problem is… lack of job security.

I remember as I was growing up, my father only had two jobs. He was a high school teacher for the earlier part of his life, and later on he went into the real estate profession.

Two jobs, and they spanned his entire lifetime!

And the one career change he made was something he wanted to do. He didn’t make the change because he was losing his job as a teacher. In fact, the school district wanted him to stay.

But that’s a far cry from the way things are today. In fact, the days of job stability, and working for a single employer for your entire working career are long gone.

You’ll probably change jobs at least 11 times before you retire.

Downsizing, rapid business expansion and outsourcing are terms that we’re all too familiar with.

Before I got involved in the health industry and started my own indoor air quality business back in 1996, I’d already held 5 jobs in 5 completely different industries.

I worked as a telecommunications technician (in the Army), as a framer, on the green chain at 2 separate lumber mills, as a farm hand and finally as an Alaska fisherman for seven years (which was the hardest and most stressful job I ever had).

Now, you may be thinking to yourself, “You must’ve been a problem employee”.

But the fact is, nothing could be further from the truth.

I was in fact a model employee for every company I worked for, and never left a single employer on bad terms.

For example…

I began working as an Alaska fisherman in 1988. My main motivation for doing this was the money. Quite honestly, that’s the only reason I took the job.

And if you’ve ever seen that movie “The Perfect Storm” or watched those shows on the discovery channel, you have an idea of what it’s like to fish in Alaska.

My own story isn’t much different and it taught me why being an Alaska Fisherman is know as “The Most Dangerous Job In The World”.

The winter of 1995 had been an especially bad winter in Alaska. Fishing boats and fishermen's lives were being claimed by the Bering Sea almost weekly.

I was working on the outside deck after dark and we were in an unbelievable storm. It was the worst I'd seen in my 7 years of fishing. The kind of thing you only see in the movies.

I was scared to death!

But I had my own way of dealing with my fears. I'd never look out at the horizon when we were in a storm like this because I didn't want to see the big picture. I didn't want to know how high the waves really were. So I'd just concentrate on my job, which was to get all the fish onto the boat. As long as I did my job, and didn't look up, I could almost convince myself that the storm wasn't that bad.

While this certainly wasn’t the best way to deal with stress, at the time, it was the only way I knew how.

As always, the captain was in the wheelhouse driving the boat. His job was to keep an eye on me and watch for the dangerous rogue waves that would come out of nowhere and slam into us broadside. He'd tell me if I was in any real danger.

And then it happened!

I heard the captain's thundering voice over the intercom system.

Kevin! Hit the deck!

Before I could react, I was buried under a wall of water that hurled me all the way across the deck of the boat, face first into the railing on the other side.

When the water settled, and I realized what had happened, my immediate thought was, "Thank God I'm still on the boat" The impact had knocked out my front teeth and caused serious facial damage, but at least I was still alive, and on the boat.

If that wave would have lifted me just a few inches higher, I would have been thrown right over the top of the railing into the freezing waters of the Bering Sea. And there's one thing I knew for sure. In a storm like that, there's no way in hell the captain would have got that boat turned around in time to save me. I would have died right then and there.

It was at that moment I decided my life as an Alaska Fisherman was over.

While it was a great experience, I’ve never regretted my decision to leave the fishing industry. I just didn’t want to deal with that much stress in my life.

Decades of research has linked stress to everything from heart attacks and stroke to diabetes and a weakened immune systems, and none of us want to deal with that.

I’ve since found much better ways to deal with stress, and you can too by using the resources on this site.

-----------------------------------------

Kevin Thompson is a national authority on indoor air quality and health issues. His free Health Articles & News Update service gives you instant access to the world's most respected and sought after health experts in 70 categories, including Men’s Health, Women’s Health and Children’s Health just to name a few. Find out how this free service is changing people's lives and how you too can live a longer, healthier and more prosperous lifestyle... beginning today!

How To Destress Your Life Naturally

2007-12-28T05:26:00.000-08:00

How To Destress Your Life Naturally
By: DAVE WOYNAROWSKI, M.D.
The World's Top Anti-Aging Specialist

What would you say if I told you that a lot of today's stresses are not environmental!

You'd probably say, "What are you talking about! If so and so wasn't doing this and my boss wasn't doing that and he kids listened better I would be a lot calmer!"

Well that is probably true, but your ancestors had to deal with disease starvation and wild animals which had to be very stressful!

I don't think A.D.D. and Chronic Fatigue and Fibromyalgia were survival advantages!

My point is this: As I've said before Food is the most powerful drug ever invented. And the biggest missing in our diets if Omega 3 fatty acids.

With the proper amount of fish Oil Omega 3 fatty acids in your body you will notice you are a lot calmer and much more able to handle stress creatively!

A while back I talked about the effects of stress on longevity and health. All of it was bad!

Well, I have recently uncovered some additional evidence that Omega 3 fatty acids are needed for us to respond properly to stress.

And I mean serious stress, like the kind our ancestors faced, AND the version of it we face today!

Undoubtedly this is how our ancestors survived the tremendous stresses in their lives.

In all of the cardiac studies with fish oil it shows there is an inverse relationship between fish oil intake and death and development of heart attack in humans.

We have talked in the past about all kinds of reasons for this: the blood thinning effect of fish oil via platelets, the direct anti-inflammatory effect of fish oil on the formation of clogged heart arteries.

The latest research suggests that Fish Oil has adaptogenic properties with regards to the human response to stress.

This includes a direct effect on a very primitive part of the human brain called the brain stem. It is from this area that nervous discharges happen.

One type of nervous discharge is called "sympathetic".

This funny name refers to the type of nervous discharge that causes blood vessels to tighten blood pressure to go up and people to get anxious and stressed out.

It also leads to increased cortisol which is the hormonal equivalent of suicide by stress!

Fish oil attenuates this type of discharge and allows the body to respond in a graded sensible manner instead of a ballistic blast.

Most of you are aware of fish Oil's effects on the brain as well. I've referenced many studies in the past on depression and behavioral modification with Fish Oil via serotonin and dopamine, brain chemicals.

Another very cool and very healthy thing happens when adequate fish oil is present in the system.

The body starts using fat preferentially as a fuel during times of mental and physical stress.

So there you have it! Improve your brain chemistry, buffer your body's ability to handle both mental and physical stress, burn more fat, reduce cortisol and the illness it is associated with including aging!

What more could you ask for! Make sure you go to the site and order as the winter flu season comes upon us and take advantage of the beneficial immune effects that fish Oil can also give you!

Breast Augmentation: A Public Health Perspective

2007-12-28T05:19:00.000-08:00

Breast Augmentation: A Public Health Perspective

By: Diana Zuckerman, PhD

More than 150,000 women had breast augmentation surgery last year; an all-time high. At the same time, the number of teenagers who choose breast implants has more than doubled in the last two years.

And yet, the controversy about breast implants still rages. As is often the case when the media covers medical issues, there are experts on all sides of this issue, and the consumer is left totally confused.

As a Congressional investigator in the early 1990s, I had access to all published and unpublished studies of breast implants, and was appalled to learn that almost one million women had breast implants, but they had never been objectively evaluated in either clinical trials or epidemiological research. That situation has changed. After the FDA started restricting access to silicone gel breast implants, the implant manufacturers started to fund research in an effort to prove that they were safe.

As a scientist trained in psychology and epidemiology, I have studied both the desire for implants and the possible physical risks. Despite all the controversy and media coverage about breast implants, there are surprisingly few studies on the psychological benefits of implants, the local complications caused by breast implants, or the long-term risks. Instead, there is a great deal of misinformation in the media, and many women make the decision to get breast implants with unrealistic expectations about how it will change their lives, little awareness of the financial consequences, and without the resources to cope if problems do occur.

Breast Implants and Self-Image
Plastic surgeons claim that breast implants have a very positive impact on a patient’s self-image. It would be easy to study this objectively, by evaluating women’s self-esteem and body image before, after, and several years after getting breast implants. No such study has ever been conducted.

Surveys indicate that when plastic surgeons ask their patients if they are satisfied, most say that they are. However, that is not an objective way to study the impact on breast implants. There is no doubt that some women are very satisfied with their breast implants, but any evaluation of patient satisfaction should be conducted by someone other than the plastic surgeons or their staff. If you want honest and accurate answers, it is important for patients to feel that their answers are anonymous. Since implants are a lifetime commitment, it is also important to study them several years later, since that is when problems become more likely.

From a psychological point of view, improving one’s appearance, with plastic surgery or other means, can help a person feel better about himself or herself. On the other hand, there are individuals who feel unattractive because of a particular physical shortcoming, who then “solve” that problem, and then focus on a different shortcoming. There are other potential problems specific to implants: a woman who changes her appearance by getting breast implants may find that men treat her so differently that she feels uncomfortable. If the implants seem obvious (for example, because of the swooshing sound of saline, hardness from capsular contracture, or because they don’t feel the same as natural breasts) she may become more self-conscious rather than self-confident.

Are Breast Implants Approved by the FDA?
It may surprise you to learn that there are almost no published studies of the safety of saline breast implants, and that no breast implants were ever approved by the FDA until a few months ago. In May 2000, for the first time, the FDA approved several styles of saline breast implants made by two manufacturers, Mentor and McGhan. The FDA decided to give women the choice of buying implants even though FDA advisors expressed a great deal of concern about the complications experienced by many women with implants. The FDA did not approve saline implants made by other manufacturers, and did not approve some of the styles of implants previously sold by either Mentor or McGhan. That means that many women are walking around today with implants that never were approved by the FDA and probably never will be.

Saline breast implants are made with silicone outer shells with saline inside. The implants, commonly called “silicone implants,” have the same kind of silicone outer shells, with silicone gel on the inside.

No type of silicone gel breast implant has ever been approved by the FDA. When the FDA reviewed the safety research in 1991, they determined that the studies did not prove that implants were safe. The sale of silicone gel breast implants was therefore restricted to mastectomy patients, patients with breast deformities, and any augmentation patient who had a broken silicone gel implant that she wanted to replace. All of those women are required to participate in a study of the health risks. A small number of first-time augmentation patients were recently included in these studies.

Saline Implants
FDA approval of some Mentor and McGhan saline breast implants is based on studies that are not published. For detailed information, check out the FDA Web site or the summary on the Web site of the National Center for Policy Research for Women and Families.

The manufacturers studied local complications such as pain, implant rupture, and the rate of subsequent surgery and implant removal. Mentor reported that 43 percent of the augmentation patients in their study experienced local complications within the first three years, including:

* asymmetry, scarring, or wrinkling (32 percent)
* needing additional surgery (13 percent)
* severe capsular contracture (10 percent)
* implant removal (8 percent)

Even more women (60 percent) with McGhan implants reported at least one serious complication in the almost four years of that study. In the first three years, McGhan patients experienced the following:

* asymmetry, scarring, or wrinkling (27 percent)
* needing additional surgery (21 percent)
* severe capsular contracture (9 percent)
* had at least one implant removed (8 percent)

The complication rates were even higher for patients who got new breast implants to replace previous implants, and higher still for women getting implants for reconstruction after a mastectomy.

If these complication rates sounds very high to you, you’re not alone. The FDA decision to approve saline implants has been questioned by members of Congress because one of the manufacturing companies is under a criminal investigation and because the FDA did not require long-term studies or studies of whether saline breast implants cause serious diseases. Long-term research is essential, because many of the implant patients who have had problems, complain of systemic diseases that developed years after getting their implants.

Instead, the FDA apparently relied on studies that had been reviewed by the Institute of Medicine, which did not find a significant increase in systemic diseases among implant patients. However, the Institute of Medicine only reviewed studies that had been conducted previously, and these studies were not conclusive.

Silicone Gel Implants
The Institute of Medicine report primarily focused on silicone gel breast implants, and found no statistically significant relationship to systemic disease in most of them. However, several studies found an increased risk of connective tissue diseases, although the risk was not always statistically significant. These trends can mean several things:

* Illness could occur by chance (in other words, whether or not the person has implants)

* The sample could be too small to detect a real risk (this is especially likely when rare diseases like scleroderma (connective tissue disorder) are studied)

* The study is not well designed—for example, most of the studies include women who had implants for a few months or years, which is probably too short a period of time to develop connective tissue disease or cancer.

Whether or not silicone gel implants cause systemic disease, a new FDA study shows that they break more quickly than has been acknowledged. The new FDA study, published in September, 2000, showed that many women with silicone gel implants walk around with broken and leaking implants without knowing it. Using magnetic resonance imaging (MRI), researchers determined that almost half (48 percent) of the women who had silicone gel-filled implants for only six to ten years had at least one ruptured implant, even though they didn’t know it. Even more of the women (79 percent) who had gel-filled implants for 11 to 15 years had at least one ruptured implant. What was surprising was that the women had not realized the implants were broken and had not sought any medical care. Since this study excluded any women who had already reported implant problems or removal, the actual breakage rate is even higher.

Even more worrisome is that more than one in five of women had silicone gel “migrating” away from the broken implant capsule. The long-term risks of migrating silicone are unknown, but there are studies documenting serious health risks and fatalities when liquid silicone migrates to vital organs. Since silicone gel can break down to liquid form, this is a serious concern, especially since these women were not aware of what was happening and only found out because they were randomly selected for a study.

What Are the Local Complications of All Implants?
There are some known risks of implants that are true for either saline-filled or silicone gel-filled implants:

All surgery for breast implants, whether silicone gel or saline, has risks. These include the risk of infection, hematoma (blood or tissue fluid collecting around an implant), the risk that one or both of the implants will have to be removed (requiring additional surgery), and the potential costs of repeated surgeries if the implants are replaced.

All breast surgery, including implants, can interfere with a woman’s ability to breast-feed a baby. Women with implants are less likely to be able to nurse than women who have not had breast surgery.

All breast implants will eventually break, but it is not known how many years the breast implants that are currently on the market will last. As shown in the recent FDA study, most implants last seven to 12 years, but some break during the first few months or years, and some last more than 15 years.

The most common complaint is capsular contracture, which occurs when a woman's body reacts to the “foreign body” by forming a capsule of scar tissue around the implants that can become too tight. If that happens, the breasts can become very hard, misshapen, and painful as a result, often requiring surgery or removal. The appearance is common among actresses and models, who sometimes look like they have two balls attached to their chests instead of natural breasts. The result is especially unattractive if one breast has contracture and the other doesn’t, or if the contracture causes the breast to feel very hard or to change in shape. View a photo of capsular contracture on the FDA Web site.

Although the epidemiological studies have not proved that systemic disease is caused by breast implants, several European studies have indicated that breast surgery (whether for breast implants or to reduce the size of breasts) may be associated with an increased risk of connective tissue disease or rheumatism. If these disorders, which include diseases such as scleroderma and fibromyalgia (a syndrome characterized by chronic fatigue and body aches and pains), are related to breast surgery, all women with implants would be at increased risk, regardless of whether the implants are filled with saline or silicone gel. Since women with implants often have multiple surgeries, the risks of systemic illness are potentially increased even further.

All breast implants interfere with mammography, because implants can obscure the view of a tumor. Implants, therefore, have the potential to delay the diagnosis of breast cancer. Although specially trained technicians can perform mammography in ways that minimize the interference of the implants, not all women have access to a mammography technician with this expertise. Unfortunately, even with expert technicians, about 30 percent of the breast will still be obscured. Experts estimate that 20,000 to 40,000 women who already have implants will have a delayed diagnosis of breast cancer because of their implants.

Although there are no long-term safety studies of saline implants, it is assumed that they are safer than silicone gel implants because if they break, they can be more easily removed. In contrast, silicone gel can be very difficult or even impossible to completely remove from the body once an implant has ruptured. In addition, it is not always obvious that a silicone gel implant has broken, and the gel can migrate slowly over time into various parts of the body. However, there is research evidence that bacteria and mold can grow in a saline-filled implant, and nobody has studied what happens when the implant breaks in a woman’s body. In addition, even saline implants can leak small amounts of silicone or platinum into the body, which come from the outer shell (the “bag” that holds the saline) of the implant. The long-term health risks of those leaks are unknown.

Financial and Insurance Concerns
Breast augmentation usually costs $5,000 to $7,000 and many physicians will sell the procedure on the installment plan. However, the initial cost is small compared to the lifetime costs, even for women who like their implants.

Since implants can break at any time, and are almost assured of breaking within seven to 12 years, a woman needs to consider the lifetime expense of additional surgery and replacement. Although unusual, some implants break within a few days, weeks, or months of surgery. Some implant manufacturers promise to replace the implants for free, but the expense of the implant may be a small percentage of the total cost of augmentation. Some doctors also promise to provide their replacement services for free, but that does not include the cost of the medical facility, anesthesiologist, and so on.

Augmentation is almost never paid for by health insurance, so the costs of additional surgery can be very expensive. Women with implant problems can have many surgeries within a few years.

An even greater problem is that breast implants can make a woman uninsurable. While many insurance policies will merely exclude the implants, or the entire breast area from coverage (a terrible problem if the woman later gets breast cancer), some major insurance companies have decided to totally exclude any woman with breast augmentation from their policies.

The costs of removing a broken silicone gel implant are substantial. If the implant breaks and the silicone gel spills out, it can mix with the breast tissue and other tissue and be almost impossible to remove. Surgical efforts to remove broken gel implants can take hours and cost tens of thousands of dollars. In addition, a mastectomy may be necessary to remove the silicone in an otherwise healthy breast.

What Have I Got to Lose?
Many cosmetic changes are easy to undo. Breast implants are not. Once the skin and natural breast tissue have been stretched by breast implants, they will never look the same as they did before the implant surgery. Most plastic surgeons try to persuade their patients to replace a problem implant, warning them that they will be depressed by their appearance if they are taken out and not replaced. This should be of particular concern to parents who are considering implants for their daughters. If a 17-year-old dyes her hair, she can dye it back or grow it out. If she decides to get breast implants, it is a decision that will permanently change her body. If she wasn’t satisfied with the size of her breasts before implants, imagine how she will feel to have breasts that are just as small and also sagging.

Why Weren’t Implants Studied Before They Were Sold to Women?
With all the problems and unanswered questions about breast implants, the obvious question is “Why weren’t implants studied first and improved before selling them to women across the country?”

The FDA did not have the authority to regulate any kinds of implants or medical devices until 1976. Implants had been sold since the 1960s, so they were allowed to stay on the market until the FDA reviewed them. Meanwhile, there was a substantial backlog of products that the FDA needed to review, and cosmetic products like breast implants were not a priority. Unfortunately, the manufacturers did not conduct long-term studies until the FDA required them.

Conclusion
The more than one million women who have breast implants are, without their realizing it, part of a natural “study” to learn what the risks are. Women deserve to be told what is known, and what is not known, before they make this decision. And, if a woman with implants complains of symptoms, she needs to find a plastic surgeon who has a reputation for helping women with implant problems.

Surgical Solutions to Obesity

2007-12-18T07:03:00.003-08:00

Surgical Solutions to Obesity

With: Dr. Elliot Goodman

There are a host of medical problems associated with obesity. Stroke, diabetes, heart disease, and joint problems are just a few of the known consequences, and yet nearly one quarter of American adults are obese, and this number is rising. An estimated three to five percent of adult Americans are morbidly obese. For these individuals, medical problems, in addition to social and practical problems, are a near inevitability. Fortunately for some, the battle against obesity has a surgical weapon. It's called bariatric surgery.

Below, longtime general and bariatric surgeon, Dr. Elliot Goodman of the Montefiore-Einstein Center for Weight Reduction Surgery, talks about the procedure, and its effect on the physical and emotional lives of his patients.

First, could you tell us what bariatric surgery is, and who undergoes this procedure?
Bariatric surgery is the surgical treatment of severe obesity. And when we say severe, we mean anybody who is at least a hundred pounds overweight. People who undergo bariatric surgery have generally been obese for decades, and they most often have a history of childhood obesity.

What does the surgery entail?
In the surgery, we staple the stomach to make it much smaller, and we reroute food so that it bypasses the first few feet of intestines. We actually rearrange the anatomy and the physiology of the intestinal tract.

And what does this do to the body?
Well in addition to dramatically reducing the size of the stomach, the surgery also changes the hormonal condition of the patient. You're changing their sensitivity to insulin, you're changing their metabolism of iron and calcium and other nutrients.

And a lot of things which would otherwise get absorbed don't get absorbed. There are hormonal changes induced which suppress appetite. There are hormonal changes induced which increase the body's sensitivity to insulin, because most severely obese patients are resistant to insulin, which is why so many of them are diabetic. So it's one operation that has manifold effects on body metabolism.

Does this surgery actually treat diabetes in some cases?
Absolutely. I hear stories of patients who are on three or four different medications for diabetes, and a hundred units of insulin -- which is a big daily dose of insulin -- and within a few weeks they're off. They're off the medications even before they've lost a significant amount of weight. Also, people who have very high cholesterols will often see their cholesterol dipping down to normal. So these are some of the more dramatic effects of the operation.

Coronary artery disease and high blood pressure also respond well. It's great to see patients who may be on five, ten, twelve different medications, over time say, "Well, I dropped this medication," or, "I halved this dose." Within a year or two, they may be down to the bare minimum of medications.

I imagine that the surgery may also solve some of the more structural problems in the body, like joint pain?
Absolutely. People with aches and pains or degenerative joint disease are well served by this surgery.

Could you describe the experience of one patient who has responded well to the surgery?
Sure. I operated on a woman about a year and a half ago who was about three-hundred and fifty pounds overweight, and had been obese for most of her life.

She was only in her early forties, but was so big that she had to come into the office with a walker. She was unable to sit in any of the chairs even though we have fairly heavy-duty armless chairs, and she was too heavy to weigh in our office. Our scale goes up to five hundred pounds.

Did she describe to you her reasons for wanting the surgery?
She told me she couldn't work, couldn't fit into an armchair, and couldn't really go out anywhere. She said she could not take the bus, because she couldn't get up the stairs into the bus, or sit down in the bus. She didn't go out to shop because people would stare at her, whisper about her behind her back, or just blurt out obscenities at her.

Was bariatric surgery a last resort for her?
She'd been struggling with this for a very long time. She had tried everything else: diets, over the counter pills, and exercise, when she was younger and abler. And she had decided that if she didn't do anything at this point about her weight, having failed at everything else, her life expectancy was extremely limited. She wasn't sure whether she'd be around in a few more years. And I agreed that her weight was life-threatening.

What happened after the initial consultation?
First she was seen by our nutritionist, and then she was evaluated by one of the psychologists we use.

Why do you do a psychological evaluation?
Many reasons. A lot of patients who come in, perhaps at the suggestion of their own doctors, don't understand that this is a very big operation, and that it can occasionally go wrong, and that it can occasionally lead to complications, including death. This is not a tummy tuck, or liposuction. They need to understand the severity of the procedure, and the small chance of major complications.

Also, there are patients who may be depressed. If they are severely depressed, we'll often recommend that they defer surgery -- get the acute depression under control and then come back.

Binge eating is another problem among some of our prospective patients. They will respond to stress by eating, and will eat so much that they induce vomiting. If it persists after surgery, particularly in the early days post-surgery, binge eating can be very dangerous. After the surgery, patients have very small stomachs - approximately the size of an egg -- and if they try and stuff too much food into them, they can actually break down the surgical staples, causing a leak, which can be potentially fatal. So we need to weed these patients out.

How long, for our case study patient, did the whole testing period take?
The whole process took about six to eight weeks. After she was seen by the nutritionist and psychologist, she underwent a medical workup, just to make sure that she would be able to tolerate the operation and the anesthesia.

And the operation was successful?
Yes. The first big milestone was that we could actually weigh her. She dropped below five-hundred pounds. And then she was down to four-fifty, then four-hundred, and so on. Two or three months after her surgery, she was able to walk without the walker. Eventually she could sit down in our waiting room and get up without assistance. And her joint trouble began to subside.

She has a job now, and she's going back to school. Through the process of the operation, we were able to draw her back into the mainstream of life.

Do your patients keep in touch with you long after surgery?
Yes, the longevity of the relationship with the patients is quite remarkable. I don't think patients call their surgeons years after an operation to say, "Hey, three years ago you took out my gall bladder." But I get calls all the time from bariatric surgery patients. I bond with these people for years.

Just recently a patient called me up out of the blue and said, "You're the second person I've told that I'm pregnant." This was a patient who had been trying to get pregnant for ten years. But before the surgery she weighed three-hundred and fifty pounds, and she was essentially infertile.

What You Need To Know About Rhinoplasty: Nose Jobs

2007-12-18T07:03:00.001-08:00

What You Need To Know About Rhinoplasty: Nose Jobs

By: Jonathan Pontell, MD

Rhinoplasty, commonly referred to as a nose job, is any surgery done to change the shape of the nose. Rhinoplasty may be done for purely cosmetic reasons, for purely functional reasons such as to improve nasal breathing, or a combination of the two.

Because the nose has a very prominent central location on the face, the changes made with rhinoplasty can make a dramatic difference in a person’s appearance and lead to great increases in self-esteem and self-confidence.

Cosmetic rhinoplasty can change an almost infinite number of variations in nasal shapes. The goal of the surgery is to give an improved nasal contour that is in harmony with the rest of the face, while maintaining or improving nasal breathing. Most often, rhinoplasty is done to make a large nose smaller or a wide nose narrower, but occasionally the opposite is true.

The Consultation
Anyone considering rhinoplasty should see a board-certified facial plastic surgeon, otolaryngologist/head and neck surgeon (ENT), or general plastic surgeon for a consultation. The patient should seek out a surgeon who has extensive training and experience with both the cosmetic and functional aspects of this operation. It is advisable to ask to see a portfolio of before-and-after photographs of other rhinoplasties the surgeon has performed.

The consultation is an opportunity for me to listen to patients’ goals, to examine them, and to come up with a surgical plan. I examine the external and internal nose to determine what changes are possible. It is very helpful for patients to be able to clearly express what they do not like about their noses so I can determine if their goals are realistic. I also attempt to explore exactly what a patient’s motivation is for wanting nasal surgery. It is important to make sure that the patient has carefully thought about the decision to have surgery and that the desire is not based on a whim, to please someone else, or because of a recent life-changing event, such as a divorce.

During the consultation, I use computer imaging to show patients the changes that are possible. Computer imaging is a powerful tool that is useful in establishing clear communication between the patient and myself as to what the surgical goal should be. It is important to note, however, that the computer-simulated photographs are only an estimation of the desired outcome. Although the actual result of surgery usually closely approximates the computer-simulated images, no surgeon can guarantee to what extent a complete match will occur.

Assessing the Face
When examining the patient, I look at the entire face to determine what changes are needed to create the most aesthetically pleasing result. I take into account the patient’s ethnic background, bony and cartilaginous anatomy, skin thickness, general health status, and age. Female patients should be at least 15 to 16 years old and males should be 16 to 17 years old—ages at which the vast majority of nasal growth has been completed. Nasal surgery done prior to the completion of nasal growth may result in developmental abnormalities of the nose.

At the consultation I may also suggest that the patient undergo another procedure in combination with the rhinoplasty to maximize facial harmony and balance. The most common procedure done in combination with rhinoplasty is chin augmentation, but cheek augmentation and chin reduction may also be done in combination with rhinoplasty.

Surgery location
The rest of my consultation includes a discussion of the different locations at which I perform surgery. These locations include hospital operating rooms, surgicenters, and my office operating rooms. Patients should be sure that anesthesia given in an office operating room is provided by a licensed anesthesiologist or nurse anesthetist. Also, all of the same monitoring equipment present in a hospital operating room, such as EKG machines and blood-oxygen level monitors, should be in the office for your surgery.

Patients are usually given local anesthesia with sedation to place them in a comfortable drowsy state, but they remain awake. The other option is general anesthesia where the patient goes to sleep fully. The first option is safer and has less postoperative nausea and a quicker recovery.

Rhinoplasty Techniques
There is a multitude of variations in rhinoplasty techniques. The technique used depends on what type of problem exists and also on the individual surgeon’s preference. Most of the incisions are placed inside the nose, but some surgeons employ a technique called open or external rhinoplasty, in which a small incision is placed in the columella, which is the bridge of skin separating the two nostrils. This incision, when connected with the intranasal incisions, allows better exposure of the nasal anatomy than the more traditional techniques. The benefits of improved exposure are better symmetry and more sophisticated ways of altering the nasal anatomy, which I believe lead to better results. Also, occasionally, incisions are placed at the base of the nostrils for nostril narrowing.

Bone restructuring
Once the surgical exposure of the cartilage and bones of the nose is accomplished, many different maneuvers are used to modify them.

Nasal bones and cartilage may be shaved down if too prominent, repositioned if out of alignment or too wide, or added to if deficient. Nasal tip cartilages are often reduced in size and sutures are placed to narrow and refine them.

Often, in the case of twisted, deviated, or wide noses, cuts will be made in the nasal bones to allow them to be repositioned. Deficiencies in the nasal structure are replaced with grafts of cartilage from the nasal septum, ear or rib, or bone from the skull, rib, or hip. Nasal deficiencies may also be replaced with synthetic materials such as Gore-TexTM or SilasticTM. The advantage of using synthetic materials for nasal augmentation is that no further surgical procedures are needed to harvest these materials. The implant is simply removed from a sterile package, carved to the proper shape and implanted. The disadvantage of synthetic implants is that they can become infected or lead to thinning of the skin and eventual exposure of the implant necessitating implant removal. Implants from the patient’s own cartilage or bone almost never cause any of these problems.

After all of the modifications to the nasal structure are completed the incisions are closed and a cast is usually applied. Occasionally, depending on exactly what type of procedure was done, VaselineTM gauze or a sponge dressing may be placed inside the nose for one to two days.

What to Expect After Surgery
After surgery, patients usually have minimal pain, which is easily controlled with pain medication. The degree of swelling and bruising depends on how extensive the surgery was. If mobilizing and repositioning the nasal bones was not part of the surgery then swelling and bruising around the eyes is usually minimal. If the nasal bones were repositioned, swelling and bruising around the eyes may be significant, but is usually gone in seven-to-ten days. Most patients feel comfortable going out in public by this time. Some surgeons give steroid medications for a few days after the surgery in an attempt to minimize swelling as much as possible. By six weeks, the majority of swelling of the nose is gone, but it often takes many months for the final amounts of swelling to disappear.

Sleeping
It is helpful for the patient to sleep with his or her head elevated on a few pillows for the first week to allow gravity to aid in reducing the swelling as quickly as possible. The cast is usually removed after one week and any external sutures that were used are also removed around this time. When the cast is removed, the patient will get some idea of how the nose will look, but during the next few weeks to months, significant changes will occur with healing and the disappearance swelling.

Post-surgery activities
Patients are told not to engage in any strenuous activities for the first two weeks after surgery that could lead to nose bleeds, and to avoid direct sun exposure for the first few months, which would lead to swelling of the nose. Also, it is advisable for the first six weeks to avoid activities that could lead to the nose being hit or bumped. Patients who wear glasses may be advised to tape their glasses to their foreheads for a few weeks if their nasal bones were repositioned in order to avoid the weight of the glasses displacing the nasal bones.

Surgical Risks
All surgery is associated with risks. For patients who do not have significant medical problems, the risks are minimal. Any surgery can result in an infection, a bleeding problem, or an adverse reaction to the anesthesia medications. Again, these are extremely rare occurrences. Poor healing, the development of scar tissue under the skin, nasal contour irregularities and postoperative nasal breathing problems are also possible occurrences. All of these complications are treatable.

Surgical Costs
The surgical fee for rhinoplasty varies from doctor to doctor and may depend on how extensive the surgery will be, but a range of $3,000 to $5,000 is typical. Insurance may cover the entire cost of the surgery including anesthesia and operating room fees if the surgery is done for functional and not cosmetic reasons. Rhinoplasty, for a combination of functional and cosmetic reasons, may be partially covered, but surgery for purely cosmetic reasons is not covered by insurance.

Conclusion
The latest techniques used in rhinoplasty allow surgeons to give patients natural, aesthetically pleasing results with good nasal function. Patients with the proper self-motivation and realistic expectations for the surgery are usually very pleased.

Breast Augmentation: A Public Health Perspective

2007-12-18T07:02:00.001-08:00

Sports Doping: What Should Parents Know?

2007-12-13T08:59:00.000-08:00

Sports Doping: What Should Parents Know?

By: Donald E. Greydanus, MD

Using chemicals in the hopes of improving athletic performance is nothing new. If you were an athlete in the Greek Olympic days, your coach might have suggested you try various mushrooms to gain a competitive advantage. In the present, the pressure to excel and to win is stronger than ever. From playgrounds to professional arenas, athletes today are tempted by a wide variety of substances that promise to boost performance, appearance, and overall health. We call this phenomenon sports doping. It is important that the parents of young athletes understand how prevalent and potentially dangerous this situation is.

There is much yet to be learned about the effects and side effects of performance enhancing chemicals, especially on children.

Because these drugs are so widely available, and because many famous athletes are known users, some parents assume that drugs are OK for their children to use, especially since many famous athletes are known to be users and abusers of various chemicals.

Parents often ask me why we know so little about these drugs. In truth, well-conceived, scientific studies are often done only on adult males who are involved with competitive athletics.

It is not easy to clearly relate a side effect to a specific chemical taken, since there are many factors that may be involved for each individual. Further, many of these chemicals are called nutrients and are readily available in nutrition stores. Since some of these substances are not classified as drugs, they are not under the control of the Federal Drug Administration. The manufacturers and sellers of these nutrients are free to make extravagant and unproven claims about their products. Unfortunately, it is our children who may suffer the negative effects of these products while the makers and sellers reap the profit. ‘Buyer Beware!’ is certainly the right message for anyone who wants to become, or remain, a sports doper. I will now provide an overview of some of the most common performance enhancing substances used by children.

Creatine
Creatine has become a very popular product with teen athletes. Annual sales total over 200 million dollars. It is advertised as a natural product that will provide larger, more powerful muscles. Creatine is actually an essential amino acid, meaning that it is a necessary nutrient for human beings. It can be produced by the body from other amino acids, such as arginine and glycine. It may also be provided in the diet—creatine occurs naturally in fish, milk, meat, and other foods.

Studies performed on adult athletes indicate that creatine may increase muscle mass, probably due to the retention of fluid. More importantly, the athlete who is undergoing intense exercise training and taking creatine may increase his or her power for short-term sports action, such as sprinting and playing football. Thus, it is very popular with high school football players and track athletes. Some coaches, trainers, and even parents have pushed this product on their athletes in the hope of producing winners.

So what is wrong with taking creatine? Well, creatine has received very little scientific study. We do not know anything about its long-term effects. We do not know what doses are best and what is excessive. The doses kids take are varied and often mixed with other drugs or chemicals that have their own unknown effects. The stores that sell creatine have no idea how pure the product is, how much to use, or when to stop.

We do know that creatine produces no improvement in long-term endurance activities. A number of side effects are possible, including abdominal pain, nausea, loose stools, increase in weight due to the retention of water, muscle cramps, and muscle strains. Case reports indicate that dehydration and even death may occur when athletes take creatine and exercise in hot weather. Reduction in kidney function and enlargement of the heart muscle have been observed in kids. Additionally, creatine supplementation suppresses the body’s own production of creatine. We do not know what effects this may have on a growing child. There are simply too many unknowns about creatine at this time. It would be wise to stop the current hype.

Anabolic Steroids
Anabolic steroids are synthetic testosterone derivatives. They have become very popular with athletes who seek improved muscle size and strength, whether to gain an advantage in competition or simply to look better in a culture that reveres large, muscular bodies. Athletes at high abuse risk for these products include those involved with football, weight lifting, wrestling, shot putting, discus throwing, sprinting, and many other sports.

A number of anabolic steroid products have been available over the past several decades, including stanozolol (Winstrol7), nandrolone decanoate (Deca-Duraboline7), oxymetholone (Anadrol-507), and others. One form, methandrostenolone (Dianabol7), was available in the 1970s and 1980s as an injection and was abused by many teens. After various needle-related consequences were reported (e.g., hepatitis, HIV infection), methandrostenolone was discontinued. Today, however, a pill form is making a comeback.

Anabolic steroids are very popular around the world. Up to 11% of American high school males and up to 2.5% of high school females use anabolic steroids—a staggering number! We know that half of these abusers start with steroids while under the age of 16. About one-third of steroid users do not consider themselves athletes. We also know that the desire to excel in sports and/or personal appearance drives young people to use high doses of anabolic steroids, often in combination with other drugs. Can these kids gain muscle mass and strength? Yes, but only if they also engage in specific, strenuous exercise training at the same time. Using steroids without this training does not increase weight and power.

Anabolic steroids: a time bomb
Kids who use anabolic steroids are fooling around with a time bomb. Many dangerous side effects await the unwary user of these dangerous chemicals. Females can become masculinized, with excessive hair growth (called hirsutism), enlargement of the clitoris, and loss of hair (seen in males also). Growing athletes may increase the maturing of growth plates in bones, resulting in a shorter height than they would otherwise attain. Acne may become very severe and resistant to therapies. Some steroid users become aggressive and irritable; some become depressed. Testosterone levels may drop with reduction in the size of testicles. There are many other potential problems, such as stomach ulcers, increased blood sugar, fluid retention, and increase in injuries to tendons. Some scientific articles report a link between liver cancer and the use of anabolic steroids.

Athletes may take additional drugs in an attempt to augment the effects of anabolic steroids and/or reduce some of the side effects. Many athletes become involved with a dangerous practice known as stacking, taking many drugs at high doses for weeks or months. Some stop only before a sports event, and only if they will be tested for drugs. Some female athletes try to take just enough to become more powerful but not enough to become masculinized. Officials at the Olympic games have banned anabolic steroids from competition and have been testing for them since the 1970s.

Looking for safe alternatives
The athletic world constantly seeks safe alternatives to anabolic steroids. For example, athletes have tried a chemical called, androstenedione. It is related to testosterone and is taken an hour or so before a sports event to improve power and strength. Well-known professional athletes have even used it. However, it is not really effective and it has become less popular today.

DHEA beware
DHEA (dehydroepiandrosterone) is another chemical that is related to testosterone (and also estrogen) and promoted in nutrition stores. It is widely advertised as a wonder drug that will improve muscle size and strength, lessen depression, prevent heart disease, and increase sex drive among other unproven claims. A reputed fountain of youth, it has special appeal to adult athletes. Though hyped as a safe alternative to anabolic steroids, it is not safe and is linked to many anabolic steroid-like side effects. Excessive hair growth and endometrial cancer are reported in women, while prostate cancer and permanent breast development are reported in men. Yes, this natural product is found in human adrenal glands and even in wild yams. It is, however, a dangerous chemical. Young people and adults alike should be discouraged from using it.

Protein and Amino Acid Supplements
The use of protein and amino acid supplements to improve sports performance has been promoted for the past several decades. Do athletic children need more protein than their non-exercising peers? Yes. Does protein supplementation help their sports activity? No. Most athletes get more than enough protein from their normal intake of food. There are some athletes who try to stay very thin and/or lose weight, such as gymnasts, dancers, and wrestlers. Providing extra protein may help this select group. I do not recommend expensive protein supplements for them. I suggest they get their additional protein from evaporated milk or relatively inexpensive protein powder (egg or soy).

The use of branched-chain amino acids to increase growth hormone production has not been proven to help the athlete perform better. I point out to athletes that protein or amino acid supplements can be ineffective and needlessly expensive. Overuse may even lead to loose stools. I worry that an overabundance of some amino acids may lead to an imbalance of others and that unknown side effects may result from such supplementation.

Common Questions
Here are some questions I often receive from parents and teens regarding sports doping:

What about the use of Antioxidants?
Antioxidants are chemicals that are thought to reduce the amount of body damage done by free radicals. Some athletes are concerned that harm may be caused by the production of exercise-induced free radicals. Some antioxidants include vitamin C (ascorbic acid), vitamin E (alpha tocopherol), beta carotene (a vitamin A precursor), iron, zinc, selenium, manganese, and copper. At this point, we do not really know if these antioxidants improve sports performance. More research is needed in this area. Everyone should get a recommended amount of these substances in their diets. For example, the recommended daily allowance is 10 mg a day for vitamin E and 60 mg a day for vitamin C. Extra doses of some chemicals (such as vitamin C or beta carotene) may cause illness.

Is there a role for iron supplementation?
It has not been shown that iron will improve sports performance or that most athletes need or would benefit from iron supplementation. Runners and other endurance athletes do lose iron in their intestinal tracts, urine, and sweat, and may need more dietary iron than non-athletes. Normally, they will consume what iron they need in their diet. Athletes with a low iron level will benefit from taking a daily multivitamin with iron. This includes vegetarian teens as well as females with excessive menstrual blood loss and limited dietary iron.

Is calcium necessary?
Calcium itself is not ergogenic, i.e., does not produce sports performance improvement. It is recommended, however, that individuals between 11 and 24 years of age receive a daily intake of 1200 to 1500 mg of calcium. If intake of calcium is below this level, then supplementation is warranted. Female athletes who are required to be thin, such as gymnasts or dancers, may be on a low calorie diet and have low estrogen levels. They are at increased risk for fractures, absence of menstrual periods, and, later in life, osteoporosis. They are often afraid of calcium-rich dairy products, which may contain too much fat for them. I suggest they take yogurt or skim milk in this case.

Are there other amino acids and chemicals taken as muscle drugs?
Yes. A popular muscle drug is HMB (beta-hydroxy beta-methylbutyrate), a leucine metabolite found in citrus fruits, breast milk, and even cat food. Some studies show it increases muscle size and may allow the muscle to repair itself faster. Its effectiveness as a sports doping agent and its potential long-term side effects are unknown at this time.

Other unproven amino acids on the market include L-carnitine (found in dairy products and meats), Arginine, Glutamine (found in almonds, soybeans and peanuts), and Conjugated Linoleic Acid or CLA (found in yogurt, milk, treated cheese, venison, and beef). We do not know enough about these agents. Their use should be discouraged. The exact dose found in each bottle is unclear. They may contain impurities as well. In the 1980s, another amino acid, L-tryptophan, was linked to deaths due to impurities. Side effects observed include diarrhea with L-carnitine and drowsiness with L-tryptophan. We also do not know the effects of adding these chemicals to other sports doping agents. I advise athletes to play it safe and avoid these drugs.

A published study suggests that chromium (an essential trace element) can lead to muscle gain and a reduction in body fat. Other studies, however, have not confirmed chromium’s ergogenic properties. Side effects include gastrointestinal upset, anemia, and kidney disease. I only recommend chromium as part of a multivitamin tablet, one that does not exceed 200 mg/day of this element.

Another trace mineral, vanadium, has been marketed as a muscle builder. I tell my patients that there is no proof of this and that side effects may include diarrhea, abdominal cramps, and even a green tongue.

What about Boron?
Boron is a substance essential for plants but not humans. It is present in foods of plant origin, non-citrus fruits, leafy vegetables, nuts, and legumes. Although boron is sold to increase muscle mass, there are no studies to support claims of increased lean body mass, total testosterone, or strength.

Do some athletes give themselves their own blood to improve sports performance?
Yes. This is called blood doping (also blood packing or blood boosting). The individual saves his or her own blood and takes it intravenously before a sports event. This increases hemoglobin (protein in the blood which carries oxygen) to a high level and may allow increased endurance. Laboratory tests are not able to catch athletes who use this method. Some athletes take a product called erythropoetin, or EPO, which also increases oxygen-carrying capacity. In both cases, the blood becomes thicker, increasing the risk of strokes, heart attacks, and seizures. I tell my patients that blood doping is not allowed by sports authorities. The risks are not worth any benefit it might produce.

I have asthma. Can I take my medications? I have heard that asthma medications are not allowed for sports participation.
It is perfectly fine and indeed important for athletes with asthma to take asthma medications. These medicines include terbutaline, albuterol, and others. The confusion developed because of a medication called ephedrine. This is a stimulant drug that can also help asthma. Stimulant drugs (like ephedrine, amphetamine, and caffeine) give the athlete an unfair advantage and are not allowed in Olympic and other competition. They have a number of side effects, including increased aggressiveness, higher blood pressure, increased heart rate, loss of fluids, shakiness, and anxiety. Some athletes find that too much coffee may lead to increased urination and too many trips to the bathroom. Olympic officials have limited the amount of caffeine they will allow their athletes to take.

Are pain pills okay?
In general, it is fine to take pain pills to relieve pain from sports-related injuries. It is important to take them under a knowledgeable clinician’s direction. Some athletes have taken too many of these pills in the face of injury so they can continue with the game. This may lead to even more severe injury. I tell parents to be sure to seek careful evaluation and treatment for children who are hurt in sports. Don’t come back to the game too soon. Come back when you are healed and ready.

Why are diuretics banned in sports?
Diuretics are medications that increase urine output. They are used inappropriately by athletes who need to lose weight in a hurry (wrestlers, for example). These medicines are also used to mask the presence of other performance enhancing drugs. Athletes should be advised that using diuretics for such purposes is wrong and that a number of side effects may result, including dehydration, weakness, and heart irregularities. In addition, weakness caused by diuretic use can make an athlete more susceptible to injury.

Is it okay to use medications to calm the athlete’s nerves?
An athlete who is diagnosed with an anxiety disorder may benefit from certain medications known to improve anxiety. These are fine to take. Some athletes take pills called, beta-blockers (such as propranolol). These are used to reduce performance anxiety by controlling hand tremor, lowering heart rate, and reducing blood pressure. They are banned in some Olympic sports.

Summary
The best sports performance method is to combine a vigorous exercise plan (under the supervision of a qualified person) with a well-balanced diet. The use of chemicals and drugs is fraught with many unnecessary dangers, as outlined in this article. Parents should be guardians of their children and be sensitive to the societal pressures on their children to win at all costs. These drugs do not usually work and are not worth the price our children may pay. I advise you to tell your children, coaches, and schools to discourage the practice of sports doping. The safety of your children is at stake.

Sports and Teens: How To Reduce Some of the Stress

2007-12-13T08:58:00.002-08:00

Sports and Teens: How To Reduce Some of the Stress

By: Donald E. Greydanus, MD

If you are like many parents, you are probably very interested in having your children and teenagers become active in sports. The hope is that sports activity will be a beneficial experience for both you and your children. As a pediatrician, I am often asked a number of questions about adolescents, sports and stress. “Will my teenager experience stress as a result of sports play?” “How can I reduce some of the potential emotional problems involved in sports?” This article explores some of the factors that may lead to a negative reaction by your teenagers as they take part in various sports.

Stress and Sports
Stress is a natural part of sports participation, as stress is natural in many aspects of life.

Stress can be a good learning experience
Experiencing stress in sports can be a good learning experience for teenagers. Sports participation can teach your athlete how to handle competition, defeat, and even performance anxiety. It can teach your teenager about physical fitness, how to develop social skills and friendships, and the importance of team-play in sports and in life. The stress of trying out and not being accepted on a team can be a positive learning experience if handled well, or a very negative one if handled badly. Parents and clinicians can be very helpful to teenagers by acknowledging this fact and discussing such issues with them.

Stress can also lead to problems
Negative consequences of overwhelming stress are many, including chronic fatigue (‘athletic burnout syndrome’), depression and rapid loss of previously learned skills. ‘Burnout’ can also result from over-training, encouraged by overzealous parents, coaches, or the teenagers themselves. Children and teenagers should enjoy their sports participation and not be forced by parents or coaches to specialize in one sport too early, in the hopes of producing a famous professional superstar. Teenagers who excel at one sport may feel sad or anxious during its off-season. Encouraging other, perhaps noncompetitive sports and social activities during this time may help teenagers who are temporarily on break from their sport.

Helping to relieve sports-related stress
There are a number of techniques that can be helpful in preventing or reducing sports-induced stress. Relaxation training, meditation, hypnosis, breath control, yoga, prayer, and biofeedback are all techniques that help to relieve stress. I recommend that athletes who are under excessive sports-induced stress work with sports medicine clinicians or psychologists who can teach them some of these methods. You can talk to your health care professional to get more information or a referral, if needed.

Developing positive sports goals
Parents should avoid joining the current milieu of ‘victory at any cost’, which is noted in many organized sports programs, including high school competition. I recommend that parents and school personnel encourage adolescents to set positive goals in their sports activities. Learning the joy of physical activity and acquiring a sense of competence are two such positive goals. Our teenagers should not be placed under overwhelming pressure to win. You should not push your children beyond their abilities nor teach your children that self-esteem comes only from winning. Some young people I have treated feel that they are loved and valued only if they do well in sports. Just go to a sports event at any junior high or high school and you can see parents yelling at their children, coaches, umpires and fellow parents, in a vain attempt to teach love only through victory. Parents must be aware of this attitude and guard against it.

Psychosocial Development
We should remember that children, young teenagers and older teenagers are at different stages of development, and their level of development may influence their sports performance.

Young teenagers
Young teenagers (ages 11-14) may not be able to see into the future very well and they may only be able to manage the ‘here and now’ issues; if your child is like this, he is called a concrete thinker. Also, young teenagers often raise many concerns about various aches and pains that are sometimes (though not always) related to sports activities. Some young teenagers worry that these normal aches and pains are associated with a more grave condition. This transient stage of worry is called the hypochondriacal stage of early adolescence.

Now with all these factors combined, you may have a young athlete who has various aches or pains and is afraid the discomfort will never end. Young athletes who suffer from a minor injury may really struggle with being out of the game for a short period of time, and a short period of time may feel like forever to them. I find that a month may seem like forever to some young, concrete-thinking teenagers. You, and your child’s coach, should understand this dilemma and should not be surprised if your young teenager is temporarily irritable.

Older teenagers
Many older teenagers (ages 15-19) develop more reasoning skills as their minds mature. These so-called abstract thinkers need more logical explanations in response to questions, whether about sports, school or other aspects of their lives. Parents and coaches should be patient with these increasingly demanding minds, and provide them with explanations.

If you have an adolescent who is experiencing rapid deterioration of his athletic performance, he may be overwhelmed by common adolescent concerns of current times, such as family conflicts, mood swings, drug abuse, or depression. Keeping in mind the normal psychosocial development of teenagers can be helpful for you as you watch your children mature, in athletics and in all aspects of their lives. Do not, however, be afraid to get an evaluation from your primary care clinician or other health care professional who is knowledgeable about the effects of sports, if you suspect problems are developing.

Precocious Development
The precocious teenage athlete who starts physical development before his or her other peers (the early developer) may be called a ‘superstar’ and may become the object of considerable attention and praise from parents, other family members, coaches, and fellow students. This can be seen even in pre-junior high school sports.

Putting eggs in more than one basket
If you have a child like this, please note that only one-fourth of these young ‘superstars’ will remain in this enviable category through high school and beyond, as other peers catch up and even surpass the early developer. The resulting frustration can be quite severe for you and your child. Your teenager may be accused of being a ‘loser’ or of being lazy because she is no longer more successful than her peers. A teenager in this position may find himself considerably disturbed by these circumstances. He may experience depression or anxiety, and may express a number of negative behaviors. I advise parents of these young stars to follow them carefully and provide them with alternative activities so that they can develop healthy, well-rounded lifestyles. Actually, all parents of athletes should ensure the normal development of their teenagers’ other abilities (e.g., music, art, scholarship).

Delayed Puberty
Young people with delayed puberty (delayed physical development) are smaller than other teenagers their age, and in the sports arena they are often ignored by peers and sports coaches. When they compete against more physically advanced peers who are usually larger and stronger, the risk of injury to the less mature teenager dramatically increases. Parents should be sure that school officials match up their athletes properly to provide as low a risk of injury as possible. Those teenagers with delayed puberty should be assured that full puberty will eventually occur.

Patience, the golden rule
Maximal weight gain and muscle strength normally occurs several months after ‘the growth spurt’. A tall, thin, late-maturing boy may grow tall quickly but still not have the muscle strength and power of a shorter, more physically developed peer. Parents and coaches should avoid placing premature expectations on a teenager who may not be able to compete against more physically mature peers for several months or even years. If a developing teenager is pushed too fast, psychological and physical injury may result. Today’s pressure for victory may result in false charges of ‘sub-par’ performance - frustrating all involved with long-lasting consequences.

Adolescent Awkwardness
‘Adolescent awkwardness’ refers to a temporary time of motor incoordination in some teenage boys during their growth spurt. This temporary awkwardness is often seen in rapidly-growing boys. It can last approximately six months and affect important skills such as balance and general coordination. The growth in teenage boys, from trunk to legs, may influence this phenomenon. These teenagers should know that it is a normal growth phase and it will pass. Unrealistic performance should not be expected of these athletes.

Obesity
Some parents who perceive their children as obese may ‘push’ their children into active sports play in the hope that it will help their children lose weight. Though sports activity may be useful in helping a teenager control and even lose weight, my advice is that severely overweight children often benefit more in the long run from nutrition counseling and exercise training. Obese children may be more or less developed than their peers, but if an obese teenager is less developed, he or she may be at risk of serious injury in collision sports. Adipose tissue (fat tissue) is not as strong as muscle tissue, and puts these children at greater risk of injury.

Chronic Illness and Disability
Teenagers with chronic illness or disability can still experience the joy of participating in some modified sports. Clinicians and school personnel can work together to see that this is possible and encouraged. Parents can work with their teenager’s clinician to craft a physical activity to suit the teenager’s level of ability. Chronic illness or physical disability should not deter teenagers from participating in realistic sports activity.

Injuries
As parents of teenagers who play sports, we all fear that our children will be injured at some time in their sports careers. In fact, many are hurt and need thoughtful attention. A careful injury-management plan should be developed, and it is important not to minimize the extent of the injury. There is often a great temptation, on the part of a parent, a coach, or the athlete himself, to rush through recovery. Some teenagers find that their time away from a sport is actually a positive experience. Many do not.

Teenagers’ response to injury

The response of athletes to physical injury may involve five stages:
1. Disbelief with Denial and Isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance and Resignation with Hope

Initially, an athlete may not believe that she is injured and may try to continue playing her sport. An injured teenage athlete may isolate herself from family and friends and may become angry. She may then become depressed when she fully realizes that she will need to stop playing her sport during the recovery period. This realization may be overwhelming for a teenager. Understanding the ‘injury stage’ your teenage athlete is in can be helpful in responding to any injury-induced behavior. Various behavioral techniques, such as relaxation training or problem solving methods are helpful in combination with medical treatments and physical therapy. The teenager’s physician should be able to recommend medical professionals who can help.

Don’t succumb to the pressure
An injured teenager may not recover as quickly as he wishes and may push his parents or clinician to let him get back to the game before he’s fully recovered. You should avoid yielding to your teenager’s desire to return early to his sport. Certainly, parents should avoid putting pressure on a teenager to return to practice or competition early. Identifying realistic goals in the recovery process is important, and a teenager should get back to his sport at the appropriate time, after he has achieved the best possible recovery.

Summary
Sports offer teenagers a wealth of positive experiences. Sports participants can learn how to win gracefully and lose without losing hope. They can also learn how to put winning and losing in perspective. Many teenagers are not physically active - 50% of high school females and 25% of males are not involved in vigorous exercise. Participation in a sports regimen as a teenager may help teenagers continue regular physical activity into their adult lives.

There are, however, a number of factors that may interfere with a positive sports experience. Teenage level sports have, in recent times, become very highly organized and very competitive activities. In many cases we have lost the spontaneous, fun aspects of participating in a sport. Parents’ familiarity with adolescent psychological and physical development may help them regain their own perspective about the real benefits of sports activity for their teenage children.

Sex and Teens: What's Going On?

2007-12-13T08:58:00.001-08:00

Sex and Teens: What's Going On?

By: Jennifer Johnson, MD, MS & David Bell, MD

If there's one age group that parents wring their hands over, it's teenagers between the ages of fourteen and seventeen. They are in the throes of adolescence, which often means they are moody, private, likely to take risks, and likely to challenge authority and conventions. One day they behave like five-year-olds, the next like mature adults.

Most teenagers have entered puberty, and are actively exploring their sexuality, and it can be a profoundly confusing time.

Below, two adolescent health experts discuss what parents and their middle adolescent children need to know about sex and sexuality.

What is one of the primary concerns among teenagers, as their hormone levels are increasing and they are beginning to see changes in their bodies?
DAVID BELL, MD: One of the main things teenagers want to know is that everything is normal. They're comparing themselves a lot with their peers, and part of the process is to figure out what's normal and what's not.

JENNIFER JOHNSON, MD: There's a lot of comparing of naked bodies among kids, they're thinking, "What's he look like, compared with what I look like?" That's what happens in the showers in the gym. Of course, no one admits to looking at anybody else, but they do it because they're coming to terms with their new body and seeing it compared with other people's bodies. It's really important.

In terms of sexual development, is masturbation normal at this time?
JENNIFER JOHNSON, MD: Yes, I think the majority of kids have masturbated, especially by the time they've reached the ages of sixteen or seventeen. Most kids do it, regardless of what they've been told about it.

Medically, we know that masturbation is perfectly safe and, in fact, can be a very healthy outlet for these strong sexual drives that kids are experiencing.

Are wet dreams normal at this age as well?
DAVID BELL, MD: Yes. During their sleep at some point during puberty, boys may have a nocturnal emission, or a "wet dream." Basically it's the release of semen or sperm during the night, during their sleep.

Is this disturbing for some boys?
DAVID BELL, MD: Yes. And that's one important reason for parents to have a discussion with their teenage boys about wet dreams before they happen, just as we do with females before their first period, to prepare them for it. If a boy does not know what a wet dream is, he may think he urinated in the bed, and that can be devastating.

Is same sex experimentation normal at this time as well? How common is it?
JENNIFER JOHNSON, MD: We don't have a lot of information about how common same sex experimentation is. But certainly when and if it does happen, it's very normal. Again, it's a way for teenagers to assess their own growth, and compare themselves to their peers.

DAVID BELL, MD: I think it is important both for parents and for the teenager not to label their sexual orientation based on episodes like these.

JENNIFER JOHNSON, MD: Right. Sexual orientation is often still emerging in adolescents, and sometimes it changes during a person's life. It's important to differentiate sexual orientation from sexual behavior, because guys and girls may have same-sex sexual experiences and be completely heterosexually oriented. By the same token, boys and girls who are gay may have heterosexual relationships, including intercourse, and not have homosexual experiences until later in life.

Are children between the ages of fourteen and seventeen having sex? What does the research tell us?
JENNIFER JOHNSON, MD: The national data show that by the time teenagers are in their senior year of high school, about 60%, maybe 70% of boys have had sex, and probably about 50% of girls have had sex. By 'sex', they mean oral sex or intercourse.

So if you want to view it strictly in behavioral terms, having sex in high school is, in our society, a normative behavior, meaning more people do it than don't.

Do you find that kids who want to abstain from sex feel comfortable in abstinence? Or do they feel a lot of pressure to be sexually active?
JENNIFER JOHNSON, MD: In some schools there are very, very strong abstinence movements, and the cool thing to do is to say you're not going to have sex. But it varies a lot from teenager to teenager and from peer group to peer group.

One thing that is very certain is that the behavior in a peer group is the indication of the level of risk for a member of that group. If my daughter is hanging around with girls who smoke and drink beer at parties, I know that she in danger, because certain risk behaviors, like smoking, are linked with the initiation of sexual activity.

DAVID BELL, MD: There's also data from the Adolescent Health Survey that shows that the more connected teenagers are to either their family, to school, or to extracurricular activities, the safer they are in their relationships and behaviors.

What are the statistics on contraception use among sexually active teenagers?
JENNIFER JOHNSON, MD: One of the recent national representative surveys of teenagers found that, in contrast to the 1970s, almost two-thirds of teenagers use contraception the first time they have sex. That is a far cry from the 10-20% that we were seeing in the Seventies.

Is this increase a result of education campaigns?
JENNIFER JOHNSON, MD: Yes, I think so. Kids know about birth control and why it's important to use it. And, in general, they have access to at least condoms.

Teenagers may not ask their parents directly for information about sex, but do they want to hear what their parents have to say on the subject?
DAVID BELL, MD: I think, in some respects, yes, they do, but it's a delicate balance of when and how to deliver the information.

Sometimes the adolescent will ask about sex in reference to a friend. That opens up an opportunity for the teenager to share their own values and thoughts.

JENNIFER JOHNSON, MD: Parents need to know what's going on in these areas. On the other hand, I think it's important for parents to recognize that teenagers are becoming independent and they do, to some extent, have rights to privacy. They do have the right to have time alone in their room without anybody being in there.

That doesn't mean that parents can't talk to kids. But rather then just telling them what you think, you may open the door a lot better if you ask their opinion too.

I also think it's really important for parents to spend time with their teenager. It is very helpful, in terms of keeping communication open and demonstrating your commitment, if you do something together that you both enjoy doing.

DAVID BELL, MD: Some of the best conversations with your teenager come at unexpected times, whether riding in a car or on a camping trip...it's not this formal, sit-down talk about the birds and the bees

Club Drugs and HIV: The Agony and the Ecstasy

2007-12-13T08:56:00.000-08:00

Club Drugs and HIV: The Agony and the Ecstasy

With: Perry Halkitis, PhD

People take street drugs to escape from the realities of their lives. But when they come down in the middle of the night, or the next morning, their problems are still there waiting for them. And statistics show that people who take club drugs like methamphetamine, also known as crystal, may wake up to a brand new problem: HIV infection.

Club drugs like methamphetamine release people from their inhibitions, leading some otherwise sexually responsible men, women and teenagers to engage in risky sexual behavior. For people with HIV, club drug use can interfere with their ability to stick to their drug schedule—and may make the virus replicate faster in their bodies. Below, Perry Halkitis, PhD, a chair of the department of applied psychology at New York University, discusses the relationship between club drugs and HIV infection.

What is the state of the HIV epidemic today?
We've seen a worsening of the HIV epidemic in the last several years. Infection rates were stable during the 1990s, but in the last few years there's been a spike in new HIV transmissions across the population, especially among gay and bisexual men. In this population, there was a 14 percent increase in new HIV infections between 1999 and 2001.

What has lead to this increase?
First of all, there's a fatigue around HIV in the gay population and in the general population. People feel that the HIV epidemic is over, and they're more complacent about safer sex practices. They think there's a cure and, as a result, people are not being as safe or as responsible in their sexual behavior.

Number two, prevention efforts haven't evolved as people have become sophisticated about HIV. So "Use a condom every time" campaigns, which worked fine in the early 1980s and the mid-1980s, are no longer effective.

We're also seeing a complex interaction between sexual risk-taking and drug use in the gay population and also in the straight population. We're seeing this in particular with a subset of drugs known as "club drugs" because of their association with dance clubs and bars.

Are people still going to clubs to do these drugs?
Twenty years ago, these substances were used a lot in dance club situations. Our research shows very clearly that people do them at home, they do them with their friends, they do them in the park—they do them wherever they need to do them. Some people have suggested that maybe a better label for them would be "party drugs" because these are the drugs that people do to have wild and inhibited sex, to go dancing, or to do both of those things in combination.

Which drugs are contributing to increase HIV risk?
We're talking about methamphetamine, also known colloquially as "crystal." We're talking about MDMA, which is known commonly as "ecstasy." We're talking about ketamine, Rohypnol and we're still talking about cocaine, to some extent. Most importantly, we need to think about not just each of these drugs in isolation, but these drugs being used in combination with each other, and in combination with alcohol and prescription drugs such as Viagra.

Which drugs are the most worrisome and why?
Perhaps the most worrisome is methamphetamine. This is a psychostimulant and a form of speed. Crystal is a hypersexual drug. It's a hugely disinhibiting drug. We know, and it's been clearly documented, that people who are using this substance have sex without rational thinking, they have multiple partnerings, they just let go. They feel like they're on top of the world, so nothing is a problem and any logical thinking around safer sex practices gets wiped away.

Methamphetamine is also a problem because it's a highly addictive drug from a psychological perspective, so people have a very difficult time coming off of it because the cravings are so intense.

Does the way methamphetamine is administered affect HIV risk?
Absolutely. When a person first starts using it, methamphetamine is usually snorted. Eventually chronic users begin to smoke it because it is a more effective way of ingesting the drug; it gives a better and a longer and a faster high.

Eventually, people who are dependent on the substance become injectors of methamphetamine. They inject it in their veins or muscles because it creates a much quicker and more intense high. So transmission through injection and the sharing of needles and the sharing of works creates another route of HIV transmission that is linked to methamphetamine use.

Do we know how much club drug use is affecting HIV risk?
We know—anecdotally in New York City and from documentation on the West Coast—that when we look at gay men who have become HIV-positive, more often than not, in the last several years, these men report having used methamphetamine with sex.

So while we're not able to put an exact number on it, you can bet that a large percentage of new seroconversions are among people who are drug users.

Does methamphetamine make oral sex riskier?
We know that the mouth produces saliva, which has protective factors that assist in the prevention of HIV. When people are high on methamphetamine, they have extremely dry mouths. Suppose an HIV-negative person is using methamphetamine and is having sex with an HIV-positive person. That is more dangerous than having sex with a person who is not high on methamphetamine.

What role does depression play in drug use?
We should never deny the fact that drugs make people feel good; that's why they do them, right? What we know, also, is that people often use drugs in our society to mask bad feelings. So people who are experiencing depression or loneliness or low levels of self-esteem, which can be addressed with therapy and with medications, are self-medicating by using these substances.

The unfortunate cycle that develops is that people who are depressed, for example, go on crystal, use crystal, feel better while they're high and then crash and feel even worse than when they started.

When we address HIV in the United States, I think it's incredibly important that we think about the link that exists between drug abuse, mental health and HIV. Addressing one of those issues in isolation doesn't seem to be sophisticated any more. We need to address all those three things together.

How does drug use affect people on HIV therapy?
What we know, from our work, is that adherence—taking your medications the way you're supposed to take them—is a problem across the board. If we believe the literature, people are supposed to be adherent 95 percent of the time. It's very hard for people to be adherent 95 percent of the time when they're high. When they're feeling good, the last thing they want to do is actually stop to remember to take their medications.

Number two, we know that methamphetamine is an immunosuppressant. Methamphetamine that is sold on the street is not pure methamphetamine. It's been cut with talc, heroin and variety of other substances that have an effect on people's immune systems.

Number three, and probably most alarming of all, is that some recent studies indicate that even if an individual is highly adherent to his or her medications, if they are using methamphetamine, replication of the virus in the brain is accelerated.

What do you want to say to people who use methamphetamine?
To people who haven't started who hear wonderful tales about this drug, don't start using it. This is not a wonderful drug. The price that you will pay in the long run is not worth it.

To people who are started, I say, look for help. Because what do we know about methamphetamine and its effects on people's lives? People become physically ill and they become socially ill. They lose their friends, they lose their family and they lose their jobs. Methamphetamine has often been referred to as the "Grim Reaper," because of horrible and devastating effects it has on people's lives.

How can people reduce their risk of HIV?
Clearly, one of the strategies is abstinence from both sex and intravenous drug use. For young adults and for adolescents, becoming totally informed and educated about HIV and its transmission is going to be a very important strategy, as well as considering delaying the onset of sex until an individual is at a point where he or she can make the right choices around sex.

The consistent use of condoms, of course, is important with anonymous or casual partners. Even in the context of some relationships that are not monogamous, the use of condoms is actually a really good idea.

Finally, the mixing of sex and drugs is not a good idea. Try to keep those things separate. A glass of wine is very different from two lines of methamphetamine. The combination of drugs and sex is where a lot of the risk is happening now and where a lot of the transmissions are actually occurring, so do not mix those two things.

It's extremely important for individuals in our country to remain informed. The disease is constantly changing. There are new medications that are coming out that are effective. But people are not necessarily living their whole lives with HIV; people are still dying. So remaining informed about HIV and remaining informed about strategies for safer sex is important.

Are You Overweight? Using the New NIH Weight Guidelines

2007-12-10T09:36:00.002-08:00

Are You Overweight? Using the New NIH Weight Guidelines

By: Judith M. Ashley, Ph.D., R.D.

If you are facing the effects of "creeping" weight gain, how do you know when you should really get serious about losing those extra pounds? After all, based on the growing percentage of Americans who are overweight (see Table 1), it is likely that many of your friends, colleagues, and relatives are experiencing the same weight gain. How do we know if those "love handles" are not just a middle age phenomenon or a problem that you need to deal with?

In 1998, The National Institutes of Health (NIH) issued standards to help you determine if you are overweight or obese. These standards are based on the most extensive review of the scientific literature conducted to date regarding the relationship between weight and health risk by the Obesity Education Initiative Expert Panel. The Panel systematically evaluated published scientific literature from 1980 to 1997. The report established guidelines, or "standards of care," for physicians and health professionals to utilize in managing patients with a broad range of weight problems. The guidelines included what measurements to use to determine if a person is overweight or obese, as well as how to initiate and maintain a weight loss program.

The NIH recommends two measurements that you can determine at home---the body-mass index (BMI) and waist circumference---which will give you an accurate idea of what shape you are really in. These numbers go beyond a simple bathroom scale reading or a number from a weight-for-height table hanging in your physician's office.

Taking the Right Measurements
Body Mass Index

The BMI describes body weight relative to height and is strongly correlated with how much body mass, including fat, a person has.

To calculate the BMI, either weight in pounds and height in inches OR weight in kilograms and height in meters, can be used.

The BMI is the weight in kilograms divided by the height in meters squared [wt (kg)/ht (m)2] or the weight in pounds divided by the height in inches squared times 703 [wt (lbs.)/ht (in)2] ] x [703] (see Table 2).

For example, for someone who is 5'7" tall, their BMI would be 25 at 159 pounds, or their BMI would be 30 at 191 pounds (see Table 3).

The range that is considered healthy is between 19 to 25. A person with a BMI of 25 or greater is considered overweight; with a BMI of 30 or greater the person is considered obese; and with a BMI of 40 or greater, the person is considered extremely obese.

Solid evidence demonstrates that the risk for various diseases rises significantly when the BMI is over 25 and that risk of death increases as the BMI reaches and surpasses 30. The BMI number applies to both men and women. Some people who are very athletic and have a heavier muscle mass may have a higher BMI without the same health risks. The BMI is also used to determine whether weight loss drug prescriptions or surgery should be considered. FDA approved weight loss drugs are only recommended for those with a BMI > 30, or a BMI > 27 when an obesity-related disease already exists. Surgery for weight loss is an option when conventional methods have failed for those with clinically severe obesity measured by a BMI > 40, or a BMI > 35 with an obesity-related disease.

Waist Circumference

The waistline, or waist circumference, is a familiar body dimension that reflects abdominal obesity. The easiest way to measure yourself at home is by measuring your waistline at the level of the navel or at the narrowest waist midpoint using a tape measure. A health professional may be more specific in this measurement, using the midpoint between the lower border of the rib cage and the crest of the hip. A woman with a waist circumference over 35 inches (88 cm), or a man with a waist circumference over 40 inches (102 cm), is carrying too much fat around the abdominal organs. Fat around the middle changes the way the body uses fat, which can lead to diabetes, heart disease and cancer. Fat in a large abdomen is more likely to break down and enter the blood where it can clog the arteries.

NIH Weight Loss and Maintenance Recommendations
The NIH guidelines also include strategies for weight loss and maintenance.

The first recommended strategy is to focus on reducing overall calories. The diet should be individually planned to help cut back between 300 and 1,000 calories a day.

It is estimated that 3,500 calories translates into approximately 1 pound of weight loss, so cutting back on 500 calories over 7 days would mean a 1 pound weight loss in a week. As an example, for those with a BMI in the typical range of 27 to 35, a decrease of 300 to 500 calories per day will result in weight losses of about 1/2 to 1 pound a week and a 10 percent loss in 6 months. For more severely obese people with a BMI > 35, cutting back on 500 to 1,000 calories per day will lead to weight losses of about 1 to 2 pounds per week and a 10 percent weight loss in 6 months. If further weight loss is necessary, an evaluation is made at that point, with adjustment of the diet plan, since it is common to see the rate of weight loss decline and plateau after 6 months because of reduced energy expenditure (lower basal metabolic rate) at the lower weight.

The second recommended strategy takes into account the output part of the energy balance equation: physical activity and exercise. Increasing the loss of calories through physical activity not only helps with weight loss, but it also has benefits of its own, including improvement in physical fitness and appearance. Physical activity should be initiated slowly and become part of any weight loss or maintenance plan. The recommendation is to start out with 30 to 45 minutes of activity, three-to-five days a week, including activities such as walking or swimming at an acceptable pace. With this regimen, an additional expenditure of 100 to 200 calories per day is possible. The goal is to reduce sedentary activity (sitting, lying down, etc.). For many people this translates into a simple habit of getting up and walking as often as possible throughout their normal day. (Please see our article, Weight Loss and Physical Activity, for further information on this topic.)

Summary
The NIH guidelines discussed in this article will be influential on many fronts. By classifying certain measurements into categories (overweight, obese, extremely obese), it will help people decide if they should ask their doctors about their weight problems and the risk it may be posing to their overall health. It will also help physicians and other health professionals to determine if a particular patient should start a weight management program, and what type of goals should be set. Furthermore, since these NIH guidelines are considered the "standard of care," they are laying the groundwork for the types of services and medications covered by managed care companies and other insurance plans in the area of weight management.

Why Weight Matters

2007-12-10T09:36:00.001-08:00

Why Weight Matters: Obesity and Your Health

By: Robert Kushner, MD

We are a growing nation. In fact, according to the National Institutes of Health, more than sixty percent of Americans aged twenty years and older are overweight, and one-quarter of American adults are also obese.

What does this mean for the health of our nation? Nothing good. Obesity-related diseases are "implicated" in more than a quarter million deaths every year. Below, Dr Robert Kushner, Director of the Wellness Institute at Northwestern Memorial Hospital, discusses the grave consequences of our growing sizes.

How serious is the problem of obesity?
ROBERT KUSHNER, MD: It's the most serious problem we are facing today. Next to cigarette smoking, overweight is the second leading cause of preventable death in this country. It's estimated that 300,000 deaths per year is attributable to our diet, physical inactivity and resulting obesity.

What are the current statistics on overweight and obesity?
One in four is obese, and about one in three is considered overweight. Combined, over 60% of adult Americans are now overweight or obese. That means that the minority of this population is able to maintain a healthy body weight.

We're now hearing a lot about children being obese. What is the number there?
It's about 1 in 10, or 10%. The troubling factor there is that children are following in our oversized footsteps. An overweight or obese child is more likely to be an obese adult. So we are looking at an epidemic among our children as they become adults, and are likely to be more obese than we are today.

Why has the number of heavy people increased?
That's still debatable, and a lot of research is being done. But most of us think that it's due to our society and culture. We really live in an obesogenic society where food is plentiful, physical inactivity is everywhere. Those two factors combined lead to gaining weight.

How is obesity defined?
We currently define obesity by using a term called the body mass index, also known as the BMI. Everyone knows their cholesterol and everyone knows their blood pressure. It's equally important that everyone knows their BMI. It's a weight for height relationship that's fairly easily calculated on tables. A BMI between 25 and 30 is defined as overweight. A BMI of 30 or more is obese.

Roughly speaking, about 30 or more pounds overweight already defines one as obese.

Just 30 pounds?
Just 30 pounds. It doesn't take much to have the health complications that are associated with obesity.

Talk about those complications, the health effects of obesity
Obesity is the major cause of type 2 diabetes in this country. Obesity is the number one reason why diabetes is increasing in this country. It is fueling that disease. In addition to diabetes, obesity is also linked to increased risk of high cholesterol, high blood pressure, gastroesophageal reflux disease, certain cancers, in addition to psychological and emotional problems, as well as quality of life changes. It eventually leads to earlier death.

What are the leading causes of obesity?
The most significant factor really is our lifestyle. That's the only way that we can understand why the numbers of obese patients or individuals has risen so quickly. Again, that's the food that's everywhere and the physical inactivity.

But genetics plays a role as well. We currently think that genetics determines a vulnerability to our environment, which then brings out the obesity.

There are other causes, although less common. They include drug-induced obesity, such as people on different corticosteroids or different hormonal agents. Those medications can increase body weight, not to mention things like antidepressants and other drugs used for mental health disorders.

Rarely is an underlying medical condition a cause for obesity. That would be something like Cushing's syndrome or different kinds of glandular problems. But they are, once again, very uncommon.

What is the first step in getting treatment for obesity? Where does a person go for help?
There are several places an individual can go for help. One is, and the first that I would recommend, is to see his or her doctor. A doctor should be an active partner to a patient who is trying to get control of body weight. The doctor can also make sure that you don't have an underlying problem that is either being caused by obesity or causing the obesity itself. That needs to be ruled out right away.

Once you've done that, you can either work with your doctor or work with a registered dietitian or seek help with some of the commercial programs that are available, which can be very helpful.

Low-Carbohydrate Dieting

2007-12-10T09:35:00.001-08:00

Low-Carbohydrate Dieting: Exposing the Myths and Realities

By: Fred Pescatore, MD, MPH

Everywhere we look, we see something about low-carbohydrate dieting—television, radio, bookstores, and newspapers. Everyone we know seems to be on a low-carbohydrate diet. But what is low-carbohydrate dieting and how do we know which diet to follow, which is the healthiest, and most important, does it really work? In this brief article I am going to show you exactly what low-carbohydrate diets are and compare and contrast the most popular ones currently available with a diet I have been working with for the past few years.

I used to be the associate medical director of the Atkins Center for Complementary Medicine. Yes, that is the same Dr. Atkins whose very popular diet plan has swept the nation. In the five years I worked there, I was able to learn, first-hand, the health benefits of low-carbohydrate eating, but I was also able to learn which aspects were healthy and which ones were just hype.

When I first started working there, I had just finished residency training and knew nothing about nutrition. After all, they didn’t teach nutrition in medical school, nor was it emphasized when you were working in a hospital trying to handle life and death emergencies. Nutrition was something that was always left up to the dieticians. The doctor had to order the diet, but none of us really knew what the diets we ordered ever consisted of. Looking back, I now know what a terrible mistake this was.

Low-Carbohydrate Dieting
In a nutshell, low-carbohydrate dieting consists of eliminating most forms of carbohydrates. Carbohydrates come in many forms. They can be sugars, breads, pastas, pretzels, crackers, fruit, vegetables, and soda and fruit juices. Many people can’t believe that fruit and fruit juices are carbohydrates because they are really mostly sugar. Several recent studies even go so far as to suggest that the rise in obesity in our population is directly attributable to the rise in the consumption of fruit juices.

Sugar
For those of you who may not be aware of how fattening fruit juices can be, apple juice has more sugar in it than the same amount of soda. Sugar is the food that is eaten the most in this country. We eat 150 pounds per person, per year. That translates to 33 tablespoons each day. That may seem like an unrealistic amount, but when you begin to understand what you are eating, it is really quite easy to get to that level quickly without even realizing it. When I place my patients on the diet program I use in my practice, they come back in two weeks into the program, after having read all the food labels, and tell me that they can’t believe certain foods actually contain sugar. What’s worse, there are more than 300 foods that are not required by the federal government to list sugar as an ingredient, when in fact, they do contain sugar. As Americans, we consume more calories of sugar than we do of meat, chicken, vegetables, and breads combined.

Different forms of sugar
One of the main reasons we don’t know how much sugar we consume is because sugar has many disguises, such as brown sugar, corn syrup, honey, molasses, maple syrup, high-fructose corn syrup, dextrin, raw sugar, fructose, polyols, dextrose, hydrogenated starch, galactose, glucose, sorbitol, fruit juice concentrate, lactose , brown rice syrup, xylitol, sucrose, mannitol, sorghum, maltose, and turbinado. Essentially, any word on a food label that ends in -ose, or -ol is a sugar in disguise.

Carbohydrates
Why is keeping a low carbohydrate level so important? The explanation requires a little understanding of the basics of how food is metabolized in the body. Our bodies metabolize food in the same manner as the bodies of our prehistoric ancestors. The body preferentially uses sugar for fuel since the body doesn’t have to expend any energy to break it down for fuel. Next, the body will utilize simple carbohydrates such as pasta, bread, pretzels, and the like, simply because it doesn’t take much energy to convert these into sugar for fuel. Next, the body uses complex carbohydrates such as vegetables, brown rice, legumes, and whole-grain starches as fuel because the body has to expend energy to process these foods back into sugar in order to be used by the body. The body will then use protein for fuel, and use fat last.

Fat
The reason the body uses fat last is because fat is the perfect storage molecule for the body. Fat holds more than twice the amount of energy than either a carbohydrate or a protein, so the body, in its infinite greatness, will store those bits of energy (also known as calories) for a rainy day. For most of us in this country, that rainy day never comes and it is our hips and waist that suffer the brunt of this storage of energy.

The next logical assumption should be to eliminate fat from the diet and by doing so would solve the fat problem—right? Wrong! Because our bodies create stores of fat molecules, namely triglycerides, we have an excess of sugar in our bodies. The real key to dieting is therefore to eliminate the bottom of the food chain—sugar and simple carbohydrates—thus, forcing our bodies to utilize the complex carbohydrates, protein, and fat that we consume. Our bodies then begin to operate as they were meant to operate. Our prehistoric forefathers never had processed foods, and that is all sugar and simple carbohydrates are.

Losing Weight
By eliminating sugar and simple carbohydrates, we can lose weight easily and efficiently. I explained this concept to a patient I will refer to as Susan. She was 43 years old and was a strict believer in the low-fat philosophy, yet no matter how strict she was, she gained weight, felt less energetic each day, and needed to lose about 60 pounds. In order to explain the concept of how food is metabolized, I often measure blood insulin levels. Her insulin level was twice the normal amount when she was fasting and more than four times the normal amount two hours after she had eaten.

Insulin levels
High insulin levels have been linked to a variety of diseases: Diabetes, blocked coronary arteries, high cholesterol, high triglyceride levels, high blood pressure, strokes and most important, obesity.

Insulin is the hormone in your body that reduces your blood sugar. When there is too much blood sugar, in a condition known as insulin resistance, your body becomes overwhelmed and can’t do its job. A high-carbohydrate, low-fat diet can never correct this insulin imbalance or any underlying cause of obesity because it is too high in sugar. When you eat a low-carbohydrate, high-protein diet, your body can better metabolize the food that you eat and the insulin levels return to normal, and the weight comes off. Even if you are not overweight, the proper regulation of insulin levels is the key to avoiding some of the deadliest diseases that we face in this country.

Safe and Healthy Eating
I keep emphasizing low carbohydrate rather than no carbohydrate because that is the real key to dieting in this way in a safe and healthy fashion. Bill, a 54-year-old executive came into my office about 40 pounds overweight. He had tried all of the more popular low-carbohydrate diets and had lost about 50 pounds, but he suddenly got stuck, and for the past six months, was unable to get the scale to budge, despite having increased his sessions with his personal trainer.

I explained to him my theory as to why the body needs some good carbohydrates—in order to get the metabolism to function efficiently. I also explained to him that when the body is placed into ketosis, for example, for an extended period of time, that gimmick stops to work. Ketosis is actually what happens to your body when it is starving and your body begins to break down muscle protein. Your body will adapt and the ketosis becomes less effective at helping the body to lose weight. You can only fool Mother Nature for so long. I gave him the program I use, which consisted of more carbohydrates than he had been consuming for over a year, and within three months, he lost the remaining 40 pounds and an extra 10 to “play around with,” as he put it. He was able to do this because he had learned which carbohydrates to eat, and was not told, “eat all you want.”

Moderation is the Key
Many of the low-carbohydrate diets that are currently popular encourage the notion of “all you can eat.” While this certainly works in Las Vegas, it can’t possibly be expected to work over the course of someone’s lifetime. You simply can’t tell an overweight person to eat all of anything. It is the wrong message to send out.

The message to eat all the fat you want without worrying about it is also wrong. The most important thing I learned while at the Atkins Center was that the amount of fat does play a role in how much weight a person will lose. Also, the type of fat is vitally important. There are good and bad fats available for us to consume. I just don’t buy the belief that eating all the bacon fat you want is healthy for you.

The medical literature supports the theory of “good” and “bad” good fats such as omega-3 fatty acids—the type you find in fish. The medical literature similarly supports the theory that there are fats you shouldn’t be consuming, like the trans fats found in margarine and the hydrogenated fats found in most oils, except for olive oil and canola oil. The current fad-diet books do not take any of this research into account when helping you devise an eating plan that is supposed to make you healthy and stay that way.

Another popular book tells you that you should eat a meal that consists of anything you want as long as you do it in a certain time frame and that it is a certain set number of meals. For example, every third meal, you are allowed to eat all you can eat for an hour. That is a gimmick if you ask me. As you cannot tell an overweight person to eat all of anything, you cannot tell an overweight person they can eat any kind of food and still lose weight healthily. In medical school, I went on a chocolate pudding and French-fry diet and managed to lose weight, but it was not a healthy way to do so. Many people want to lose weight. More than half of us are seriously overweight. If you want to do something about it, you need to learn how to eat a proper diet.

The Thin Mind
Thin people think and treat food differently than we do. We need to learn how to eat and think like they do if we want to have any hope for success in the long run. And isn’t that what it’s all about—a lifetime of good health and looking good?

I should know, as I was once 80 pounds heavier than I am today. For the first time in my life, I can actually say that I have been thinner for longer than I was ever overweight. It is because I have been able to incorporate a sensible low-carbohydrate diet into my life.

Conclusion
Don’t be afraid of low-carbohydrate dieting—it is healthy and it does work. Be afraid of gimmick diets. They may just be snake oil after all.

Cervical Cancer: What's the Story with Screening?

2007-12-07T08:32:00.000-08:00

Cervical Cancer: What's the Story with Screening?

With: Alan G. Waxman, MD

It's important to recognize that cervical cancer is one of the few preventable cancers, thanks to a highly effective screening test discovered by George Papanicolau, MD, in the 1950s.

"We forget that, in the 1940s and earlier, cervical cancer was a very common cancer in the United States," says Alan G. Waxman, MD, an associate professor of obstetrics and gynecology at the University of New Mexico School of Medicine in Albuquerque. Since the Pap test was first introduced, the cervical cancer rate has dropped by roughly 50 percent. But the rate is still high among minority and low-income women, who are not screened regularly.

In the last few years, new cervical cancer screening tests have been developed and new guidelines for cervical cancer screening have been released. While the new tools will help some women, studies show that most women diagnosed with cervical cancer today are those who have never been screened for it. Below, Dr. Waxman, who cowrote the American College of Obstetrics and Gynecology (ACOG) guidelines, discusses the new technologies and recommendations.

What are the primary risk factors for cervical cancer?
Cervical cancer is sexually transmitted and this has been known for a long time. What has only been appreciated over the last 10 to 15 years is that cervical cancer is caused by the human papilloma virus, or HPV.

The risk factors for cervical cancer are therefore the same as the risk factors for acquiring a sexually transmitted disease, so women who have multiple partners are more likely to come in contact with the virus. And because of the nature of the cervix, the cervix is more susceptible to HPV when women are young. Therefore, women who initiate sexual intercourse in adolescence, which is when most women in the United States do, are at increased risk.

The virus is necessary but not sufficient to cause the cancer. Which is to say, lots of women get HPV and, in most cases, their immune system gets rid of it, or at least clears it to levels that are too low for us to detect with the available technologies.

While the exposure and acquisition of the virus is necessary, the development of cervical cancer requires other factors. For instance, women who are transplant patients, who are on corticosteroid medications long-term or who have HIV are at increased risk because their immunity is suppressed.

The other thing that increases risk is smoking. Smoking seems to reduce the ability of the cervix to fight off this infection, and there have been a number of studies that show that when a woman smokes a cigarette, nicotine and the nicotine metabolites are concentrated in the cervical mucous. I always remind my patients that this is one more excellent reason to stop smoking.

Getting Pap smears on a regular basis is the principle way to bring down the cervical cancer rate, so not having access to screening is a significant risk factor. For instance, among the Lakota Indians in North and South Dakota, cervical cancer screening is not widespread. And smoking is also more prevalent in that population. So they have a much higher rate of cervical cancer and precancerous changes.

Why has the Pap test been such a good screening test?
It's an ideal screening test for a number of reasons that you could pull right out of a textbook of public health. It deals with a disease that, in the absence of the screening, is very common. Cervical cancer is the second-most common cancer among women in the world.

Number two, treatment exists once the disease is identified. Number three, it's a disease that has a very long latent period. What that means is that a woman may develop one of the precursor lesions and not develop cancer for 10 or 15 years. And that gives us numerous opportunities to intervene and prevent cancer.

Finally, the Pap test is inexpensive and it's a test that's acceptable to the general population. By comparison, if we look at screening for colon cancer, colonoscopy and sigmoidoscopy are not all that acceptable to the general population. Those are moderately uncomfortable, time-consuming and expensive procedures, and as a result they haven't been as accepted by the general population.

What does the Pap test show?
The Pap test tells the pathologist if the cells that are shed from the women's cervix exhibit the kind of changes that precede cancer, or are cancerous.

What's the difference between the conventional and the liquid-based Pap smear?
About 80 percent of Pap smears in the United States are liquid-based. They cost considerably more, but they are still relatively inexpensive. Many labs can provide a liquid-based Pap for somewhere around $30, while the conventional test costs about $10.

In the conventional Pap smear, the cells are scraped from the outside of the cervix. They are placed on a glass slide and they're fixed. When you smear it on a slide, you're smearing the mucous, the inflammatory cells and some red blood cells as well. All that extraneous material sits there on the slide along with the cervical cells, and the cytotechnologist has to pick out the correct cells to look at.

With the liquid-based Pap smear, the provider scrapes the cells from the cervix pretty much the same way and, instead of smearing it on a slide, they put it in a little vial of liquid. The liquid is prepared in such a way that the cervical cells are isolated from the extraneous debris and placed on the slide in a thin single layer of cells. There is much less clumping of cells, so it's easier for pathologists to read.

Is the liquid-based test a better test?
The answer is probably. There have been quite a few studies showing that, when you use a liquid-based system, you pick up more abnormalities. It's not so clear whether more abnormal cells actually reflects more disease. So it seems to be a better test, but we don't know how much better it is and we don't know if the increased sensitivity of the test is enough to justify the increased cost.

If you look at who gets gets cervical cancer, 50 percent of the women have never had a Pap test, so using a better Pap test won't help them. Another 10 percent are women who haven't had a Pap test in the last five years. Another 10 percent are women in whom the Pap test showed an abnormality, but they didn't get follow-up for any number of different reasons. So when you're talking about using one kind of test versus another, the better Pap test might have helped 30 percent of the women who get cervical cancer.

What is the HPV test and when is it appropriate?
The HPV test examines the cells of the cervix for the presence of the HPV virus. If the virus is not present, the chances of developing cervical cancer over the next few years are very low. The HPV test is appropriate in a few very well-defined situations. It's appropriate if women have a borderline abnormal Pap smear. Some of these Pap results represent irritation to the cervix or inflammation of the cervix that is unrelated to HPV and some represent precancerous changes. We need a way to determine which is which, and the HPV test is a helpful test there.

The American Cancer Society (ACS) and ACOG recently concluded that it may also be helpful to use the HPV test, along with the Pap smear, as a way of doing primary screening in women over 30. The beauty of it is if both the Pap smear and the HPV are negative, the woman is at an extremely low risk of having cervical cancer in the next three to five years, and the professional organizations strongly recommend that she not have further testing for another three years.

In women under 30, HPV is so common, it's not as cost-effective to screen them for HPV because the many positive results would lead to too many unnecessary cervical cancer tests.

How often should women be screened for cervical cancer?
According to the new ACS and ACOG guidelines, women should start screening about three years after they start having intercourse or at age 21. ACOG recommends annual Pap test until age 30. ACS suggests annual exams if conventional Paps are used and exams every other year if the liquid-based Pap is used. And after age 30, both recommend spacing the Paps out to every two or three years.

A woman who has had a hysterectomy and doesn't have a cervix and doesn't have cervical cancer risk factors such as a prior history of cervical cancer, DES exposure, or a suppressed immune system, does not need a Pap smear.

Common sense says that a postmenopausal woman who has had regular Pap smears all her life and has never had an abnormality is at extremely low risk of developing a new abnormality. The ACS has said low-risk women who are over age 70 don't need Pap tests any more. The U.S. Preventative Services Task Force says there's no data one way or another, but it seems reasonable to stop doing Pap tests at age 65 in well-screened, low-risk women. And ACOG hasn't come out with a distinct age cutoff.

Is there a danger that women who forgo PAP testing might not have an annual gynecological exam?
Screening for cervical cancer has, for decades, been the ticket that has gotten American women into reproductive healthcare services. When we see a patient for an annual GYN exam, we do a lot more than screening for cervical cancer. We do breast exams and examine the ovaries. We talk to them about diet, nutrition and other health factors such as sexual abuse and domestic violence, if that's appropriate, as well as sexually transmitted diseases and contraception. In older women, we talk about the transition into the menopause. So there is a lot more that goes on at the annual GYN visit than just a Pap smear and it's important for both providers and patients to know that. So if a woman's provider says she doesn't need a Pap smear for another two or three years, she still may benefit from these other services.

Understanding Breast Pain

2007-12-07T08:31:00.002-08:00

Understanding Breast Pain

With: Sandhya Pruthi, MD & Robin Smith, MD

Tender breasts are just one of the many uncomfortable and annoying symptoms millions of women experience prior to their periods. While most women have just mild breast discomfort, others experience more severe pain each month. And some women have breast pain that is not associated with their menstrual cycle, which is known as noncyclic pain.

Sudden or severe breast pain is often a very alarming symptom for women. Breast pain is not usually a sign of breast cancer, but experts say it's important that women with breast pain, particularly severe pain associated with their menstrual cycle, or any kind of noncyclic pain, be evaluated for breast cancer. "The reassurance is a big part of the evaluation of breast pain," says Sandhya Pruthi, MD, the section head for the Breast Diagnostic and Cancer Clinics at Mayo Clinic in Rochester, Minnesota.

Below, Dr. Pruthi and other members of the team at Mayo's Breast Diagnostic and Cancer Clinics, Robin Smith, MD, and Jennifer Hazelton, a clinical nurse specialist, talk about the most common causes of breast pain, as well as strategies for easing the pain.

What are the most common kinds of breast pain?
DR. ROBIN SMITH: The breast pain that women experience has been broken down into three primary types. The first is called cyclic mastalgia, and this is pain that is associated with the menstrual cycle. Typically a woman's symptoms start within the two weeks prior to her menstrual cycle, worsening until the onset of her menstrual period, and then they tend to get better. Some women have pain throughout the entire month, but it improves and worsens according to the time in the cycle.

The second type of pain that women experience is called noncyclic mastalgia, which is pain that may be intermittent or constantly present, but does not appear to be associated with the menstrual cycle at all.

And the third type is breast pain that is actually pain from another source, such as the chest wall. Conditions such as costochondritis, caused by inflammation in the rib joints, can sometimes be perceived as breast pain, as can a number of other medical conditions in the same area.

How do women describe their symptoms?
DR. ROBIN SMITH: Women with cyclical breast pain tend to experience pain in both breasts. It is often described as heaviness, aching, or fullness. It seems as though the patients with noncyclic breast pain have pain that can involve both breasts, but it's more often one-sided, and it tends to be localized to one area in the breast. Sometimes patients will use terms such as "sharp" or "burning" to describe it.

There's a wide spectrum in terms of severity because we often pick up breast pain simply by asking patients about their breast symptoms, and most of these women are not very bothered by their pain. Other women actually do have pain severe enough to cause interference with school and work, their physical activities, leisure activities and sexual activity.

Why do hormonal fluctuations cause breast pain?
DR. ROBIN SMITH: I wish we had the answer to that. It seems obvious to all of us that there's a hormonal role in the cyclical type of breast pain, because it changes with the menstrual cycle and it tends to improve with changes in hormones, such as pregnancy or with menopause. There have been a number of studies performed over many years trying to detect a hormonal abnormality that might explain why some women experience pain and others don't, or why some women experience severe pain and others have only mild symptoms. Unfortunately, there have not been consistent results. One potential explanation is that certain women may have breast tissues that may be more sensitive to normal circulating hormones.

What causes noncyclic breast pain?
DR. ROBIN SMITH: When someone presents with noncyclic breast pain, we carefully evaluate them to see if we can find an explanation. And of course, what the patient is usually concerned about is the possibility of cancer. Fortunately, the risk of cancer is low, but it's not insignificant. About 2 to 3 percent of women who come to a clinic for evaluation for breast pain—usually that's reasonably severe breast pain—have a cancer at the site.

So the majority of noncyclic breast pain is caused by benign conditions. Sometimes we will find benign tumors in the breast, such as a fibroadenoma, which is a common benign tumor, or a breast cyst that may have been causing her localized pain. But most of the time we don't find a clear-cut explanation for noncyclic breast pain.

Why isn't breast pain usually a symptom of breast cancer?
DR. ROBIN SMITH: Although pain can be a symptom of cancer, it is surprising how seldom this is the case. Cancers start out as small clusters of abnormal cells that grow over time and may spread to other sites. Malignant tumors in the breast may not cause any symptoms for months, or occasionally, years. Cancers can cause pain by inducing inflammation or swelling, by invading a region with a rich nerve supply or by putting pressure on other sensitive tissues, but this does not occur until the tumor becomes larger. The risk of breast cancer in women with localized breast pain is low, but not insignificant, and merits appropriate medical evaluation.

Do infections cause breast pain?
DR. ROBIN SMITH: We do see patients with mastitis, an infection of the mammary gland, or sometimes an abscess. Quite often these occur around the time of pregnancy and lactation, and it can be very painful. Usually, these women have other clinical findings of redness, swelling, maybe some discharge from the nipple.

DR. SANDHYA PRUTHI: Postmenopausal women describe pain around the areola that is called periductal mastitis. They don't always have the classic red breast, nipple discharge or even the sign of an abscess. It's just a very subtle set of symptoms where the woman says, "You know, it just hurts behind the nipple."

What role does diet play in causing breast pain?
DR. ROBIN SMITH: There have been some studies supporting an association between caffeine and breast pain, but other studies have really not supported a relationship. But I have many patients come in and simply tell me that they know that if they drink too much coffee or soda that has caffeine, they experience a worsening of their symptoms. Other women don't find a relationship between caffeine and their symptoms. I think it's worthwhile, in a woman whose symptoms are severe and who has a significant caffeine intake, to undertake a trial of bringing that caffeine consumption down.

When would you advise a woman with breast pain to be tested for breast cancer?
DR. SANDHYA PRUTHI: Right away. If a woman has breast pain, particularly if it's new, we advise her to make an appointment with their doctor and have it evaluated. Then it's up to the doctor and the patient to decide on the next workup. But definitely, any woman who says, "I'm having breast pain that's new or bothersome," should be evaluated.

DR. ROBIN SMITH: In a woman over 30 to 35 we would start with a mammogram, and usually for localized breast pain, our practice has been to also perform an ultrasound of that area that is causing the symptoms. In a younger woman, we would often start by doing an ultrasound of the area and then proceed depending on what is found.

What can be done to deal with breast pain not caused by breast cancer?
DR. ROBIN SMITH: What we typically do is meet with our patients and go over a variety of simple measures that they can do that don't involve medication. We talk with them about their diet, wearing a supportive bra, sometimes wearing a soft bra at night that can provide support.

JENNIFER HAZELTON: I think a lot of women, just being women, kind of let their shopping for themselves go. And I see women with bras that have absolutely no elastic whatever left in them, and we've had a number of women call back and say, "Wow, I can't believe what a difference that made." Another thing we recommend is a cold compress to the area of pain for 20 minutes at a time. It seems to be more helpful with a focal pain that's noncyclic.

Exercise helps because endorphins are released when people exercise, which provide a natural kind of relief. But there's a lot of exercise that involves movement of the breasts, so, we recommend biking or kind of a gentle walking while wearing a very supportive bra.

DR. SANDHYA PRUTHI: We'll also often recommend anti-inflammatory pain medication, such as acetaminophen or ibuprofen, when a woman first comes to the clinic about breast pain.

What is the next step after lifestyle modification and pain relievers?
DR. ROBIN SMITH: We're still determining what the next best step is. There have been a number of medications used for cyclical breast pain, and those include tamoxifen, danazol, bromocriptine and others. The difficulty is that, while these medications are very effective in relieving breast pain, they are associated with some potentially serious and very bothersome symptoms.

The side effects of tamoxifen are usually similar to menopause (hot flashes, vaginal dryness or discharge), but also include endometrial carcinoma and blood clots. The side effects of danazol are less serious, but it can be associated with masculine side effects, including acne and an increase in facial hair or other hair growth. And so we have a great deal of interest in measures that we could use short of those very potent medications.

DR. SANDHYA PRUTHI: Usually if the lifestyle modifications aren't working women can try taking 400 international units of vitamin E twice a day. We say, "Try this for three months and see if it works, and then if it does, great. Keep taking it. And if it doesn't let us know."

And then my personal next step is to try capsules of evening oil of primrose, which is a gamma linoleic acid that has actually been approved in the United Kingdom for managing cyclical breast pain. We're conducing an open, randomized, double-blinded, placebo-controlled study looking at the effectiveness of vitamin E, evening oil of primrose, or a combination of the two, compared to a placebo. It is expected that the study will also open soon at other sites.

JENNIFER HAZELTON: We are doing a study looking at the effectiveness of four acupuncture treatments over a two-week period in women with noncylic breast pain. Preliminary results are promising.

When is surgery recommended?
DR. ROBIN SMITH: I try everything short of surgery for my patients so they can avoid a procedure that has anesthesia risk and potentially deforming consequences. And surgery in and of itself can cause future breast pain. So a woman could remove a tender area of the breast in exchange for pain related to a scar in the same vicinity. But sometimes we do find that our patients experience pain relief when a cyst is drained, and that can be done by using a needle to drain the fluid out the cyst. Sometimes that cyst fluid will recur, but often the pain will be relieved for quite a while or indefinitely. And a benign growth like a fibroadenoma that causes localized pain at the site can also be removed.

What is your advice to a woman who is having pain?
DR. ROBIN SMITH: I think that a woman who has some fairly mild symptoms of cyclical breast discomfort that is not interfering with her activities and always resolves with her menstrual cycle just needs to know that that is common and that nothing particular needs to be done with regard to evaluation and treatment. She should continue with breast cancer screen appropriate for her age.

Women who have more severe cyclical breast pain can manage the symptoms with their doctor or talk to their doctor about a referral for a consultation in a breast center. For a woman with noncylic breast pain, particularly localized to an area of the breast, I would recommend she undergo a careful evaluation in a breast center. It is also reasonable for women with a new onset of breast pain or a change in breast pain symptoms to undergo medical evaluation.

Bloating Explained

2007-12-07T08:31:00.001-08:00

Bloating Explained

With: Grace Janik, MD & Linda Bradley, MD

There's nothing like bloating to make you feel sluggish and uncomfortable. Who feels like working or going out when you're convinced you're lugging around extra water or gas?

Although many women have had days where the skirt they wore yesterday can't be zipped today, the precise cause of this feeling of fullness and tightness is sometimes unclear. That's because both gynecological and gastrointestinal troubles can lead to bloating, and sometimes it's due to a combination of these problems.

Hormonal Bloating
If bloating in a premenopausal woman follows a pattern, it's likely to be related to the menstrual cycle. During the last two weeks of the menstrual cycle, known as the luteal phase, women can retain water, which causes swelling in not only the abdomen but sometimes in the hands, feet and breasts.

The rising levels of hormones also have a direct effect on the gastointenstinal tract. "This hormonal effect causes the GI tract not to empty as quickly and to produce gas," explains Grace Janik, MD, director of the Reproductive Endocrinology at St. Mary's Hospital in Milwaukee.

Because stool and gas are moving more slowly through the intestines, women often have constipation and bloating in the two weeks before their periods. When women get their periods, their hormone levels drop and they sometimes get diarrhea.

Although it's less common, women can also have hormone-related bloating from changing or going on or off birth control pills or from the contraceptive Depo-Provera. Bloating due to these contraceptives, however, usually subsides after about three months.

Abdominal distension may be a sign of early pregnancy, particularly in women who aren't using birth control. And older women who are taking hormone therapy for menopausal symptoms such as hot flashes may also have discomfort from abdominal bloating.

Gynecologist Linda Bradley, MD, director of hysteroscopic services at the Cleveland Clinic Foundation, says after she takes a medical history, she often suggests that younger women keep a diary of their symptoms to determine if the bloating is cyclical. If it appears to be related to the menstrual cycle, she may prescribe a mild diuretic or birth control pills. Exercising, avoiding gas-producing foods and adding bulk fiber to the diet may also ease premenstrual bloating.

Sometimes, Dr. Bradley says, women are not necessarily seeking treatment. "You wouldn't believe how many women just want to know that it's nothing bad," she says.

Gynecological Obstruction
If abdominal bloating is persistent rather then cyclical, it might be due to a mass such as an ovarian cyst or uterine fibroid, or, especially in women over 50, an ovarian cancer tumor. "Age makes a difference," Dr. Janik says. "An increase in abdominal size is much more concerning in women in the postmenopausal range."

To determine if a mass is present, gynecologists will usually perform a transvaginal ultrasound so that they can see if there is a mass on the ovaries that is putting pressure on the bladder or bowel and causing abdominal distension. Women with ovarian cancer may also have ascites, which is excess fluid around the abdomen that can cause bloating.

Gastrointestinal Bloating
Bloating that is not hormonal in nature is often due to gastrointestinal problem. Lin Chang, MD, an associate professor of medicine in the division of digestive diseases at University of California, Los Angeles, says that the first step in figuring out the cause of abdominal bloating is taking a detailed history to determine, among other things, if it's associated with eating or drinking and or with other symptoms.

Bloating can be caused by diet, particularly if someone who has a high salt intake or eats a lot of gas-producing foods such as cruciferous or leafy vegetables or beans. Calcium supplements can also cause gas in some people. Doctors may recommend that people avoid these foods to see if they're the culprit.

But the most common gastrointestinal cause of abdominal bloating, Dr. Chang says, is irritable bowel syndrome (IBS). IBS is a common condition characterized by abdominal discomfort and diarrhea and/or constipation and abdominal bloating.

Women with IBS do not usually have more gas and bloating than other people, but instead have a hypersensitivity to gas. While IBS is difficult to treat, it may be helped by medications that ease constipation, tricyclic antidepressants or even psychotherapy.

Other women may have only abdominal bloating, Dr. Chang says. This may be the result of a partial or complete intestinal blockage. There are many possible causes of these blockages, including scar tissue from prior surgeries, certain medications, abdominal infections and hernias.

Those who have bloating, along with discomfort in the upper gut, may have a food intolerance such as an intolerance to lactose, the sugar in milk, or fructose, the sugar in fruit. Such intolerances can be handled by simply avoiding lactose or fructose. Women with lactose intolerance may also choose to treat milk products with the enzyme lactase.

In rare cases, women may have parasitic infection or an inflammatory bowel disease (IBD) such as Crohn's disease or ulcerative colitis. Dr. Chang notes that bloating is not the prominent symptom of IBD; these diseases are usually distinguished by red-flag symptoms such as blood in the stool or a family history of IBD.

Bloating is very common in women, but if you have bloating that's making you uncomfortable, especially if it's persistent, experts say that getting it checked out is worthwhile.

When You Should Listen To Your Body

2007-12-07T08:30:00.002-08:00

When You Should Listen To Your Body

Best Selling Author of "Combat Conditioning"

In a recent conversation with a client, I was asked what I thought were the most important qualities that help a person succeed in an exercise program.

Without hesitating I said, "There are two things that every trainee needs to know how to do - and both are mental. The first is called "listening to your body." The second is called "telling your body what you want it to do."

Now, think about this for a moment. It would be easy for me to say, "Do 100 Hindu squats, 50 Hindu pushups and a back bridge each day - that's the secret." And truth is, if you do those exercises, you'll succeed in a big way.

Yet, there is something "foundational" that anyone who wants continual success needs to understand. First, your body is talking to you all the time. It's telling you how it feels. It's telling you if it's tired, injured, too hot, too cold, unbalanced, stressed out, too tight, full of aches and pains ... or ... "on top of the world."

Your body is constantly talking to you. Question is, do you ever listen? If not, you're ignoring the messages in which your body is leading you toward what it wants to do - as well as all the signals that tell you to be careful.

I remember the day I was gung ho mixing dips and pullups and Hindu squats together during a workout in the gymnastics school where I often train. The first couple rounds went well and I was looking great. Then all of a sudden, I wasn't feeling the best. I needed a longer rest, but I refused to take it. I was ignoring my body's signals.

I jumped up to do another set of dips and something didn't feel right but I refused to pay attention. Next thing you know I felt a sharp twinge of pain in my shoulder.

Now THAT got my attention. I shut up and listened.

I moved to another area of the gym, away from the parallel bars and tested the shoulder with some basic pushups. They didn't feel right, so I did the smart thing for a change, changed clothes and called it a day.

Woke up the next day and was a bit sore, got a massage for the shoulder, slapped on some Zheng Gu Shui (Chinese linament) and within a couple days was back to normal. If I hadn't listened to my body, I would have injured myself far worse and the recovery wouldn't have been so quick.

So listening to your body is essential.

At the same time, what do I mean by "tell your body what you want it to do?"

This is when you "program your mind and your muscles" to accomplish a specific goal. Whether it's doing 100 straight pushups, 25 pullups, running hill sprints, swimming a mile, doing 500 straight Hindu squats or walking on your hands ... you mentally picture what you want to do in the future and you tell your muscles that you WILL do it.

Your body responds to your commands. Your muscles get stronger because you tell them to do so. You shed excess pounds because you look your flesh "in the eye" and tell it that "YOU" are the captain of this ship - and that you're the one issuing orders - not the other way around.

You can get your body to do almost anything, it seems ... but not unless you tell it what you want it to do.

The key to these two principles is balance. Both of these keys represent the yin and the yang of fitness. As such, there will always be a bit of overlap in the two.

Sometimes in telling yourself to do what you want - you may go too far and cause yourself a slight problem. No big deal so long as you readjust and move to the listening phase. On the other hand, if all you do is "listen" but you never give commands,you may be listening to nothing but "I'm tired" crapola.

Strike a balance between these two principles and you'll live a lifetime of superior health and fitness.

What's Your Health Worth?

2007-12-07T08:30:00.001-08:00

What's Your Health Worth?
By: DAVE WOYNAROWSKI, M.D.
The World's Top Anti-Aging Specialist

I got the following question emailed to me the other day. "Doc, How many fish oil capsules should a person take daily and what's the cost per day?"

This really got me thinking. You see I'll admit that I occasionally get someone writing in grousing about how expensive this anti-aging and preventative health stuff is!

I have practiced Traditional Internal Medicine for 16 years now and I have seen some dramatic changes.

If we sit down and analyze these changes, I think we can answer Tom's question a little better, as well as do some more of my favorite and apparently most irritating thing: predicting the future!

What is Traditional Medicine? Well in many countries around the world it is exactly the kind of vitamin and herbal supplementation that many of you are doing right now. In places like China the compounds making up Instant Endurance have been used for centuries.

In this country Traditional Medicine centers on prescription drugs, scientific technology, and the body as a machine without a soul.

The actual hierarchy from my standpoint is (in descending order of importance of impact on National Health Policies):

1) Drug Companies

2) Drug Company Lobbyists in Washington

3) Insurance Companies

4) Insurance Company lobbyists in Washington

5) Health Plan Administrators

6) Hospital Administrators

7) Doctors

8) And last in line, you know who the patient who is actually paying for a lot of all of this!

Right now our traditional medical system is a 1 Trillion dollar a year industry!

Complementary and alternative Medicine gross around 25 Billion at this point.

It is predicted that these numbers will be absolutely reversed by the year 2050.

In other words Complementary and alternative Medicine will be a 1 Trillion dollar a year industry with the consumers holding all the power!

Traditional medicine will be relegated to 25 billion.

What this means to you is that the longer you live the less likely you will be to have effective affordable Health Insurance Coverage.

In other words, you and I are on our own together.

Now let me answer Tom's email question the best I can.

The amount of fish Oil a person should take depends on what they are trying to achieve.

If you do a "meta analysis" of all the studies on all the conditions that fish Oil has been studied in the average dose you come up with is 7.4 grams a day.

This is close to 6 capsules.

However the heart benefits begins at as little as 1-2 caps per day. Arthritis, and Alzheimer's may require 8 to 10 a day.

As far as costs go at the current sales price of $59.95/120capsules, let's say 4 a day to make it easy, a months worth, that is approximately $2.00 a day.

If you are only interested in heart health then your cost goes down to 50 cents a day. Many of my patients on fixed incomes do not find this unaffordable, especially when they realize they are getting almost side effects free heart coverage!

Those folks who buy in case lots have a cost reduction to just over a dollar a day.

Now I am not going to go into some long winded lecture on how you can have incredible health for under $1.00 a day. I will let my customers do that in the testimonials section of the website.

I will remind you of a short list of things that Fish Oil has been shown to improve:

1) Heart disease

2) Cancer including breast, prostate colon and lung

3) Arthritis, both rheumatoid and degenerative

4) Stroke

5) Irregular heart rhythms from both the top and bottom parts of the heart.

6) Multiple Sclerosis

7) Attention Deficit Disorder

8) Depression

9) Hormone levels

10) Sexual and Athletic Performance

Again this is a short list. I personally believe this is worth a h*ll of a lot more than 2 bucks a day, but it's up to you to decide.

In time as my predictions about the fate of "modern medicine" come to pass, this will look even more attractive as a way to maintain great health.

Death By Breathing

2007-12-07T08:29:00.000-08:00

Death By Breathing
By: DAVE WOYNAROWSKI, M.D.
The World's Top Anti-Aging Specialist

Here's another great question.

Dear Dr. Dave,

I'm quite confused over one aspect of Instant Endurance. One of the components is supposed to help us take in more oxygen which is good for the brain, blood, organs, etc... On the other hand, we have things like anti-oxidants(?) which are supposed to retard aging. Is there a contradiction here?

Thank you very much.

Truly,

Tan P. K.
Singapore

Every now and then someone writes in an absolutely great question that I never thought of. Usually I say to myself," I wish I had thought of that!"

In the case of Tan P.K. from Singapore I found myself saying just that.

This gentleman's question cuts right to the heart of the anti-aging matter and I think will instruct all of us in some fundamentals that I have not touched upon before.

First let's take a little hypothetical trip back about 12 billion years. Again I say hypothetical because this is an evolutionary point of view and I am not in a position to state this as fact, so please do not take any religious offense to this!

The story goes like this:

Two very different cells came into contact with each other billions of years ago.

One cell had a very limited capacity to use oxygen which at the time was present on the earth's atmosphere in somewhat greater amounts than it is now.

The other cell was primarily a non oxygen user. But it was bigger badder and hungrier than the one that used oxygen.

So the big bad hungry non oxygen using cell ate the little high energy oxygen using one.

Funny thing is that the big cell couldn't digest the little one.

As a matter of fact the little cell rather liked being inside the "stomach " of the big cell because there was all that unused oxygen lying around.

At some point it became apparent that these 2 cells, one now living inside the other, were greater than the sum of their parts.

Each conferred a survival advantage to the other, so they learned to coexist and thrive as a new unified organism that could use oxygen very well.

It is thought that the little cell that got eaten and liked it was the forerunner of the modern day mitochondrion ( mitochondria pleural).

In all of our cells there are mitochondria. They are the veritable powerhouses of the cell. Most if not all oxygen metabolism takes place there.

Mitochondria are truly the energy generating furnaces of our body. They take oxygen food and water and convert it into our energy needs.

As such they are exposed to lots of oxygen and this burning of oxygen creates what are now known as "oxygen free radicals" or simply free radicals.

Many of you already know that free radicals are damaging. They have a lot of energy and when they glom onto something and give up their energy to it bad things can happen.

Such as Inflammation heart disease joint destruction and cancer.

The mitochondria are well equipped to handle this at least when they are young because of many buffers. Perhaps the most important of which is Co Enzyme Q 10 one of the main ingredients in Regenerizer.

The bioactive plant compounds in Instant Endurance are also loaded with anti-oxidants, as is fish oil which actually acts as a free radical sponge to soak them up.

This is important because as we age or as we engage in high level physical activities, free radicals start to build up.

Ageing causes this because the actual amounts of things like CO Q 10 in the mitochondria decrease as we age.

In high level athletics we actually consume more oxygen and thus generate more free radicals.

One of the biggest mistakes I see world and other class athletes make is under supplemnetation with anti-oxidants. They generally feel that they are in such good shape that their bodies can handle the oxidant load.

Nothing could be further from the truth.

Now many of you know that I am a distance runner and a grappler.

I aggressively buffer the oxidant load in my body generated by these activities with all of my compounds from Fish Oil to Regenerizer to Instant Endurance.

Why? Well elite distance runners do not live normal life spans as a whole. They succumb to heart disease and stroke at a level even higher than the general populace. This is undoubtedly due to the high oxidation loads from free radicals in their body.

No one has done a study on Grapplers!

I always tell my runner friends," Don't run for longevity! And if you do run long distance make sure you take enough anti-oxidants!"

Now please not that there are some distinct advantages to running and other types of exercise in that these groups of individuals tend to be more health conscious and this may account for better health and longer lives in the non elite group.

In other words its not the running, but the lifestyle that accompanies it that helps most!

And that my friend is the paradox!

Oxygen, the very thing that keeps us alive, the very thing we cannot do without is slowly killing us! The more of it we use the more damage we do UNLESS we protect ourselves with anti-oxidants.

The more active you are the more you need them!

And the younger you want to stay, the more you need them.

Recently the editor of a mixed martial arts magazine that I am for confidentiality reasons not able to name wrote me to tell me that he loves my products. He feels the effects and they have improved his game.

This is not in a small part due to the buffering of free radical oxidants that impair performance, Impair recovery and dull the Brain.

Ken Brown Triathelete wrote to tell me how he won his age class after taking My Fish Oil.

He said," Your Fish Oil made a monster out of me!"

The only thing more impressive than that is Ken himself whose picture and testimonial are up on the site now.

So whether you care trying to slow the aging process and prolong disease free life, or are an athlete looking for an edge in strength, endurance, recovery and mental sharpness, remember that the very air we breath can kill us.

And remember it does not have to be so!

As Tan P. K. pointed out Instant Endurance supplies you with the ability to extract more oxygen, AND the ability to buffer the damaging effects of same giving you the best of both worlds!

2007-12-07T08:28:00.001-08:00

It's amazing but true. Most people get up tired and go to bed tired. Going to bed tired is somewhat understandable - but waking up tired is inexcusable.

How can you be tired when you wake up? You haven't even done anything yet, right?

Okay, perhaps you didn't get enough hours of rest. Or perhaps you got the hours of sleep, but there wasn't enough rest in the sleep. Or maybe you're under immense stress and this is affecting your energy level.

All of the above is understandable - yet, it can still be overcome, and with ease.

Let me tell you how you can take 5 simple steps to greater health and energy ... NOW! Here they are:

1. Before lopping off to bed at night, mentally program yourself for energy. How do you do this? Simply say "I'm going to wake up totally energized tomorrow." Why is this important? It's important because most people say "I'm tired" when they go to bed and this leads to them waking up in the same mental state they went to bed with.

2. When you wake up in the morning, immediately focus on a big image of something you want to do, be or accomplish.

3. As you focus on this mental picture, tell yourself, "I am going to do everything I set out to do today." When you say this to yourself, say it with ENTHUSIASM.

4. After doing this, sit up in bed, pull your feet close to your buttocks and begin to massage the kidney point at the bottom of each foot. Start with your left foot. Massage deeply at least 50 times, then massage the right foot the same number of times. Doing this will amaze you. It will cause your energy level to rise ... and fast. Not only that, it is one of the cornerstones to raising your sexual energy to a peak. This is covered in detail in my new course on Chuang Shang de Gong Fu. Check it out at Chinese Culture Secrets

5. When you're finished massaging the kidney points of each foot, raise your energy further still by taking a cool to cold shower. The hot shower is fine to finish up with .. but start with the coldest water you can take. It will increase the vital energy in your body in an instant.

Last of all, remember to consult your physician before engaging in any health regimen. The above will work for most people - but it is not for everyone.