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“Low risk” nurse with normal cholesterol but self-destructive lifestyle ends up with heart transplant after CCTA

Posted by Colin Rose on December 20, 2010

Here in a nutshell is a demonstration of the problem with expecting technology to substitute for good clinical medicine and save us from our self-destructive addictions. If anyone is puzzled about the dichotomy between the exorbitant cost of the US medical system and its relative lack of effect on any measure of health here is the reason.

Below is a story from theheart.org followed by the actual paper in the Archives of Internal Medicine minus the references.

In the absence of any symptoms attributable to coronary artery disease there was no reason to do any more testing but the temptation to use high tech tools without good indication is irresistible to many doctors. CCTA is the latest expensive test to detect coronary atherosclerosis. Patients think that they will never have a heart attack and live longer if the disease is detected and some surgical procedure, like an angioplasty or bypass is done and doctors making $millions from doing them are not about to discourage them and point out the total lack of evidence for any significant benefit from angiography or the surgical procedures in patients with chronic coronary disease.

The authors have labelled this patient “low risk” because her “cholesterol” was normal but clearly she was at high risk based on her obesity and hypertension, both indices generally of  junk food addiction, in spite of her being a nurse.  When she started new exercises she probably got muscle pain from weight lifting. With an obvious self-destructive lifestyle, she should not have been “simply reassured” as recommended by the editors. But instead of encouraging her to make meaningful lifestyle change her doctors ordered tests with no clinical indication.

Framingham scores, lipid profiles and CRPs can be very deceptive because they do not assess LDL modification in the arterial wall, essential to the formation of atherosclerotic plaque. In spite of having “normal” numbers for all the usual “risk factors” she had advanced atherosclerosis in her coronary arteries. Apparently no dietary history was taken and no attempt was made to encourage her to change her lifestyle, an example of gross diagnostic and therapeutic incompetence, all too common in an era of absolute faith in the power of technology to protect us from our self-destructive addictions. Doctors abdicate professionalism by ordering tests instead of dealing with the real problems, like junk food addiction, which take much time for which they are not compensated and risk alienating patients who demand a high-tech fix or reassurance so that they can continue their risky behaviour.

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Case study shows how “just-in-case” CCTA in a low-risk patient may spectacularly backfire

DECEMBER 17, 2010 | Reed Miller

San Francisco, CA – Coronary computed tomographic angiography (CCTA) in patients with a low pretest risk of coronary disease wastes resources and can even lead to horrendous outcomes, a case study published December 13, 2010 in the Archives of Internal Medicine shows. The report tells the story of a 52-year-old white female who initially presented with chest pain and had a CCTA; this was followed by an unfortunate chain of events in which she suffered an aortic dissection during cardiac catheterization and that culminated in her having a heart transplant.

Part of its ongoing “Less is More” series begun last April, the latest case, reviewed by Dr Matthew Becker (St Vincent’s Heart and Vascular Institute, Erie, PA), Dr John Galla (Providence Hospital, Mobile, AL), and Dr Steven Nissen (Cleveland Clinic, OH), describes how the well-meaning attempt to reassure a patient with a low risk of coronary disease backfired spectacularly.

“Perhaps the most important point to be learned from the case described by Becker and colleagues is that there are safer ways to reassure patients,” say journal editors Drs Rita RedbergMitchell Katz, and Deborah Grady (University of California, San Francisco) in an accompanying editorial. “Patients value our advice. Talking with our patients should be our first choice for reassurance.” They add that “applying the ‘less-is-more’ principles prospectively could have avoided this unfortunate case.”

From diagnostic uncertainty to disaster
The 52-year-old nurse had hypertension and mild obesity and had recently begun an exercise and diet regimen to control her weight and blood pressure. She presented to her primary physician with chest pain, but no other symptoms: she had a normal ECG with a normal lipid profile and normal C-reactive-protein level. Her doctor attributed the chest pain to a musculoskeletal cause but performed a CCTA to reassure her that she was not at risk for a coronary event.

The CCTA showed discrete, noncalcified, nonobstructive plaque in the mid and distal segments of the left circumflex and dominant right coronary arteries and diffuse, complex calcification in the proximal left anterior descending (LAD) coronary artery. Because that calcification was difficult to quantify, the physician recommended that she undergo cardiac catheterization to get a clearer look at the LAD.

This exam, performed at the local community hospital, revealed only a mild irregularity in the LAD, but during the procedure, the patient complained of chest pressure, which prompted an aortogram that revealed an aortic root dissection that was compromising the left main coronary artery.

So the patient underwent urgent coronary artery bypass graft (CABG) surgery and stayed in the hospital for two weeks with a residual left ventricular ejection fraction of 35%. The bypass graft soon failed and was treated with multiple drug-eluting stents, but despite her compliance with dual antiplatelet medical therapy, a stent in the vein graft supplying the circumflex artery developed a thrombosis, causing an ST-segment-elevation MI complicated by cardiogenic shock. The thrombosis was successfully treated, but the patient remained in refractory cardiogenic shock and ultimately underwent orthotopic heart transplantation.

Unnecessary testing happening every day
“With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification,” say the authors. “Lacking randomized data suggesting improvement in clinical outcomes and with clear risks, including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.”

They acknowledge the risk of complications associated with cardiac catheterization is low, but catastrophic events are always a possibility. They believe the physicians in this case overestimated the stenosis in this patient’s coronaries because they did not fully appreciate the CCTA’s potential for false-positive findings. Complete visualization of all segments of the coronary tree with CCTA is often hindered by cardiac motion, which can lead to the appearance of “blooming artifacts” of coronary calcification that may cause the observer to overestimate the extent of stenosis.

Becker et al point out that previous studies comparing CCTA with conventional coronary angiography in diverse patient populations show CCTA’s sensitivity is between 79% and 100% for the detection of obstructive coronary disease, but its specificity is only 64% to 85%, corresponding to “an unacceptably high false-positive rate” of up to 81% in some populations.

As reported by heartwire, the recently released professional guidelines on Appropriate Use Criteria for Cardiac Computed Tomography list CCTA as “inappropriate” for detection of CAD patients with a low risk of heart disease, ability to exercise, nonacute symptoms that may be an “ischemic equivalent,” and an interpretable ECG.

Patient could have been simply reassured
“If a test is not sufficiently accurate to change clinical management in a particular setting, it should not be done,” but according to Redberg et al, often these tests are done anyway—sometimes even before the patient sees a physician—because nobody has assessed the patient’s pretest probability of the disease or properly considered how the test result will change the clinical management of the patient.

“There are cases where [the test presents] more risks than benefits, and you really need to consider the risks and benefits and not [assume that] just because you can do the test, you should do the test. And this case highlights that,” Redberg told heartwire.

Cases like this where an inappropriate test leads to many complications and near catastrophe are rare, “but to have a CT or another test that was just done for reassurance, when you could have just told the patient ‘You’re fine,’—I think that’s done every day lots of times.

“You don’t know which [tests] are going to lead to that kind of problem, but you do know which of those is not going to give you any benefit, so if there is no benefit, it’s better not to be taking any risk, even a small one.”

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Left Main Trunk Coronary Artery Dissection as a Consequence of Inaccurate Coronary Computed Tomographic Angiography

Matthew C. Becker, MD; John M. Galla, MD; Steven E. Nissen, MD

Arch Intern Med. Published online December 13, 2010. doi:10.1001/archinternmed.2010.464

ABSTRACT


A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain.

REPORT OF A CASE

A 52-year-old white female nurse with a medical history that was notable for hypertension and mild obesity presented to her local primary care physician with the recent onset of chest pain. Further investigation revealed that in an effort to lose weight and assist in the control of her hypertension, she had adopted a new diet and exercise program several weeks earlier. At her initial presentation, she described 48 hours of nonexertional, sharp chest pain that was aggravated by elevation of her right arm and deep inspiration. She denied associated symptoms of shortness of breath, nausea, vomiting, or diaphoresis, and her office electrocardiogram showed no abnormalities.Other than mild hypertension (blood pressure, 142/85 mm Hg), the results of her physical examination were unremarkable except that elevation of her right arm and palpation of the right chest wall reproduced the symptoms with which she presented. With a normal lipid profile and an ultrasensitive C-reactive protein level, she was diagnosed as having atypical chest pain most likely of musculoskeletal origin. Hydrochlorothiazide was used to treat her hypertension, and cardiac computed tomography angiography (CCTA) was performed to exclude the possibility of coronary artery stenosis and to reassure her. Interpretation of the CCTA findings suggested that both the left circumflex and the dominant right coronary arteries had discrete areas of mild, noncalcified, nonobstructive plaque in their mid and distal segments. The large-caliber left anterior descending coronary artery (LAD) was reported to have diffuse and complex calcification of the proximal segment, which made accurate quantification of the luminal stenosis challenging.

Subsequently, the patient’s physician recommended cardiac catheterization to enable more precise assessment of the LAD luminal stenosis. Selective coronary angiography was performed at the local community hospital and revealed only a mild luminal irregularity of the LAD. Shortly after the second injection of contrast, the patient complained of intense chest pressure and was noted to be hypotensive and tachycardic (blood pressure, 78/45 mm Hg; heart rate, 110/min). Mild “staining” of contrast was noted in the left coronary cusp of the aorta, and an ascending aortogram revealed a dissection of the aortic root extending into, and resulting in compromise of, the left main coronary artery. An intra-aortic balloon pump was placed, and the patient underwent urgent coronary arterybypass with saphenous vein grafting of both the LAD and the left circumflex coronary artery.

Following a prolonged, 14-day hospital course and a residual left ventricular ejection fraction of 35%, the patient was discharged home with intensive cardiac rehabilitation. Unfortunately, within 6 months of the bypass, she presented again with escalating chest pain and was noted have premature graft failure that was treated with percutaneous coronary intervention with multiple drug-eluting coronary stents. Despite her compliance with dual antiplatelet medical therapy (aspirin and clopidogrel daily), she presented 8 weeks later with an ST-segment elevation myocardial infarction complicated by cardiogenic shock. Emergent catheterization revealed thrombosis of the stent in the vein graft supplying the circumflex artery that was successfully treated with a catheter-based intervention. However, the patient remained in refractory cardiogenic shock and ultimately required urgent orthotopic heart transplantation.

COMMENT


Emergency department visits for chest pain syndromes represent a large and growing health care burden. Because patients with chest pain require urgent triage and timely management, there are great incentives for developing a new generation of novel, complementary diagnostic strategies. A recent addition to the diagnostic armamentarium, multidetector CCTA, can noninvasively generate reconstructed images of the coronary circulation. However, the brisk expansion and rapid adoption of CCTA over the past decade has outpaced supportive clinical data and has led to the referral of a much larger, and often lower-risk, segment of the population for coronary artery catheterization. We believe that in this case the unwarranted use of advanced diagnostic imaging (false-positive CCTA findings) directly contributed to unnecessary cardiac catheterization that resulted in a tragic complication and significant morbidity.Advanced diagnostic imaging technologies or the latest biomarker cannot, and should not, replace a thorough history and physical examination with subsequent decision making guided by the bestevidence-based practice. The need for testing in patients with chest pain is based on the clinician’s estimation of the pretest probability of coronary disease. In a patient with a low pretest probability (<10%) of having significant coronary disease, the preferred course is to reassure the individual and to focus the treatment plan on primary or secondary prevention strategies. Additional diagnostic testing rarely garners useful information and exposes the patient to unnecessary risk—both from the diagnostic test itself and from subsequent invasive testing because of false-positive results. While the risk of complications associated with cardiac catheterization is low, catastrophic events can occur. As opposed to CCTA, in appropriately selected patients coronary angiography allows the presence, location, and, most importantly, the functional significance (eg, fractional flow reserve, intravascular ultrasonography) of lesions to be determined. Because there is often discordance between luminal stenosis and the physiologic significance of lesions, functional testing has assumed critical importance in the assessment of patients with a moderate pretest probability (10%-90%) of coronary disease.

Therefore, given the possible adverse consequences of the overuse of diagnostic imaging in a broad and uncensored population of patients with chest pain, recent joint professional guidelines emphasize that ” . . . an appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication. . . . “Furthermore, because of differences in body habitus, coronary physiology, exercise physiology, symptom presentation, and disease prevalence, the diagnostic accuracy of stress testing may be affected by the female sex. In addition to having a markedly different ST-segment response to exercise from a young age, data suggest that ST-segment depression tends to be less sensitive and specific for coronary artery disease in women. With normal electrocardiographic findings, negative cardiac biomarkers, and a classically atypical presentation, our patient had an age-specific risk level that was below average. She had a low pretest probability of coronary disease (<10% risk of myocardial infarction or death per 10 year interval), making further testing inappropriate and the chance of false-positive study results unacceptably high. However, in an era of rapid advancement in diagnostic imaging strategies, the savvy clinician must not forget the basic tenets of data-driven medicine, patient selection, and risk tolerance and ultimately realize when less may be more. Such is precisely the case with CCTA.

Because CCTA is rapid and noninvasive and has wide availability, it has increasingly been used to detect coronary atherosclerosis in a broad array of patient populations. However, the lack of randomized data suggesting clinical benefit, as well as technical and anatomical limitations, restricts its application in many patients. Studies comparing CCTA with conventional coronary angiography in diverse patient populations suggest that CCTA is highly sensitive (79%-100%) for the detection of obstructive coronary disease, with a positive predictive value ranging from 86% to 91%. However, these same studies report suboptimal specificity (64%-85%) and negative predictive values of 83% to 90% that correspond to an unacceptably high false-positive rate of up to 81% in selected subpopulations. Further limiting the diagnostic accuracy of CCTA is the fact that complete visualization of all segments of the coronary tree is hindered by cardiac motion (heart rate, >70/min), smaller vessel caliber (<2 mm), and tortuousity that may result in portions of a vessel moving in and out of an imaging plane. Furthermore, given its high attenuation coefficient, the presence of coronary calcification commonly produces a “blooming artifact” that makes accurate assessment of adjacent arterial luminal challenging and may result in overestimation of the degree of luminal stenosis, which is likely the case in the patient described herein. Therefore, CCTA often overestimates the presence and severity of coronary atherosclerosis to a degree that is dependent on the study population, the equipment used, and the experience of the interpreting physician, which may lead to unnecessary, higher-risk, and costly invasive procedures.

Nevertheless, the use of CCTA has increased dramatically over the past decade, with some estimates suggesting up to 26% per year. In an era in which comparative efficacy of therapies has assumed critical importance, the unchecked growth of CCTA seems not only unfounded but also irresponsible and unsustainable. Aside from its cost implications, CCTA also exposes the patient to substantial amounts of ionizing radiation. It is estimated that the collective dose received from medical radiation increased by more than 700% between 1980 and 2006, with increases in computed tomography accounting for more than 50%. Furthermore, 64-slice CCTA (without tube current modulation) exposes the patient to an average effective dose of 15 mSv of radiation compared with only 7 mSv for diagnostic coronary angiography. With recent data suggesting that 1.5% to 2.0% of all reported cancers in the United States may be linked to ionizing radiation from computed tomography, there is reason for pause.

In conclusion, our patient suffered a rare but devastating complication from an cardiac catheterization that was the direct result of unnecessary CCTA and false-positive findings. With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification. Lacking randomized data suggesting improvement in clinical outcomes and with clear risks including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.

Posted in atherosclerosis, cardiology, CCTA, cholesterol, coronary artery disease, coronary computed tomographic angiography, diet, ethics, heart transplant, junk food, lifestyle, obesity, professionalism, surgery, technology, waist circumference | 1 Comment »

Want to reduce taxes? Eat less, stop smoking.

Posted by Colin Rose on March 31, 2010

The chickens are coming home to roost. $Billions are thrown at the disease care system (medical system) to treat preventable diseases of lifestyle, like obesity, hypertension, atherosclerosis and diabetes which account for at least half of the cost of the medical system; Quebeckers would rather pay more taxes than eat less and stop smoking. It would be political suicide for Charest to even suggest there was such a trade-off. So, people, if you really have to have your cigarettes, poutine, smoked meat and steamés, you will have to pay more taxes to treat the disastrous consequences of your self-destructive lifestyle.

MacDonald's


Say ‘ah’ and make a health ‘contribution’
kdougherty@thegazette.canwest.com KEVIN DOUGHERTY
The Gazette
31 Mar 2010

QUEBEC – Quebecers can look forward to paying a new “health contribution” and a 15-per-cent sales tax in 2012 under the budget Finance Minister Raymond Bachand brought down yesterday. “The initiatives we are announcing today will have little impact on…read more…

Posted in drugs, lifestyle, obesity | Tagged: , , , | 4 Comments »

Getting more for less in health care (National Post, 06 Oct 2009)

Posted by Colin Rose on October 6, 2009

Esmail assumes that producing “health care” is analogous to producing widgets; the law of supply and demand applies to both. Not so. Demand for “health care”, really disease care, is infinite. Deluded inhabitants of developed societies believe that any money spent on doctors and hospitals will prolong their lives. But, there is no correlation between per capita expenditure on doctors and hospitals and any measure of health. The cost of disease care will continue to rise as long as demand is fueled by absurd expectations of a necessarily finite system, driven by the latest, doctor-self-aggrandizing story on some “life-saving” technology. The cost of disease care can only be contained if doctors are put on salaries and practice according to the Hippocratic Oath and the best evidence for effectiveness and safety of treatments. Only then will doctors have an incentive to do less. Unlike the present perverted fee-for-service system, there would be no incentive to administer profitable but superficially attractive and potentially lethal procedures or drugs for non-life threatening disease. Also, unlike the present system, there would be a primordial incentive, less work for the same money, to prevent the diseases of lifestyle that account for most of the cost of the disease care system and most of the premature deaths in our society.


Getting more for less in health care
NADEEM ESMAIL
National Post
06 Oct 2009

Thanks to poor fiscal management, the government of Ontario finds itself in a difficult fiscal situation. It must find a way to eliminate the significant deficits that are expected until at least 2015/16. Given that tax increases are certain to damage…read more…

Posted in ethics, lifestyle, professionalism | Tagged: , | Leave a Comment »

WHAT YOU EAT MAKES YOU FAT

Posted by Colin Rose on September 13, 2009

Great article, Joe. We appreciate there are those that are confused. But there are also large numbers who know what is healthy to eat, but easily blind themselves to reality; they are junk food addicts. That “food”  that the cruise passengers are piling on their plates is specifically formulated to appeal to addictions to sugar, salt and the mouth feel of fat. Unfortunately, treating junk food addiction is just as hard as treating addictions to tobacco, cocaine or heroin. Doctors are not trained to and not paid to treat addictions. They are paid to “treat” the symptoms of junk food addiction, like hypertension, Type 2 diabetes and “cholesterol” and do futile gastric bypasses. “Treatment” of these symptoms deceives the addict into believing that s/he can avoid the consequences of the addiction and makes the addiction worse. Americans are inundated with direct-to-consumer (DTC) drug advertising, claimed to be a First Amendment right by corporations with $billion ad budgets, promoting this deception and doctors are paid to prescribe those drugs.  Canada is catching up fast. Obesity rates are rising and there is pressure from the media to allow DTC in Canada, presumably guaranteed by the Bill of Rights.

The solution? Each individual has to balance the transient pleasure of addiction against the long term disastrous consequences of the addiction. In our society this is the hardest thing most people have to do 24/7/52 for a lifetime and doctors must avoid aggravating addictive behaviour.


WHAT YOU EAT MAKES YOU FAT
JOE SCHWARCZ
The Gazette
13 Sep 2009

Occasionally, I like to spy on people. Only for the sake of science, of course. And what better opportunity to do that than on a cruise ship? I like cruising. Besides outstanding entertainment, impeccable service, interesting ports, activities galore…read more…

 

Posted in addiction, diet, drugs, ethics, food, junk food, lifestyle, moral hazard, obesity, professionalism, statins | Tagged: | 2 Comments »

Once-a-day trap

Posted by Colin Rose on March 30, 2009

Not mentioned is the moral hazard effect of taking any pill that one thinks will obviate the need for constant vigilance in lifestyle choices. The deceptive hype behind multivitamins and “cholesterol” pills has been largely responsible for the pandemic of obesity and Type 2 diabetes.


Once-a-day trap
BY JULIE BEUN-CHOWN Canwest News Service
National Post
30 Mar 2009

Joe Schwarcz is known for his blunt, take-noprisoners style when he gets fired up. For the past 25 minutes, the erudite director of McGill University’s Office for Science and Society and outspoken star of the Dr. Joe Show on Toronto’s CFRB radio has…read more…

Posted in diabetes, Type 2, diet, drugs, junk food, lifestyle, moral hazard, obesity | Tagged: , | Leave a Comment »

Escaping the dungeon of our own desire

Posted by Colin Rose on February 27, 2009

Why do we need to keep having to prove for ourselves that Seven Deadly Sins, codified 1500 years ago are still valid? Every few generations we forget the power of the addictions to which the human brain is prey and become convinced that some form of technology will save us from the consequences of self-destructive lifestyles. One hopes we and our descendants have learned the lesson that constant vigilance is lifestyle choices is and will always be essential, regardless of the technological sophistication of a society.


Escaping the dungeon of our own desire
MICHAEL GERSON Washington Post Writers Group
National Post
27 Feb 2009

There is now a minor but raging academic debate taking place over the effect of an economic downturn on your health. In the traditional view, unemployment can cause a kind of recession flu — a funk that leads to stress-smoking, unhealthy comfort foods…read more…

Posted in addiction, lifestyle, moral hazard | Tagged: , , , | Leave a Comment »

‘The Heart Truth’ for both men and women

Posted by Colin Rose on February 26, 2009

Unilever, the maker of Becel margarine, would like us to believe that Becel is a health food; the more you eat the better. To that end Unilever contributes $millions to various cardiovascular and dietetic organization who reciprocate by putting the Becel logo on their literature and web sites.

There is no such thing as a healthy refined fat. Both margarine and butter are junk food, naked calories. Besides, pure fat is tasteless. The taste in butter and margarine comes only from their salt content. Obesity is the major nutritional problem and refined fats (butter, margarine or oil)are the most concentrated form of calories and should have no place in a healthy diet.


The Heart Truth’ for both men and women
Margaret McKellar, brand manager, Becel.
National Post
26 Feb 2009

Re: Barbara Kay, Apparently Men No Longer Have Heart Disease Or Strokes: That’s The Message From Becel Margarine And The Heart And Stroke Foundation, Feb. 16. I have had personal experience in dealing with loss due to heart disease and stroke. My…read more…

 

 

Posted in atherosclerosis, cholesterol, diet, junk food, lifestyle, obesity | Tagged: , , , | Leave a Comment »

The Atherogenic Football Diet

Posted by Colin Rose on February 1, 2009

Who are the coaches and “nutritionists” that advise football players to eat atherogenic, obesogenic , diabetogenic, hypertensogenic diets just so they can trample the opposing team? They should be banned from the game.
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By Madison Park
CNN

(CNN) — Football players guzzle protein shakes, down steaks and lift weights. They train and gain weight, hoping to build mass under the careful eye of the team’s coaches, nutritionists and gurus.

“It was a scripted lifestyle where they tell you how to eat, how to take care of yourself, how much body fat you should have,” said Chuck Smith, a former defensive end for the Atlanta Falcons and the Carolina Panthers.

But once their glory days are over, they have the same problem as millions of other Americans: They’re fat.

footballobesity

Football Team

“When I trained, they told us to eat all you can eat,” said Smith, who played in Super Bowl XXXIII with the Falcons. “Drink beer, eat peanut butter to gain weight. All those eating habits were great for football. But when I got done, no question I had to make adjustments.”

Without scheduled practices, meals, and games on Sunday, it became tougher to keep in shape.

When players were younger, they had the opposite problem.

Many tried to gain weight, believing that bigger is better. But as they age and retire from football, many are seeing that “big” is causing problems.

Smith, who weighed 274 pounds during his professional days, often had four plates of food in one sitting “to keep my weight up.” After retirement, Smith had to unlearn those habits.

“I had to retrain my thinking,” he said. “I don’t need to be full. I don’t have to stuff myself to feel comfortable. That took a long time. You stuff yourself to gain weight, then you get out of shape.”

Smith learned he had high cholesterol (he had to take Lipitor), and his blood pressure was climbing, too.

“I had to take the bon-bons out of my mouth,” said Smith, 39. “I had to empower myself. Strength coaches, nutritionists aren’t going to take care of me. Guys have to empower themselves to take care of themselves.”

Smith is now a fitness trainer at Defensive Line Incorporated, where he works with football players. Through healthy foods and workouts, he trimmed his body fat, lowered his cholesterol and shed 50 pounds.

Some players understand the risks, said Dr. Archie Roberts, a former National Football League quarterback and retired cardiac surgeon.

“They understand that if they stay 250, 300, 350 pounds as they age, that’s going to shorten their life span and cause them more health problems,” he said. “Others don’t get it and they’re unable — for whatever reason — to lose the weight, and they will suffer the consequences, just like anybody else in the general population carrying too much weight.”

Diabetes, hypertension and high cholesterol are all cardiovascular risks associated with obesity.

Roberts heads the Living Heart Foundation, a nonprofit promoting health for former football players. For five years, he has conducted research to determine whether former football players are at added risk for heart problems (they’re not).

After left tackle Bob Whitfield retired from the New York Giants in 2007, he gained 20 pounds. The 37-year-old Pro-Bowler is trying to lose 40 pounds, which would bring him to 290 pounds, the lowest he has weighed since ninth grade.

“You don’t want to be the person at the buffet and people look at you crazy,” Whitfield said. “Overall, you want to have a healthier lifestyle. It doesn’t mean you want to be muscled up. … I don’t want to be the biggest man in the room anymore.”

Looking back at his career, Whitfield doesn’t think his size made him a better player.

“When that mass gets too heavy, you decline, you can’t accelerate, you don’t have as much force,” he said. “I never felt that being bigger gives you a competitive advantage. I put it on flexibility, the explosive nature of your movements.”

Several decades ago, 300-pound players were a rarity; now, the league has more than 500, Roberts said.

Decades ago, the Washington Redskins’ offensive line was known for its size and dominance.

“They had the largest line in the NFL, called the Hogs, 20 years ago,” said Dr. Ben Levine, director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital in Dallas, and professor of medicine. “If you go back and look at their size, they’re about the size of the running backs today. The impression was these guys were massive, huge. They couldn’t play in the NFL today. They’re too small.”

Smith said he wasn’t forced to gain weight, but perceptions exist on how a player should look based on his position. That “needs to change in the NFL,” he said.

Being faster, stronger and more aggressive is more important than size, Smith said. He drew an analogy to airline stewardesses: “We want her to be tall and slim so she can walk down the aisles. Now is there really a difference between a 135-pound woman and a 150? Well, maybe a little bit different in the hips, but the same effectiveness happens when she does her job.”

He added, “I’m a classic example that size doesn’t matter.”

But that’s not what young, aspiring players think.

Jackie Buell, director of sports nutrition at Ohio State University, said she encounters players who seek to gain as much as 30 pounds by next season and seldom care whether it’s fat or muscle.

Buell’s research examined 70 college linemen and found that nearly half have metabolic syndrome, meaning that the players have at least three of the five risk factors of developing diabetes and heart disease. Her next project is to explore whether junior high and high school football players are developing metabolic syndrome.

“My fear is, these young men have this metabolic profile, what happens when they stop working out intensively?” Buell said. 

Posted in atherosclerosis, athlete, cholesterol, diabetes, Type 2, diet, drugs, football, junk food, lifestyle, obesity, statins, waist circumference | Tagged: , , , | Leave a Comment »

Every disease is “genetic”. So what?

Posted by Colin Rose on December 29, 2008

Every disease is caused by some combination of nature and nurture, genetic susceptibility and the environment, especially nutrition. Fortunately, most of the common fatal diseases and those costing the most to the disease care system are mostly environmentally caused. Attempts to find a simple genetic cause for atherosclerosis, hypertension, obesity and Type 2 diabetes were and are unscientific fishing expeditions driven by the analogy that we could immunize the population against these chronic diseases of lifestyle, as we can immunize against acute infectious diseases like polio or smallpox. As this paper makes clear the four-billion year old genetic code is a highly refined, self-referential system that is unlikely ever to be completely understood.

Unfortunately, changing the environment, aka lifestyle, necessitates conquering legal addictions to junk food, tobacco and alcohol. We would much rather spend $many billions on a futile attempt to find a magic genetic bullet to obviate the destructive consequences of addiction than face the painful necessity of eliminating them. 

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Genetic diseases may be tougher to crack, new research suggests 

Last Updated: Friday, December 26, 2008 | 4:07 PM ET 

Finding a cure for many genetic diseases — including some cancers and neurodegenerative ailments — may be much more complicated than previously thought, new research indicates.

An international team’s work on alternative splicing, the process that produces 75,000 of the proteins in human cells, found that small changes in the environment near an alternative splice could produce a large change in the proteins produced.

That’s important, because mutations in DNA sequences in alternative splicing cause more than half of all genetic diseases.

If the materials used in splicing are seen as forming a long sentence, then the individual parts can be considered words, said Tim Nilsen, director of the Case Western Reserve University School of Medicine’s Center for RNA Molecular Biology in Cleveland.

“Adding or deleting one word,” he said “can radically change the meaning of the sentence.”

Biologists believe that rules hidden in the DNA code control alternative splicing, so once the code is broken, cures can be found for genetic diseases.

But the finding by Nilsen’s team on the importance of the environment means the code is much more complicated than thought. That will likely delay that progress of scientists who hope to amend the code to cure genetic diseases, said Joseph Nadeau, chair of the medical school’s genetics department.

“It’s context, not [genetic] code, that’s important,” he said.

The study, Dynamic regulation of alternative splicing by silencers that modulate 5′ splice site competition, was published in the Dec. 24 issue of Cell.

Nilsen led a team from three U.S. institutions — Case Western, Columbia University and the Memorial Sloan-Kettering Cancer Institute — and the Max Planck Institute for Biophysical Chemistry in Germany.

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