Exercise is good, not bad, for arthritis

When pain strikes, it’s human nature to avoid doing things that aggravate it. That’s certainly the case for people with arthritis, many of whom tend to avoid exercise when a hip, knee, ankle or other joint hurts. Although that strategy seems to make sense, it may harm more than help.
Taking a walk on most days of the week can actually ease arthritis pain and improve other symptoms. It’s also good for the heart, brain, and every other part of the body.
A national survey conducted by the federal Centers for Disease Control and Prevention showed that more than half of people with arthritis (53%) didn’t walk at all for exercise, and 66% stepped out for less than 90 minutes a week. Only 23% meet the current recommendation for activity—walking for at least 150 minutes a week. Delaware had the highest percentage of regular walkers (31%) while Louisiana had the lowest (16%). When the CDC tallied walking for less than 90 minutes a week, Tennessee led the list, with 76% not walking that much per week, compared to 59% in the  District of Columbia.

Beyond walking

Walking is good exercise for people with arthritis, but it isn’t the only one. A review of the benefits of exercise for people with osteoarthritis (the most common form of arthritis) found that strength training, water-based exercise, and balance therapy were the most helpful for reducing pain and improving function. “Swimming or bicycling tend to be better tolerated than other types of exercise among individuals with arthritis in the hips or knees,” says rheumatologist Dr. Robert H. Shmerling, associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center.
Exercise programs aim to help people with arthritis:

• increase the range of motion in the affected joint
• strengthen muscles
• build endurance
• improve balance

You can create an exercise program of your own, with help from a trusted doctor, nurse, or physical therapist. Or you can try one that’s been developed by arthritis experts. Examples include the Fit and Strong! program from the University of Illinois at Chicago, or one of several programs developed by the Arthritis Foundation: its Exercise Program, Walk with Ease program, or Aquatics program.
The fatigue, pain, and stiffness caused by many types of arthritis present a barrier to exercise—but these are the same symptoms that tend to improve with regular exercise.
If you have arthritis and don’t currently exercise, start slow. Take a five-minute stroll around your block, swim, or workout on an exercise bicycle. Do it every day, and then gradually increase the time spent exercising or how hard you exercise, but not both at once. If you have heart disease or other health issues, check with your doctor before embarking on an exercise program.
“If exercise was a newly developed medicine, it would be a blockbuster,” says Dr. Shmerling. “It has an excellent safety profile, and enormous benefits for people with arthritis, heart disease, and a long and growing list of other health problems.”

Gov. Christie’s weight-loss surgery: a good idea for health

New Jersey Governor Chris Christie’s revelation yesterday that he had secretly undergone weight-loss surgery back in February shouldn’t come as a big surprise. He has been publicly (and privately) struggling with his weight for years and fits the profile of a good candidate for this kind of operation.
Although weight-loss surgery, also known as bariatric surgery, should be considered a last resort when diet and exercise don’t work, it can do some amazing things. Among people who are severely overweight, it can yield a 25% to 35% weight loss within two years. In many people who undergo the surgery, type 2 diabetes, high blood pressure, high cholesterol, and the disruptive and potentially harmful snoring pattern known as sleep apnea disappear. It can also improve a number of other health problems, ranging from arthritis and heartburn to infertility and incontinence.

Good candidates

In general, weight-loss surgery is appropriate for people with a body mass index (BMI) of 40 or higher, as well as for those with a BMI of 35 to 39.9 and a severe, treatment-resistant medical condition such as diabetes, heart disease, and sleep apnea.
Much of the speculation about Christie’s surgery was whether he did it for political reasons or concerns about his future health. But there shouldn’t be any speculation about whether he was a good candidate for it. While the Governor never made public his exact weight, the estimate is over 300 pounds. At just under 6 feet tall, that gives him a body mass index of at least 41. Christie also acknowledged trying to lose weight many times, using different weight loss programs. He had some initial success. But like most obese people, he regained all the lost pounds and more.
Even if Christie’s claims of otherwise being in good health are correct, he was at high risk of developing problems directly related to his weight. I believe his choice was a good one for his health.

Types of weight-loss surgery

Christie underwent laparoscopic gastric banding, also known as lap banding. There are also two other types of weight-loss surgery.
Gastric banding is done laparoscopically, meaning through small holes made in the abdomen. The surgeon wraps an adjustable silicone band about two inches in diameter around the upper part of the stomach. This creates a small pouch with a narrow opening that empties into the rest of the stomach. The small size of the upper stomach make a person feel full much sooner than before. Depending on the person’s rate of desired weight loss and how he or she feels, the band can be easily tightened or loosened as needed by injecting or withdrawing sterile salt water saline through a port implanted just under the skin. Compared with gastric bypass, the surgery is simpler and has a lower risk of complications immediately following the operation.
Gastric bypass, also known as the Roux-en-Y procedure, shrinks the size of the stomach by more than 90%. This makes a person feel full after eating very small amounts of food. In addition, the body absorbs fewer calories because food bypasses most of the stomach and upper small intestine. The operation is done through an incision made in the abdomen or laparoscopically. The surgeon converts the upper part of the stomach into a small pouch about the size of an egg. The small intestine is then cut. One end is connected to the stomach pouch and the other is reattached to the small intestine, creating a Y shape. This allows food to bypass most of the stomach and the upper part of the small intestine, although both continue to produce the gastric juices, enzymes, and other secretions needed for digestion. These drain into the intestine and mix with food at the crook of the Y. Gastric bypass surgery is not reversible.
The gastric sleeve technique transforms the stomach into a small, narrow tube by removing the curved side of the organ creates a small pouch using the side of the stomach rather than the bottom. One advantage is that no rearrangement of the intestines is needed. The vertical pouch the sleeve procedure creates is less prone to stretching compared to the pouch left by a gastric bypass. Like gastric bypass, the gastric sleeve technique is not reversible.

After surgery

For the first few months after surgery, appetite is usually turned down. Eating too quickly or too much overfills the stomach pouch. That can cause vomiting or pain in the chest and upper abdomen. After a high-carbohydrate meal, a person who has had gastric bypass surgery may suffer from “dumping syndrome,” a reaction that causes flushing, sweating, severe fatigue, nausea, vomiting, diarrhea, and intestinal gas. To prevent nutritional deficits, it’s also a good idea to take vitamins (especially vitamins B12 and D) and minerals (especially calcium and iron).
If you are considering weight loss surgery, realize that you must commit to a life-long change in the way you eat. Surgery without lifestyle change will either make you miserable or not result in successful weight reduction. Likely both.

Wal-Mart Could Transform Care–But Does It Want To?

“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.

“Wal-Mart’s in retail, we’re not in health care.”

But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.

Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.

Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.

Background: Wal-Mart’s Growing Role in U.S. Health Care System

In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.

“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”

And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care. Continue reading “Wal-Mart Could Transform Care–But Does It Want To?”

Do Nice Patients Finish First?

As the authors of a commentary published by the Journal of the American Medical Association note, there’s been plenty of research on how to deal with difficult patients. So they decided to look at the flip side: how do physicians treat nice patients? Do they get better care?
It all depends on how you define “nice” and “better,” one of the authors, Allan Detsky, a professor in the departments of medicine and of health policy, management and evaluation at the University of Toronto. Generally patients who “communicate well, understand their problems, are able to make decisions, adhere to diagnostic and treatment plans, are pleasant and express gratitude for the services they receive” are more pleasant to treat than those who don’t, the commentary says, but the definition of niceness is still pretty subjective.
(Physicians know it when they see it — those are the patients to whom they give their home phone numbers.)
Moreover, “what’s nice in a social context may not be the same in a clinical” one, Detsky tells the Health Blog.
“Better” care might also mean a bunch of things, the commentary says. “It could include more care, less care, appropriate care, extensive follow-up, diligent searches for abnormalities or implementing a strategy of watchful waiting,” the authors write. In some cases a physician who felt she was going the extra mile for a patient she particularly liked could actually be doing harm, say, by looking so hard for problems that she turns up something that proves to be nothing but requires invasive tests.
In an ideal world, patients would choose a doctor with whom they had good chemistry, for lack of a better word. In the real world of limited choices and time, that doesn’t always happen.
Nor are physician preferences likely to be managed away with the same type of guidelines offered to physicians regarding difficult patients. All doctors (and patients) can do is be aware of the likelihood that patients perceived as “nice” may be treated differently from those who evoke the opposite reaction.
“Human nature is human nature,” says Detsky.

Doctor and Patient or Provider and Consumer?

We wince when journalists are called “content providers,” so we sympathize with a perspective piece in the current New England Journal of Medicine bemoaning “the new language of medicine.”
The two physician-authors, Pamela Hartzband and Jerome Groopman, do not wish to be called “providers,” thankyouverymuch. Nor do they want their patients to be called “customers” or “consumers.” Instead they prefer specific job titles: doctors, nurses, physical therapists, etc., to describe specialized medical professionals.
The root of the new vocabulary, as they see it, is a focus on the industrialization and standardization of medical care in the pursuit of cost control. They write:

The relationships between doctors, nurses, or any other medical professionals and the patients they care for are now cast primarily in terms of a commercial transaction. The consumer or customer is the buyer and the provider is the vendor or seller. To be sure, there is a financial aspect to clinical care. But that is only a small part of a much larger whole, and to people who are sick, it’s the least important part.

(We’ve seen this debate before, specifically with regard to high-deductible health policies and other proposals that urge making patients into more cost-conscious consumers of health care.)
Groopman and Hartzband — here’s a review by the WSJ’s Laura Landro of the most recent book they wrote together — also mourn the replacement of “clinical judgment” with “evidence-based practice” in the medical nomenclature. Data, on its own, will never indicate one clear way to proceed even with many common conditions or diseases, they say.
To wit: conflicting guidelines over things like prostate-cancer screening, even when everyone is looking at the same studies.
“When we ourselves are ill, we want someone to care about us as people, not as paying customers, and to individualize our treatment according to our values,” they write. To that end, they urge a return to “doctor,” “nurse” and “patient.”

Reader Consult: What Could Take the Place of the 510(k) Process?

Medical-device regulation is a tricky balancing act. Consumer advocates say the current process doesn’t ensure the safety and efficacy of devices on the market, while the device industry says the FDA’s process is inefficient and expensive and keeps products from reaching patients in need.

Today, as the WSJ reports, the Institute of Medicine weighed in with its own much-anticipated report on device regulation. Notably, an 11-member committee recommends scrapping entirely the streamlined approval pathway known as 510(k), under which a device such as a joint replacement or heart defibrillator can be approved …

A.M. Vitals: Killer Hospital Germs and Autism

Here is what’s making health news this morning:

Killer Bug Is Traced at NIH Hospital (WSJ)

Researchers stalked a deadly strain of antibiotic-resistant pneumonia that killed six patients last year at the National Institutes of Health’s elite research hospital in Bethesda, Md., demonstrating that gene sequencing can help in the fight against hospital-acquired infections.

Autism Risk Rises With Fathers’ Age (WSJ)

Older fathers pass on more new genetic mutations to their children than younger fathers, increasing their children’s risk of autism, schizophrenia and other diseases, says new research published in Nature.