Obesity: A Health Appraisal

Obesity: A health appraisal

Key points: History and physical examination can often reveal clues of decompensation due to being overweight and obese. Some of these subtle clues are attributable to other conditions or reasons. Most people who have an elevated BMI in the obesity or upper overweight range likely have some signs and symptoms owing to their weight.

A person who comes into a clinic and would like a preventive visit with a physical examination and bloodwork is often looking to identify an underlying health condition that may develop into a greater concern.  Sometimes, they are hoping to verify that their current health is good enough or to make sure that they won’t get a condition that a family member had, like cancer or a heart attack or stroke.  Sadly, the yield of a general health check is fairly low.  One review of 14 trials by Krogsboll in 2012 showed no reduction in morbidity of mortality in cardiovascular or cancer related causes with physical examinations.   

Is there any benefit in performing a physical examination and evaluation?  Perhaps, we shouldn’t throw out the baby with the bathwater just yet.  It may be that some issues are not completely addressed with the provider’s (in)attention to early examination findings that may characterize a health risk.  Most doctors will pick up the skin lesion that needs to be biopsied, but it may be less obvious if a patient has mild lower extremity swelling or a slightly elevated blood pressure.  Also, it is often more difficult to provide recommendations for a person who has an insidious disease process such as being overweight, beyond “lose weight” and “exercise more”.  In my practice, there have been numerous occasions when I have found a patient with obesity having near normal routine bloodwork screening, including normal cholesterol, kidney function and electrolytes and mild elevated liver tests.  Yet, there may be adjustments occurring in the body to maintain homeostasis that are resulting in some effect, even without more than a subtle change on the exam.  Perhaps what we are not checking on the exam and not seeing in these blood tests that gives us a more complete picture.

As the body usually compensates for being overweight to a certain point, it is useful to look for clues that might alert one of early decompensation.  The best place to start is a recall of any signs of symptoms such as with a review of systems checklist.  You can fill this out before you are seen by the clinician.   I look for several things: fatigue, shortness of breath, sleep issues, dry mouth, nighttime urination, increased thirst, night sweats, palpitations, swelling in the legs, weight gain and fibromyalgia.  Any of these items leads me to ask follow-up questions and directs me in the examination.  Sometimes, when asked further, people will comment on things that they weren’t sure should be included, e.g. increased swelling after eating a high salt meal, during the summer months or with traveling or see an indentation where the socks were on their legs.  Patients with insomnia may describe having no problem sleeping during the day but racing thoughts that prevent them from sleeping at night or waking up from sleep because of pain or the need to urinate.  What is difficult is that sometimes these behaviors get normalized by the patient, such as “I used to work the graveyard shift before I retired” or “I have always been a night owl” or “I drink a lot of fluid”.       

Sometimes people who have signs of decompensation try medications over the counter or take substances to aide them. When people drink more than 3 to 4 cups of coffee or 1 to 2 cans of soda, it alerts me to the possibility that they could be stimulating themselves in the setting of poor sleep efficacy, such as in obstructive sleep apnea. They may also be taking common over the counter sleeping medications, such as benadryl or other products and even alcohol. Unfortunately, these substances can feed into behavioral cycles and make it more complex to evaluate a patient.

On the examination, I will look at several physical measurements, which have been found as risk factors to conditions seen with increasing rate in obesity.  I use the body mass index (see body mass index table), which factors in height and weight, as a useful estimator of risk.   A BMI of 30 is associated with obesity.   Certainly, in someone who has a high muscle mass, the BMI can be a less useful predictor.   A lower BMI cutoff of 26 for a person of Asian ancestry has been associated with similar metabolic consequences as a BMI of 30. In addition to that the waist measurement (at level of umbilicus) can often be a useful finding for visceral obesity. A waist circumference of greater than 40 inches in a man or 35 inches in a women is a sign of increased risk of obesity-associated health problems. A neck circumference greater than 17 inches in a man and 15 inches in a woman can also signal possibility of obstructive sleep apnea (OSA). Another measurement which is useful for looking at risk of OSA is the mallampati index. It refers to how visible your posterior mouth (uvula and pharynx) is on examination. The higher the index (I to IV), the greater the risk of obstructive sleep apnea. Consult with your physician to determine the role of weight on your health.  Sometimes, we attribute our health issues to short-term concerns, while the health problems linked to our weight persist.  A trained clinician can determine subtle physical findings that may raise concerns of health impact of your weight.

Other examination findings are present. Vital signs may often signal obesity-related decompensation. These include an elevated blood pressure, systolic and possibly diastolic and a rapid heart rate. These are signs of increased resistance from increased fatty tissue around the vascular beds. A narrow pulse pressure (subtracting systolic from diastolic numbers) can be a sign of low functioning thyroid. The heart sounds can be heard on the chest wall — sometimes more dampened from obesity but a louder pulmonic site (just left of the upper sternum) second heart sound is common, as the heart as to pump harder into the pulmonary bed from increased tissue resistance.

There are also a number of skin findings from obesity on the examination. The body may have darker, scalier, sometimes velvety-appearing skin in the back of the neck or sometimes in the groin area or under the arm. This is known as acanthosis nigricans and is related to a higher insulin production in the body and “insulin resistance”. This can be a marker of diabetes and prediabetes. There may be vertical markings on the abdominal wall from tissue stretching. A very red or violaceous appearance could be a sign of the body producing too much cortisol, such as in a condition known as Cushing’s syndrome. The skin of the legs can be compressed and leave a marking known as “pitting edema”. This can be a seen in the setting of decompensated obesity and indicate likelihood of obesity-associated sleep apnea and high blood pressure.

In summary, there are multiple signs and symptoms of obesity. These findings become more apparent at higher levels, as the body is no longer able to compensate from the excess weight. As these changes are gradual, they may be misattributed to other causes or syndromes. Anyone who assess their BMI, waist circumference, neck circumference and mallampati index or who has been found to have an elevated blood pressure or fasting glucose should consider working on a health optimization plan to reduce the harms of excess weight.

Thank for reading. Dr. Cirino

The Art of Medicine

                                                The art of medicine

Doctors often spend time looking for medical conditions that are treatable.  For instance, a patient who is diagnosed with an acute bacterial pneumonia has myriad findings that correspond with this diagnosis, including the preceding symptoms, physical findings, radiographic findings and less commonly a positive sputum culture.  Although we do not always have a conclusive diagnosis, we have enough information to treat the process with empirical antibiotics.

Sometimes with chronic conditions, we don’t acknowledge that it may be causing a problem until it can no longer be denied.  The same is with regards to obesity – the health effects worsen with the degree.  Earlier on, a person may note a feeling of fatigue, swelling in the legs, worsening heartburn or sleeping problems.  He or she may wonder if they have chronic fatigue syndrome, because they are not feeling as much energy during the daytime. 

As is common with chronic conditions, people may take medications that treat the symptoms and delay medical visits.  They may consult naturopaths, chiropractors or acupuncturists with these concerns and be given different treatment options, sometimes not addressing the association with their weight and their health.  Terms like fibromyalgia, chronic fatigue syndrome, “adrenal fatigue”, or even chronic Lyme disease may be brought up during these visits, without realizing the process may be linked to their obesity or other behaviors.  Sometimes, clinicians may enable these concerns without doing any major work-up of conditions that can present similarly.  Many times patients will have limited benefits or be informed that “treatment options may take several months”, only to end up back to the problems that they hadn’t had fully addressed in the first place.

Not only are patients seeking information with other clinicians, they are also seeking out information online.  Information has become more available at an alarming rate.  In the past twenty years, literature that was once only available in specific libraries is now available at the click of a button or swipe of the finger on personal computers or cellphones.  The transition has not been without its growing pains.  With the information comes sifting through material that could be a source of bias or change the emphasis of evaluation.   By searching a diagnosis and checking symptoms, the process of determining a potential issue can be driven in reverse, an attempt to rule out the concern.  What would be ideal is that a process is identified before it becomes more severe and leads to more, potentially irreversible or life-threatening damage.

Although there are information databases that allow one to list out their symptoms and provide a possible diagnosis with statistical likelihood, it hasn’t replaced the job of a physician, who has been trained to sift through information on history and physical examination and work toward a greater understanding of the health issues.  Even this training has its shortcomings as it manifests in the modern age of medicine.  Tests have sometimes usurped the decision-making skills of a physician and can sometimes send a patient on a roller coaster of anxiety and stress while a process, possibly discovered incidentally on one test, obligates a physician to order further tests.  This is compounded by the fact that the average patient visit has decreased to around 10-15 minutes a visit, which is seldom enough time for the patient to work through his/her concerns, or a physician to review and truly understand how the patient’s complaints related to an underlying condition.

Sometimes by spending more time with a patient can be useful to develop a rapport with the patient and open a bridge of communication that sometimes leads to more informed decision-making.  A patient and physician can come up with an agreement of time points and concerns for further testing and monitor the process through time.  Sometimes it provides reassurance that it is being evaluated through time, and allays the fears that came up from self-searching online.  In some cases, asking the patient what is their reason of coming in – or major underlying motivator- of health seeking behavior can be a good way to explore their condition and interact with the patient toward the goal of understanding the condition.

The Benefits of Weight Loss: A Work in Progress

A focus on the “endgame” of weight loss can be discouraging as you embark upon a health journey.  The reality is that becoming healthier is a work in progress.  Although a body weight gohal can serve as a long-run goal, health gains can be realized even in early weight loss.  As little as 3-5% of weight loss (e.g. 5-15 lbs) can produce sustained health benefits, including an improvement in glucose control and insulin functioning, a reduction in blood pressure and diastolic dysfunction and a reduction in severity of sleep apnea. 

As one loses weight, there is a gradual, whittling away of the forces that are exerted on the heart and the rest of the body by obesity.  For instance, a weight loss of approximately 15 pounds leads to a reduction of systolic and diastolic blood pressures by 8.5mm Hg and 6.5 mm Hg.  In another study, with the same average weight loss, there was also reduced peripheral resistance and increased cardiac output.  There were also improvements in glucose levels (fasting (5% reduction) and after meals (10% reduction) as well as reduction of insulin levels (approximately a 15% reduction).  A weight loss of approximately 10 kilograms would amount to a significant reduction in severity of obstructive sleep apnea, as measured by Apnea hypopnea index by 11 events per hour.    

Sustained behavior change places priority on the moment-to-moment behavior over the long-term goal.  A person who focuses on the choices that he/she faces in the day will gradually bolster the new behavior when the days become weeks and the weeks become months.  The day to day activities involve not only healthy eating but managing overall stress levels, nurturing mindfulness and avoiding any triggers to stress-eating and other unhealthy eating patterns.

While some diets boast short-term weight loss goals, the most sustainable diet relies on a gradual strengthening of one’s consistency in healthy eating in order to reinforce new, healthier patterns.  As one pursues this direction, the body will not stop at a 5 to 15 pound short-term weight loss goal but will continue to shed weight until it reaches a new steady state at or near one’s ideal weight.

Momentum builds as one begins to feel feedback from their body or receive it from others.  One might notice less knee pain or find bending down to put on socks easier.  S/he may wake up more restored from the night with greater energy during the day.  One develops a greater self-esteem and efficacy as they continue to see the results of strengthening discipline fortified by a collection of moments when healthy eating was chosen. 

The role of exercise in weight loss, I would suggest, is more for stress reduction and coping.  While not required to achieve weight loss, it is a part of optimal fitness.  The body starts to thrive activity as one loses weight.    What once may have been nearly a work-out just walking from the bed to the bathroom or from the car to the store becomes more manageable, so increased activity follows.  In stride, the person may develop a new routine such as walking or other physical activity for daily stress management and conditioning. 

In the beginning of an exercise regimen, it is more important to focus on consistency rather than on the amount of time or level of difficulty.  Walking may be sufficient to avoid injury or strain and begin in the direction on physical conditioning.  There are often chronic tendonitis issues of the feet, knees, hips and back in someone who is obese.  It is crucial to avoid overworking the body and aim for consistency and an activity as tolerated.  An injury could set a person back enough to make it possible to lose their efficacy and go back to prior unhealthy behaviors.

Homeostasis and the Body

Homeostasis of the body and development of the diseased state

All living organisms have systems which work in concert to maintain functions in the setting of external or internal perturbations.  This process is known as homeostasisWhether it is the acquisition of energy through food or the ability of the body to adjust to threat of physical harm, or “fight or flight”, the body is able to accomplish and optimize its function to allow for maximal effect.  From a single-celled organism to advanced animals, the ability of an organism to adjust becomes a multi-systemic process.

While a single-celled organism could die (“lyse”) if it came across too much alcohol, sodium or sucrose (table sugar) in its environment, an advanced organism has a multi-cellular system to buffer the direct effects of these substances up to a point.  What might be poisonous on a cellular level, in an advanced organism, multiple cells lining its digestive tract can begin to manage these substances and reduce the direct harm.  After the substance is absorbed from the intestines and filters into the liver cells, toxins can be metabolized to less harmful products.  For example, alcohol is broken down in two steps by alcohol dehydrogenase and its product aldehyde by aldehyde dehydrogenase in liver cells to form acetate, which is then converted to carbon dioxide (exhaled) and water (urinated).    For alcohol, the lethal dose 50 (LD50 = a calculation of a dose in which a level is expected to kill half of the population) is a blood alcohol between 0.35 and 0.40 percent, which constitutes about 17 beers in 1 hour for a man weighing 180 pounds.  For sugar, a potentially LD-50 for the same adult would approach 5 lbs  – or more than 250 pieces of “fun size” Halloween candy (20,000 calories).  That’s a lot of candy corn!  For salt poisoning, a more common event with drowning survivors or drinking sea water if stranded at sea, it is estimated that as little as 25 grams of sodium (around 4 tablespoons) at one time for an adult and 7-13 grams for a child could be lethal.  It is definitely not a wise decision to conduct a salt-eating challenge to boost your social media followers.

The greater the perturbation in the system, the less compensated the adjustment and more harmful or life-threatening the consequence.  The body’s shift from “compensated” to an “uncompensated” or “diseased state” can occur rapidly, such as from a poison or drug ingestion or insidiously, such as the long-term effects of high glucose levels on the tissue of the kidneys, eyes and nerves.     It is at this crossroads where a patient may present with symptoms or have signs of a developing dysfunction. 

I am always amazed when I see a patient with severe anemia from a slow-bleeding colonic tumor presenting with no more than a gradual fatigue and weakness to the point.  If a patient were to develop an acute, significant gastrointestinal bleed from a stomach ulcer, s/he may suddenly become weak and dizzy – and probably pass dark, tarry stools or even blood in the stool.  At a much higher blood count than the patient with a slow-bleeding tumor, their systems decompensate.

Our body makes similar functional adjustments as one gains weight through time.  The adjustment process can become more severe as weight gain occurs, leading to a breaking point, when the health effects of weight impact the quality of life.  Many people may have noticed early signs and symptoms of these changes, including fatigue, body aches or fibromyalgia symptoms and sleep disorders.  They may have already sought out providers or tried different medications or used substances to treat the problems with a temporary effect.  A person may take ibuprofen for back pain or body aches.   He or she may drink caffeinated beverages for an energy boost.  They may take sleeping pills for sleep apnea.  They may take herbal or homeopathic medications and potentially delay the recognition of the underlying problem. 

Behavioral Loops and Eating

The Link between Behavior and Eating

Remember when you had a difficult day as a child.  Your mother or father may have tried to cheer you up with your favorite desert (ice cream or a cookie!) and a pat on the back or a hug.  As children, we all remember the times when we ran late for school and skipped breakfast to avoid missing the bus.  Or when we ate desert or snacks and didn’t want to eat our dinner.  I remember the times as a child when my parents, after discovering an empty refrigerator and not want to go shopping for food, ordered pizza and bread sticks out of convenience and had it delivered.

 As humans mature, behaviors become more fixed and predictable.  These behaviors include the selection of food and how it is eaten.  Food preferences intersect with life skills, such as cooking, time and stress management.  If there is a challenge to the consistency of our daily routine from a real or perceived stress or trauma, eating patterns may change.   Many people can recall how adjustments, such as a change in jobs, relationship status or the death of a loved one or having a child, brought a conflict to the routine.  Any of these changes in homeostasis can increase the risk of becoming overweight.  There is a direct correlation with prolonged distress, abuse or trauma and sleep deprivation and obesity.  There are many factors that are likely behind this and will be explored further.

The science behind behavior and why it is difficult to lose weight

As an experiment, I went on a super-low carbohydrate diet.  Although I usually keep a fairly low-carbohydrate diet, I admit to indulging more lately with fruit and chocolate or my children’s leftover salty snacks.  It was with this increasing momentum toward the “dark side”, that I decided I would try this change to see how it affected my behaviors with these types of foods.

The first few days was especially challenging, with a feeling of nausea, some gnawing stomach cramps, inattention and fixation on food, while experiencing cravings for some of my go-to-sweets, including fruit and chocolate.  I woke up the morning of my second day of no carbohydrates after I had a dream of eating fried dough loaded with powder sugar, a food that I haven’t had since I was a child. 

The images produced in my brain got me to thinking about what how our brains are affected by our life experiences as it relates to stress and food.

As images of a memory of <insert sweet substance> are evoked in our minds with craving, deep forces rooted in our brain are at play.  Although there is a “blood-brain barrier” from the body, modulators known as neurotransmitters can be actuated in the body and have effects on the brain.    Indeed any action, food, drink or substance that results in a positive response leaves an impression in the rewards centers of the brain, the nucleus accumbans.  The memory center – the hippocampus and the emotional center – the amygdala are also involved in a concerted effort in reinforcing a behavior.   A surge of the neurotransmitter dopamine, produces a feeling of desire that activates the memory centers, leading to repeating the behavior in the future.    Another neurotransmitter serotonin does not cross the blood brain barrier and is produced in the brain (5% of production) and body (95% of production in GI cells).  Through its action in the brain, there is an increase of pleasure and satisfaction.  Picture a boy who is given a cookie by his mother when he falls down and hurts himself.  A behavior loop is forged through these neurotransmitters, by which these earlier experiences serve as a future “fast track” to pleasure and calming in the setting of a future adversity.  This may be why we are more likely to treat ourselves to higher sugar, salt and fatty foods, when we are experiencing stress.

The stronger the surge of dopamine is, the greater is the “high” and the future desire and craving.  Unfortunately, the brain does adjust after repeated stimulation by down-regulating the amount of inhibitory dopamine receptors (D2) available, which leads to a dampening of future pleasure.  Similarly, serotonin levels have been shown to decrease in the brain, in the setting of addiction.  This creates a behavior that seeks to find the pleasure of the initial use with diminishing returns, causing one to increase dosage for the similar response.  In the absence of the signal, there is an enhanced period of displeasure.  Interestingly, with regard to serotonin deficiency, there is a greater tendency to overeating, obsessional thinking and depression and anxiety, satisfied in part by repetition of the behavior.    Behavioral cycles generated by fluctuations in dopamine and serotonin are greatest with cigarette, alcohol, drug use and a high sugar diet and can be especially difficult to break.

As with drugs of abuse, a high sucrose diet has been shown in rat models to increase activity of dopamine, particularly after high sucrose intake.    Acetylcholine is another important neurotransmitter that works in concert with dopamine in the nucleus accumbens and promotes muscle action and learning and memory. In this study, dopamine levels peaked early into the meals, while acetylcholine peaked toward the end of the meal.  The release was delayed after rats were fed a high sucrose diet, suggesting that this may affect the signaling of satiety, allowing rats to increase intake. When rats are fed regular high sucrose diets, there develops dopamine desensitization in these rats, suggesting sucrose dependence tantamount to what would be seen in drug dependence.  The rats in this study also showed behaviors mimicking drug dependence, with an increased consumption of sucrose, including binge eating in the first hour of access and escalation of daily sugar intake.  They even showed signs of withdrawal upon sucrose deprivation.  

Simply put, the brain and body communicate and form a pathway to our thoughts and actions.  A behavior may represent a higher form of instinct – conditioning, and attached to this is a reward that reinforces continued use.  Therefore, one can imagine how truly difficult it is to change this behavior.  Removal of what is interpreted as a reward is met with resistance both biologically (including the actions we are driven to do or the thoughts we have), enough often to sabotage our efforts.  When you see a person with advanced lung disease smoke into their tracheostomy tube or an intravenous drug abuser inject just after they had a valve surgery for infective endocarditis – and otherwise defy reason – you can gain an appreciation that there are powerful circuits that are being activated with these addictions

Our eating patterns and selection of foods are reinforced behaviors, which are sometimes linked to coping with an adversity, whether real, such as verbal or physical abuse and other trauma, or perceived, such as fears and anxieties of the past and future welling up in the present.  Sometimes a pattern of behavior repeats itself not from the original type of stimulus but from a perceived stressor.  Thus, a maladaptive behavior becomes reinforced.  Put a reward likes cigarettes, drug and alcohol – and even sugar – into the pattern, and it creates a biological adaptation to these substances – resulting in tolerance and addiction – with a behavior leading to increased consumption.  This could manifest as someone binging or “grazing” large quantities of sugar in food.

When Your Mind Stands in the Way

The Influence of our Behavior and Finding Optimal Health

Behavior can block finding health

How many of you have indulged in ice cream, alcohol, shopping or another gift after a hard day? For many of us, our coping strategies may involve behaviors that reward us during challenging times – sometimes at the level of a mindless reflex. Although these behaviors provide an instant relief to stress, they can potentially sabotage one’s efforts to become healthier.

After all, behavior is the crux of one’s health and the cornerstone to a longevity plan. Studies support that a low-risk lifestyle, e.g. regular physical activity, eating healthy, abstaining from smoking and excessive alcohol, is responsible for a 11 year delay of all-cause mortality. Conversely, harmful behavior is largely responsible for up to three-quarters of chronic health conditions seen in clinical medicine.

A careful look at the world’s centenarian centers, or “blue zones”, reveals many common ingredients to longevity.  The locations include Okinawa, Japan, Sardinia, Italy, Loma Linda California, Nikoya, Costa Rica and Ikaria, Greece.  There is no coincidence that living in these places allows for the similar tenets of a low-risk lifestyle, including regular purposeful physical activity, a wholesome, natural diet, avoidance of smoking, stress management, plenty of leisure time, social support structures and a healthy environment.

Behavior is intertwined with our actions, words and thoughts, as we adjust to real or perceived stressors. Even though we are the vessel of our behaviors and can regulate them, we can become blinded to them.  Behaviors are truly at the crossroads of our conscious and unconscious thoughts and our involuntary and voluntary nervous system.  Actions that result in pleasure or less pain are reinforced and repeated; actions that result in less pleasure or more pain are avoided.

Sometimes, a potentially harmful behavior can become reinforced because of its leads to a perceived positive outcome. One can develop a complex network of thoughts when it comes to addressing these behaviors, sometimes with a blockade to protect from deeper fear or shame.  The emotional response centers react suddenly – even before our logic centers – and drives us to a behavior. Addressing this response can be the first, critical step to managing our behavior patterns.    

The result of a repeated negative behavior can lead to health issues.  A person may come in with a complication, e.g. someone who smokes comes in with chest pain and fears a heart attack, and genuinely wants to avoid health issues.  During a short clinic visit or hospitalization, the behavior is often addressed with a “don’t do that, do this, or else” approach, a method that falls short in motivating behavior change.  The patient may quit the behavior out of necessity for the short term, only to revert to the behavior when they feel better or when the stressors worsen.  A “fear of death approach” is generally not effective, after a person feels better or doesn’t necessary experience ill-effects from the substance or is not motivated to change.

An approach that addresses consequences undercuts the understanding of the origin and reason for the behavior as a coping mechanism.  The patient often meets these questions with a sense of shame and conflict, in some way fueling their fear of no longer having a substance as a coping strategy.  Intertwined with this is the person’s physical dependence on the substance.  The same holds for behaviors other than substances, including food choices, excessive phone or TV, gambling or sexual addictions.   Harmful behaviors have one thing in common – they are resistant to change, even if one has reason and insight on the importance.  

I once evaluated a patient who was a longstanding smoker for a necrotic, vascular insufficiency ulcer – an all-too common risk for infectious complications.  I discussed with her to determine her readiness to quit smoking after she was taken to the operating room to remove the damaged tissue (a debridement).  She stated that if she goes back home, she will start smoking again, regardless of the consequences.  She simply wasn’t able to imagine herself not smoking.  She knew that smoking was harmful to her but conceded to smoking in light of the possible consequence of amputation.

Another patient came in for a new visit and complained of generalized body pains and emotional challenges related to his dog being diagnosed with cancer. After a series of visits trying to assist and counsel the patient, it became clear that his preoccupation centered on whether I could prescribe him more pain medications to assist in his coping.  Ultimately, he buckled under repeated visits and no increase in pain medications with displays of anger, arranging for a new doctor visit in another clinic.  After establishing with a new physician who prescribed him a greater quantity of pain medications, he actually called our clinic and boasted to my medical assistant that he was able to get more pain meds.

Both patients had an underlying drug dependence that affected their behavior and usurped their ability to cope in another manner.  Both patients did not realize that their behaviors were affected by the substance of abuse, whether their dependence was acknowledged or concealed.  A common finding in a person with dependence on substances is that an attempt in coping with real or perceived stressors ropes in a substance that then becomes the favored coping strategy only to later become the central trigger to the stress.

Here are some methods that you can use to address a behavior that you wish to change:

  1. Define the behavior that you wish to change and set a goal: Say you want to stop swearing at people when you get angry. Get a good feel as to what level of stress may cause this to happen and realize when this line is crossed.
  2. Slow down: Sometimes a delay in the execution of a behavior can allow the judgement centers to take over and stop it.
  3. Define a replacement behavior and begin to use it: This is usually trial and error but can sometimes help to supplant the harmful behavior with one that it more positive.
  4. Keep practicing and don’t give up: As you are working toward a behavior change, a relapse can occur. This does not mean you are back to where you started. Think about the reasons that a relapse of an old behavior occurred. Work toward improving this.

Refer to The steps to behavior change post for more tips on behavior change. Thank you for reading this post. Please like, comment and share.

Health and Wellness: A Moving Target

Health and Wellness:  A Moving Target?

It is estimated that 90% of the $3.3 trillion spent on health care yearly is directed to those with chronic health and mental conditions.  One-third of the approximate 800,000 deaths that occur in the United States is attributable to heart disease and stroke.  More than one-third of the United States population is obese.  Associated with this, there has been an increase in the prevalence of multiple chronic medical conditions, including type II diabetes mellitus, hypertension and heart disease, obstructive sleep apnea and cancer.  Pharmaceutical companies offering treatments for these conditions have seen steady gains in profit with the use of statins, anti-hypertensives and diabetic medications.  Meanwhile, the behaviors that are linked to health decision-making often go unaddressed in the usual medical visit or worse in the acute care setting, and these issues get medicated without a proper communication of prevention and mitigation.  The wound under the band-aide of healthcare continues to grow.

The medical system has been under greater strain, as it faces a burgeoning population of those with health issues.  The most tangible answer is often providing medications and not addressing the underlying behaviors.  The individual often relinquishes his/her responsibility to behavior change with the allure of medications.  Learned helplessness can be cyclical and compound the problem.  The hope for wellness becomes a pipedream with no clear progress toward the goal.

The fuel options that we put in our bodies have dramatically altered.  Most Americans have found themselves regularly eating foods that have been processed thoroughly enough to nearly remove all of the nutrition.  Children are fed cereal in the morning, sandwiches or pizza for lunch in their school cafeteria and macaroni and cheese for dinner.  The tradition of passing on family recipes has become a lost art.

In the last decade, the pendulum is shifting toward a more wholesome, natural diet.  Although a health trend today, the concept of eating natural food was the only option in the past, when fruits and vegetables were cultivated from smaller farms and beef, chicken and eggs were distributed to more local stores or bought directly from the farm.  After the second world war, as the population of the United States became larger and more dispersed, there were greater strides to up-scaling food processing and packaging.  Processed foods, such as cereal, snacks and dessert foods, made their way onto US American tables, with a trend away from home-cooked meals.  The rising popularity of fast food restaurant chains, such as McDonald’s and Burger King, created more convenient ways to eat prepared meals with access to a variety of more processed foods and sugary drinks. 

A dietary change came from the medical field’s recognition that heart disease was becoming more common in people living in the United States.  Meanwhile, a major demographic shift in the population was underway with a longer lifespan, owing to improved public health measures in the early part of the 20th century.  This longevity came with it the compromise of a burgeoning rate of cardiovascular disease.  A consensus theory was reached in the medical field that the source of it was the western diet.  The vessels of those with cardiovascular disease are filled with atherosclerotic plaques, which compromise blood-flow to vital organs, including the heart itself.  These plaques are largely cholesterol-laden.  The theory was that dietary trends were contributing to this increased incidence and since cholesterol was found in these plaques, cholesterol and fat in the diet were primarily targeted. 

The food industry followed suit, removing the fat from their packaged products, making an already unhealthy food, even unhealthier by replacing it with more sugar.  Compounding this was the production of other sweeteners, namely high-fructose corn syrups (HFCS) in the late 1960’s from a U.S. corn surplus.  The FDA gave it the designation of generally recognized as safe (GRAS) in 1976, giving the food industry the “green light” for what became the standard replacement for sugar during the eighties and beyond.  The majority of foods, including soft drinks, sauces, salad dressings, cereals and dried snacks have some degree of HFCS, often masked by one of its numerous aliases, including “fructose”, “fructose syrup” or “corn sugar”.

In the ensuing decades up to now, there has been a new, literally widening demographic in the United States and in much of the world that has access to these processed foods.  Health statistics show trends in the body mass index (BMI*), which is one marker for health, with stark increases in BMI throughout much of the United States.  Not only has there been the increased BMI levels, but there have followed increased prevalence of diabetes and cardiovascular diseases.  Even more telling is that these increases of BMI have disproportionately affected those in a lower income echelon and that our youth are increasingly more likely to become obese.  The United States and much of the rest of the world are truly facing an obesity crisis.  Where will our future take us?  Moving onward past finding fault, the future lies in our hands through a shift toward active responsibility and empowerment.  Obesity doesn’t occur from national sloth or gluttony.  It is a disease condition that occurs from dietary disequilibrium.  Likewise, getting healthy doesn’t just occur in those who are ultra-disciplined or who exercise all day.  It is the hope that through the information presented in this book, one could reverse or prevent obesity toward the goal of achieving even greater health

The Journey Begins

Thanks for joining me! Your Health Forum by Dr. Cirino is written and curated by a board certified physician in internal medicine and infectious diseases. I invite you to embark on the journey to finding optimal health. Please feel free to post comments, examples or questions, so that we may better serve the public. Welcome!

Disclaimer: The health information is given in general terms and is not necessarily applicable to every specific patient’s care and needs. The views expressed on this site are for educational purposes only and are not meant to replace the specific, tailored care received from a primary care physician or other clinician.

Good company in a journey makes the way seem shorter. — Izaak Walton

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