Sedentary Lifestyle

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redsoxmogul

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Hi everyone,

I've been a long time reader of these forums and am thankful for all the insightful posts that have made my decision to pursue PM&R an informed choice.

In light of the new articles in Lancet and JAMA related to the obesity pandemic and the sedentary lifestyle (and as a PM&R hopeful), what is the role of PM&R in dealing with the rising rates of inactivity?

Will the role of prevention vs. rehab become a more important focus for those interested in outpatient MSK?

I'm very curious to know what the future beholds the possible role of PM&R in this growing pandemic.

http://archinte.jamanetwork.com/article.aspx?articleid=216645
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The fatter and more inactive people are, the more power wheelchairs people need, and the patients will come to you for that...$$$$$$:rolleyes::rolleyes::rolleyes:


Seriosly, the less healthy people are, the more Vascular disease, MSK problems, and strokes occurr. That means more patients for us. I work very hard in my community and with my individual patients with things like Dietary changes for health, importance of glycemic control, and the importance of exercise.

But if we preach that stuff, we have to practice it as well. Luckily I enjoy that kind of training.
 
Currently, there is no effective treatment for obesity in the long-run.

In the majority of people, exercise programs last just a few weeks and the people give up.

"Dieting" is an abysmal failure, yet everywhere you go, people are telling you about the new latest diet.

Weight loss pills provide modest weight loss, but often come with a lot of side effects.

Lap band produces moderate weight loss, but creates a highly restrictive diet.

Gastric bypass can produce impressive results, but is high-risk for complications.

One of the main problems I see is everyone blames someone else for their obesity. They blame their parents for training them to "clean their plate." They blame fast-food. They blame Walmart. They say they don't have time to exercise or cook healthy meals.

You can preach a healthy life-style all you want, but until people commit to it, they just get fatter.
 
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PMR 4 MSK said:
Currently, there is no effective treatment for obesity in the long-run.

In the majority of people, exercise programs last just a few weeks and the people give up.

"Dieting" is an abysmal failure, yet everywhere you go, people are telling you about the new latest diet.

Weight loss pills provide modest weight loss, but often come with a lot of side effects.

Lap band produces moderate weight loss, but creates a highly restrictive diet.

Gastric bypass can produce impressive results, but is high-risk for complications.

One of the main problems I see is everyone blames someone else for their obesity. They blame their parents for training them to "clean their plate." They blame fast-food. They blame Walmart. They say they don't have time to exercise or cook healthy meals.

You can preach a healthy life-style all you want, but until people commit to it, they just get fatter.
Click to expand...


So what do you do? Order the power wheelchair for them? I sure as hell did not go into PM&R to just give up on anything. I am empathetic, but firm. I expect all of my patients to TRY. If they stop trying, they are no longer my patient.

My wife and I both struggle with our weight. So we ride our bikes to work, try to exercise at least 5 days/wk, and I started competing in Triathlons (to keep me training) that I FINISH LAST IN!!. I am a slow swimmer and a slow runner, but I keep doing it to help manage my weight and stay healthy.

My patients who have been with me for more than 5 years know that I have these issues, and have lost 35# (with more to go) over the past 3 yrs. They notice and it does make a difference (in terms of how responsive they are to the education) to know that their doctor has the same issues (but keeps trying)
 
RUOkie said:
So what do you do? Order the power wheelchair for them? I sure as hell did not go into PM&R to just give up on anything. I am empathetic, but firm. I expect all of my patients to TRY. If they stop trying, they are no longer my patient.

My wife and I both struggle with our weight. So we ride our bikes to work, try to exercise at least 5 days/wk, and I started competing in Triathlons (to keep me training) that I FINISH LAST IN!!. I am a slow swimmer and a slow runner, but I keep doing it to help manage my weight and stay healthy.

My patients who have been with me for more than 5 years know that I have these issues, and have lost 35# (with more to go) over the past 3 yrs. They notice and it does make a difference (in terms of how responsive they are to the education) to know that their doctor has the same issues (but keeps trying)
Click to expand...

Diet is way more important to weight loss and changing body comp than exercise. I applaud your exercise efforts, but obviously don't overlook diet. (I doubt you are overlooking it...just saying. :))
 
RUOkie said:
So what do you do? Order the power wheelchair for them? I sure as hell did not go into PM&R to just give up on anything. I am empathetic, but firm. I expect all of my patients to TRY. If they stop trying, they are no longer my patient.)
Click to expand...

Like everything in PM&R, you set long-term and short-term goals, then use your available tools to meet the STGs one at a time.

Dx:
Osteoarthritis Knee, bilateral
Lumbar spondylosis
Morbid Obesity, BMI 45
HTN

Long-Term Goals:
Reduction of knee pain to minimal
Reduction of back pain to minimal
BMI <30
BP < 135/80

Short-Term Goals:
4 weeks
Completion of 8-10 session of PT
Appointment with dietician
Titration of tramadol to pain relief w/o significant side effects
Weight loss of 10 pounds
Exercise log showing 20 minutes of activity per day

Some will meet their goals, others will fail
If they are willing to keep trying, so am I
If they give up, I try to prod them a little more, then I give up.
 
Then our practices are similar. That is exactly the approach I take.
 
facetguy said:
Diet is way more important to weight loss and changing body comp than exercise. I applaud your exercise efforts, but obviously don't overlook diet. (I doubt you are overlooking it...just saying. :))
Click to expand...
but of course!:nod:
 
redsoxmogul said:
In light of the new articles in Lancet and JAMA related to the obesity pandemic and the sedentary lifestyle (and as a PM&R hopeful), what is the role of PM&R in dealing with the rising rates of inactivity?

Will the role of prevention vs. rehab become a more important focus for those interested in outpatient MSK?
Click to expand...
Dr. Laskowski at Mayo did an editorial for the PM&R journal on this topic a few years ago. Might be something you enjoy reading.

http://www.pmrjournal.org/article/S1934-1482(09)01234-9/fulltext
 
Somewhat on topic (but a bit off): have you guys given any of Gary Taubes books a read? Interesting perspective, to say the least.
 
redsoxmogul said:
Hi everyone,

I've been a long time reader of these forums and am thankful for all the insightful posts that have made my decision to pursue PM&R an informed choice.

In light of the new articles in Lancet and JAMA related to the obesity pandemic and the sedentary lifestyle (and as a PM&R hopeful), what is the role of PM&R in dealing with the rising rates of inactivity?

Will the role of prevention vs. rehab become a more important focus for those interested in outpatient MSK?

I'm very curious to know what the future beholds the possible role of PM&R in this growing pandemic.

http://archinte.jamanetwork.com/article.aspx?articleid=216645
Click to expand...

Is this the Lancet article?
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61031-9/abstract
 
facetguy said:
If you like Taubes, you'll enjoy a guy named Peter Attia, MD.
http://eatingacademy.com/

He recently gave a presentation on the history of how all the low-fat dogma got started:
http://vimeo.com/45485034
Click to expand...

Thanks for the link; will definitely check it out. I'm by no means a Taubes follower, although I do think there is something useful that could be distilled from his take on things.
 
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I think the sedentary lifestyle can be a big trigger for the random aches and pains people get too-so I always try to get people stretching and doing something aerobic 3-4x a week-I sell this as body maintenance just like brushing and flossing your teeth.

I agree diet is bigger factor than exercise when it comes to weight management but I think a physically active chubby person will have less aches and pains and a healthier cardiovascular system than a skinny couch potato.

As a doctor I can advise and encourage and lead by example (I run and swim and weight train) but if the patient isn't ready to make a committment to changing their lifestyle then after the first few visits I quit talking about it. It is not within my power to make someone lead a healthy lifestyle against their will.

If they are already in the mindset to get healthy there is a lot I can do to help. I design training regimes for people with spine or MSK problems who want to start jogging or swimming but don't know how to get started.
 
Wow! Thanks guys for all the responses! Thank you for providing insight in the role of PM&R!

I just finished a week of shadowing a local PM&R Sports Med Dr. and all the comments in here have held true and echoed the sentiment of leading by example and understanding the motivation of the patient.

I believe the role of PM&R is just beginning considering the importance of having people needing someone to provide a training regimen tailored to their particular health conditions.
 
I think PM&R docs have an advantage when advising people with health problems on how to get active, because the average ambulatory outpatient is still less complex to get walking, weight training and into sports than a person post amputation, CVA, TBI or plain old fashioned multi-organ failure spent 6 weeks lying flat on their back in ICU.
 
facetguy said:
New study suggests diet more important than exercise for weight:
http://www.bbc.co.uk/news/science-environment-18985141
Click to expand...

One of the big problems with instituting an exercise program to help with weight loss is that exercise makes you hungry. So if you don't diet when you start a new program, in all likelyhood you will eat more and gain weight.

In addition, most online calculators WAY overestimate caloric expenditures during exercise. For example, I have a Garmin705 computer for my bicycle. I have been on rides that the Garmin told me burned 1000kcal. I rode with a friend who has a strain gauge power meter on his bike. He weighs very close to me. He burned 550kcal.:confused:
 
RUOkie said:
One of the big problems with instituting an exercise program to help with weight loss is that exercise makes you hungry. So if you don't diet when you start a new program, in all likelyhood you will eat more and gain weight.

In addition, most online calculators WAY overestimate caloric expenditures during exercise. For example, I have a Garmin705 computer for my bicycle. I have been on rides that the Garmin told me burned 1000kcal. I rode with a friend who has a strain gauge power meter on his bike. He weighs very close to me. He burned 550kcal.:confused:
Click to expand...

The only real way to know is to do a calorie test with O2 monitoring in a closed circuit. One of my old attendings did a lot of these studies. A study I did with him used the system to help calculate things in the study.
 
PMR 4 MSK said:
The only real way to know is to do a calorie test with O2 monitoring in a closed circuit. One of my old attendings did a lot of these studies. A study I did with him used the system to help calculate things in the study.
Click to expand...
a power meter comes damn close. If you know how many kj you produce, that is a quick conversion to kcal.
 
PMR 4 MSK said:
The only real way to know is to do a calorie test with O2 monitoring in a closed circuit. One of my old attendings did a lot of these studies. A study I did with him used the system to help calculate things in the study.
Click to expand...


Before med school, I used to run the metabolic assessment department at a health club where we did closed circuit testing. I'd love to believe that the results I got were always accurate, but so many variables can throw off the individual tests....poor mask fit/gapping, moving or being uncomfortable during the 15 minute resting metabolism test, subjects' claustrophobia, e.g.
That said, getting both your resting metabolism and VQ threshold tested sheds light on just how few calories you really need to maintain your goal weight and just how hard you really have to work to burn a significant amount during exercise. It can be pretty discouraging. But it also sheds some light on why we're a culture of fatties. As a broad generalization, we think we work out harder than we really do, and we eat way more than we really need. I think there will always be a deep pool of patients for PM&R, not solely because of the 'merican lifestyle, but it certainly contributes.
 
lobelsteve said:
I use Adidas miCoach. On IOS 5 it says I burn about 500 cal on my usual hike. On my Galaxy S3 it says I burn 750 calories.
Click to expand...

That's quite a hike. Who are you, Sir Edmund Hillary?
 
RUOkie said:
wuss. this board needs more controversy :p
Click to expand...
I just think, based on personal experiences, that exercise is much more effective than diet at decreasing your body fat %. If you can run 800m in 2mins, or even 2:30, you are very unlikely to be fat. All you need to do is improve your sports performance without getting injured. And I cannot find 1 good reason why a layman would use a calorie counter or even a heart rate monitor during his workouts? Those things are not very accurate at measuring your performance. What you really need is a stop watch and a small paper notebook to keep track of your PRs. Also try to find 1 or 2 sports at which you have more room for progress. For example running is a good choice, because there is so little technique involved. Swimming is much harder to master for most people. Some people are naturally better at cycling than running and vice versa, need to try it out to figure out. If you're a big guy, consider rowing. Also when I was young and did not play any sports I bought a book called "12 weeks guide to navy seal fitness". It at least taught me some basics about exercise. Of course once you can run at least 7minute miles and do some pushups/pullups, you can pick 1 or 2 sports and try to learn more about the specific sport.
 
Ballints said:
I just think, based on personal experiences, that exercise is much more effective than diet at decreasing your body fat %. If you can run 800m in 2mins, or even 2:30, you are very unlikely to be fat. All you need to do is improve your sports performance without getting injured. And I cannot find 1 good reason why a layman would use a calorie counter or even a heart rate monitor during his workouts? Those things are not very accurate at measuring your performance. What you really need is a stop watch and a small paper notebook to keep track of your PRs. Also try to find 1 or 2 sports at which you have more room for progress. For example running is a good choice, because there is so little technique involved. Swimming is much harder to master for most people. Some people are naturally better at cycling than running and vice versa, need to try it out to figure out. If you're a big guy, consider rowing. Also when I was young and did not play any sports I bought a book called "12 weeks guide to navy seal fitness". It at least taught me some basics about exercise. Of course once you can run at least 7minute miles and do some pushups/pullups, you can pick 1 or 2 sports and try to learn more about the specific sport.
Click to expand...
n=1 does not mean anything

You make a lot of assumptions. In cycling for instance, a stopwatch does not help you track progress since average speed is a worthless metric. There are too many other variables that come into the equation (terrain, wind speed/direction, etc.)

And if you think there is no technique to running, you have never had a patient with IT band syndrome or Posterior Tibialis Tendonitis ( I treat, and have personally had both)

Regarding weight loss and exercise, the studies are very clear. The average person GAINS WEIGHT when they institute a new exercise program. THAT is why calorie tracking is important.
 
Oh, one more thing. I'm a 45 y/o full time doctor. I work 70+ hours/wk. I've been cylcing for the past 5yrs. (100-200miles/wk). I started training for triathlons 18 months ago. I can run 7:30 miles for 3miles and 8:30miles for 10K. I also need to lose another 20-30#.

Why am I not thin?
 
RUOkie said:
Oh, one more thing. I'm a 45 y/o full time doctor. I work 70+ hours/wk. I've been cylcing for the past 5yrs. (100-200miles/wk). I started training for triathlons 18 months ago. I can run 7:30 miles for 3miles and 8:30miles for 10K. I also need to lose another 20-30#.

Why am I not thin?
Click to expand...

You work too much and the stress increases your cortisol which causes body fat retention.

Also you are over 40. Once you've deposited the fat long enough, it takes up residency.

Or maybe it's the burritos.
 
PMR 4 MSK said:
You work too much and the stress increases your cortisol which causes body fat retention.

Also you are over 40. Once you've deposited the fat long enough, it takes up residency.

Or maybe it's the burritos.
Click to expand...


I think it is the burritos. :idea:
 
RUOkie said:
Oh, one more thing. I'm a 45 y/o full time doctor. I work 70+ hours/wk. I've been cylcing for the past 5yrs. (100-200miles/wk). I started training for triathlons 18 months ago. I can run 7:30 miles for 3miles and 8:30miles for 10K. I also need to lose another 20-30#.

Why am I not thin?
Click to expand...

You are probably fit and I am sure your body fat percentage dropped. Weight loss is a pretty simple concept. There are approximately 3500 calories in a pound of stored body fat so if you create a 3500 calorie deficit through diet and exercise you will loose weight. I am sure you know all this better than me Ruokie.
 
PMR2008 said:
You are probably fit and I am sure your body fat percentage dropped. Weight loss is a pretty simple concept. There are approximately 3500 calories in a pound of stored body fat so if you create a 3500 calorie deficit through diet and exercise you will loose weight. I am sure you know all this better than me Ruokie.
Click to expand...
well that was certainly my point. I AM very "fit", but my BMI is still 27! My wife and I are in the same situation, fit but overweight. So we are back to counting calories.

I posted my personal situation as an example of the falicy of "exercise more and you will lose weight". Unfortunately, it is not fitness that predicts heart disease. It is BMI. Sucks for me since cooking (and eating) is my biggest hobby.:oops:
 
RUOkie said:
well that was certainly my point. I AM very "fit", but my BMI is still 27! My wife and I are in the same situation, fit but overweight. So we are back to counting calories.

I posted my personal situation as an example of the falicy of "exercise more and you will lose weight". Unfortunately, it is not fitness that predicts heart disease. It is BMI. Sucks for me since cooking (and eating) is my biggest hobby.:oops:
Click to expand...

Per this article "The best way to predict heart attack risk and other obesity-related diseases is a measurement that divides the circumference of your waist by your hips."

http://www.msnbc.msn.com/id/1448351...tape-may-measure-obesity-better/#.UCU8bJ2PWQw

http://eurheartj.oxfordjournals.org/content/28/7/850.full
Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies
 
RUOkie said:
Oh, one more thing. I'm a 45 y/o full time doctor. I work 70+ hours/wk. I've been cylcing for the past 5yrs. (100-200miles/wk). I started training for triathlons 18 months ago. I can run 7:30 miles for 3miles and 8:30miles for 10K. I also need to lose another 20-30#.

Why am I not thin?
Click to expand...

I probably do not need to tell you that you are not lazy or anything. I wish I could be half as productive. If I ever work 70hrs/wk I might just become obese. In fact I might become obese in the future even if I work <40hrs/wk, because I might become injured or just lazy or depressed. What I wanted to add was that while 7:30/mile is not that fast, I have almost never ever seen a person who could run this fast and was still overweight. So it's not n=1 experience. I know a lot of people who have a 6pack and eat at mcdonalds and run 7-8min/mile. But 99% of overweight people that I know cannot run 7:30/mile no matter what they eat. I know there are exceptions, but I was just posting my observations as someone who works out. I did know someone who swam at a pool 3x/week for 1hr at a very good pace. And he had a huge belly. But that is my n=1 example.
But also I've seen a lot of people who use various calorimeters and other gadgets but cannot even "run" 10mins/mile. Thats why I think counting calories when you eat or exercise is something that fat people do.
 
Ballints said:
I probably do not need to tell you that you are not lazy or anything. I wish I could be half as productive. If I ever work 70hrs/wk I might just become obese. In fact I might become obese in the future even if I work <40hrs/wk, because I might become injured or just lazy or depressed. What I wanted to add was that while 7:30/mile is not that fast, I have almost never ever seen a person who could run this fast and was still overweight. So it's not n=1 experience. I know a lot of people who have a 6pack and eat at mcdonalds and run 7-8min/mile. But 99% of overweight people that I know cannot run 7:30/mile no matter what they eat. I know there are exceptions, but I was just posting my observations as someone who works out. I did know someone who swam at a pool 3x/week for 1hr at a very good pace. And he had a huge belly. But that is my n=1 example.
But also I've seen a lot of people who use various calorimeters and other gadgets but cannot even "run" 10mins/mile. Thats why I think counting calories when you eat or exercise is something that fat people do.
Click to expand...
Again, a BMI of 27 does not equal "obese", but it is overweight. When you hit your 40's and 50's you see LOTS of weekend warrior athletes who are overweight or obese but yet "fit". I have a 55y/o friend who has a real pot belly who cycles pretty quick (and rides 4 days a week/swims 2 other days).

I just checked my BMI against other Americans, and I am still thinner than the "Average" American. And that is VERY sad. Because I am certainly overweight.
 
For people who eat the same average calories nutrition content (protein/fat/carbs) in a week, they will lose weight if they start exercising.

But human nature being what it is, most people eat more when they exercise more, because they feel they have earned a treat or they are simply more hungry after burning off those extra calories.

Since one 20oz coke can equal 30-40 minutes of brisk treadmill walking, I can see how people get in trouble.

My YMCA has vending machines in the lobby, just in case I don;t want to wait until I get home to replenish the calories I just burned off
 
Jitter Bug said:
For people who eat the same average calories nutrition content (protein/fat/carbs) in a week, they will lose weight if they start exercising.

But human nature being what it is, most people eat more when they exercise more, because they feel they have earned a treat or they are simply more hungry after burning off those extra calories.

Since one 20oz coke can equal 30-40 minutes of brisk treadmill walking, I can see how people get in trouble.

My YMCA has vending machines in the lobby, just in case I don;t want to wait until I get home to replenish the calories I just burned off
Click to expand...

My gym during residency had a bar upstairs, part of the gym.
 
411200892904AM_onlyinamerica.jpg


Only in america!!
 
Hypogonadism will cause aches and pains and that pot belly you describe in us older guys....so will vit D deficiency. Both easily supplemented. Start checking a1c in nondiabetics to get a gauge of their diet.

2 new obesity drugs were approved this summer, but only 1 is worth it's salt....Belviq. The other is just a repackage of what u can prescribe separately....topamax+phentermine=Qsymia. But it has too many REMS. When(not if) Belviq gets mixed with phentermine the weight loss results will be more dramatic....plus there will be more indications for diabetics as it has shown to decrease a1c by a significant amount.

FYI Arena(Belviq) is my favorite stock.
 
Doctodd said:
FYI Arena(Belviq) is my favorite stock.
Click to expand...

Hopefully you got in before the stock jumped a few months ago.

Just be sure to get out before everyone figures out the sh** don't work. :)
 
I got in around $2.50 and bought more over time. FYI it does work.....it's just slow and steady...unless they add phentermine, which is "when", not "if".
 
Doctodd said:
I got in around $2.50 and bought more over time. FYI it does work.....it's just slow and steady...unless they add phentermine, which is "when", not "if".
Click to expand...

$2.50? Nice work!

And I don't doubt the drug will be commercially successful. But from the little bit I've read, Belviq's benefits aren't impressive, and there are sure to be side-effects that begin to pop up. The truth is we're in such a jam when it comes to obesity that we're willing to spend billions of dollars on drugs that hardly do anything.
 
facetguy said:
$2.50? Nice work!

And I don't doubt the drug will be commercially successful. But from the little bit I've read, Belviq's benefits aren't impressive, and there are sure to be side-effects that begin to pop up. The truth is we're in such a jam when it comes to obesity that we're willing to spend billions of dollars on drugs that hardly do anything.
Click to expand...

5% weight loss is slow and steady....and slow and steady wins the race. HgbA1c reduction of 1 point is HUGE.
 
PMR2008 said:
Interesting article

http://www.bbc.co.uk/news/health-19474239
Click to expand...

Some are criticizing that study now because it was funded by Coca-Cola. In fairness though, it's not the first study to identify these so-called 'metabolically-normal obese' people (and there are metabolically-deranged non-obese people out there too). I think a lot of this comes down to insulin sensitivity.
 
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