Thursday, April 29, 2010

Fibromyalgia, Exercise and Obesity

ScienceDaily (Apr. 29, 2010) — Researchers at the Norwegian University of Science and Technology have found an association between the level of leisure time physical exercise and a future risk of developing fibromyalgia. The research team also identified BMI as an independent risk factor for fibromyalgia.

Details of the study appear in the May issue of Arthritis Care & Research, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology.

Fibromyalgia (FM) is a chronic pain syndrome characterized by widespread pain lasting more than 3 months, and tender point sites in the neck, shoulders, back, hips, arms, and legs. Associated features often include unexplained fatigue, sleep disturbances, headache, cognitive difficulty, and mood disturbances. The prevalence of FM increases with age and is considerably higher among women than men. Although the etiology of FM is poorly understood, many authors have suggested that a dysfunctional autonomic nervous system involving deficiencies in the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system contributes to the development of FM by altering pain perception and endogenous pain inhibition.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, FM has been linked to stressful or traumatic events, such as car accidents, repetitive injuries, illness, certain diseases, or FM can occur spontaneously. Some scientists speculate that a gene or genes might be involved in fibromyalgia that could make a person react strongly to things that other people would not find painful.

Longitudinal studies have shown that physical exercise is associated with less musculoskeletal pain and stiff or painful joints among aging women. The Norwegian researchers, led by Paul Mork, D.Phil., proposed that first, there is an association between levels of leisure time physical exercise and future risk of FM and, second, being overweight/obese may represent an independent risk factor for future development of FM. Data for the study was collected from the Nord-Tr√łndelag Health (HUNT) Study, the first part conducted in 1984-1986 (HUNT 1) and the second in 1995-1997 (HUNT 2). During the 11 years between HUNT 1 and HUNT 2, 380 cases of incident FM were reported among 15,990 women who provided information on relevant variables at both surveys and who reported no FM or physical impairment at HUNT 1.

"Women who reported exercising 4 times per week had a 29% lower risk of FM compared with inactive women," says Dr. Mork. "Similar results were found in the analysis of the summary score combining information on frequency, duration, and intensity of exercise; women with the highest exercise level had a somewhat lower risk than inactive women. The study further shows that a high BMI (i.e., being overweight or obese) is a strong and independent risk factor for future development of FM. Moreover, the higher relative risks for the combined effect of being overweight/obese and inactive, relative to being overweight/obese alone, point to a further disadvantage for overweight women who do not exercise."

While the causal relationship between obesity and FM remains unknown, there are some etiologic factors in common. Studies suggest that proinflammatory cytokines play a role in FM and the relationship between FM and obesity. Other studies point to dysregulation of the HPA axis, which has been observed in both FM and obesity. Finally, increased sympathetic tonus and reduced sympathetic reactivity, as recorded by heart rate variability, has been observed in patients with FM as well as in overweight and obese subjects. Dr. Mork concludes, "These findings, together with the current study, indicate that regular physical exercise, and thereby improved physical fitness, may serve as a buffer against the perpetuation of musculoskeletal symptoms that eventually lead to the development of FM."

Friday, April 23, 2010

Health Care and Politics

I have been told by many that there are two things you never talk about: politics and religion.  I realize that I have broken these rules, but these seem to be the things that are most important in life and are at the forefront of the mind recently. 

It has been interesting to hear from my liberal friends and collegues about my last comments.  I find that the conversation and communication is important for two reasons.  First, truth is independant, and the only way to identify truth is to hear it, read about it, or find it through civil discussion with those around you. The truth about health care has been weighing upon my mind in the last year.

It has been upon my mind because it is what I do for 12-16 hours per day.  I am in the business of rendering care and attempting to provide the best care possible in few minutes I have with each patient.  But I am finding that political influences of both our state and nation have drastically affected the number of minutes I can spend, the type of care I can render and the choices I can offer to my beloved patients.  I have found that these political voices can no longer be silently ignored.  

As I have read, listened and discussed this with many around me (both conservative and liberal), I am finding there are really only two voices.  Those voices speak at various points along a spectrum of desired liberties, but there are really only two voices.  There are those voices that speak the language of the founders of this republic who understood that true freedom comes from liberty, and there are those that speak the voice of progressivism whos concepts of freedom are defined by various degrees of socialism. 

I have been accused of not understanding socialism and seeing all change in society as socialistic.  This is not the case.  Socialism, as it was defined in "school," is that society in which there is no private property. It is where the collective or governmental ownership oversees the distribution of goods and services. Socialism as defined by Marxist theory is a stage in society between capitalism and communism.  These political doctrines are founded in our understanding and acceptance of the concept of property ownership.  We see this in governments around the world in varying degrees in countries like France, Venisuala, Sweden, and Laos, etc.

Private property and liberty are insperable. We lose our liberty as the right to hold private property is removed. The difference in views between our country's founders and the progressives is their understanding of the conferrance of freedoms based on the liberties granted by ownership of private property.  Communism is defined as a society where ownership of private property does not exist.  In the words of Abraham Lincoln, "We all declare for liberty; but in using the same word we do not all mean the same thing.  With some the word liberty may mean for each man to do as he pleases with himself, and the product of his labor; while with others, the same word may mean for some men to do as they please with other men, and the product of other men's labor.  Here are two, not only different, but incompatible things, called by the same name liberty.  And it follows that each of the things is, by the respective parties, called by two different and incompatible names - liberty and tyranny."

How do these political ideologies relate to medicine?  Well, lets think about a three other concepts.  First, those things that make us different from every other country in the world are defined in our Declaration of Independance: 
   "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."
We believe that being created in equality, we each have the right to life, liberty and the pursuit of happiness.  This statement does not guarantee happiness, but states that we have a right to liberty and life.  We have a right to act in this life in those ways that will bring us liberty, the right do those things that allow us the ownership of personal property and seeking those things in our lives that bring us happiness.

Second, life is full of change.  Our society is different from what it was in 1776, the time when our founders wrote the words of the Declaration, and our society will be different 100 years from now.  Change is important; however, our assessment and acceptance of change must be done with prudence.  But, that which is lost in our society today is prudence.  Prudence is of the highest of virtues because its judgement is drawn from wisdom.  Prudence was exercised as a basis of society in 1776 because of man's view of himself before his maker.  Our Declaration states that these rights are "God given."  Today, many question even the existance of a maker, and prudence is lost. With prudence being lost in our society, our general ability to assess the way societal changes affect us now and in the future is greatly limited.

Third, it is important that we understand the definition of capitalism.  Capitalism is defined as an economic system characterized by private or corporate ownership of goods or services, by investments that are determined by private decision, and by prices, production, and the distribution of goods that are determined mainly by competition in a free market
So, how then does this relate you your medical care?  Your ability to obtain care relates you your understanding of what medical care actually is.  Medical care is essentially property.  You buy services. Medical care is a service or commodity, just as your home or car is a commodity with ownership. The progressive view goes beyond the statement that "men are created equal" and asserts that men should receive equally, a socialistic view.  They extrapolate that men should therefore recieve medical care equally as it paints medical care as a right.  Medical care is not a right.  Medical care is a commodity which is purchased.  Your body was designed to heal itself.  When disease, illness or injury occurs, assistance to those bodily functions of healing can and should be sought as the "pursuit of happiness."  Medical care is thereby a service that is rendered either through purchase or through a charitable act. 
 
So then the politics of medical care then also pertain to our liberties and our freedoms. Our government was designed as a republic for our protection and to ensure life, liberty and pursuit of happiness.  Our constitution provides an environment for us to seek our own happiness while not infringing upon the lives of those around us.  We are free then to seek happiness through our own inginuity, free to protect ourselves, and free to take individual risks.  When injury or illness arises, we are free to seek care and healing above and beyond what our body will do on its own. 
 
The progressive or socialistic view is that men have the right to recieve the same or equal care.  Seen as a right, the progressive government mandates this care.  The problem with this view is that our liberties are then taken away, because a politician decides what care is best and how often you can recieve it.  In a capitalistic society, the medical provider will attempt to provide the best most efficient care to be competative in that society.  In a socialistic society, the medical provider has no incetive to become better or to provide a better service, because the same service is mandated by the governmental politician.   Yes, the care is free, but your liberties of "pursuing happiness" through the type and quality of your care is now infringed upon, and your freedom is restricted. 
 
I am affraid that our so-called "liberals," as well as our progressive republicans in society, desire to recieve the benefits of socialism in a capitalistic society.  These two concepts are diametrically opposed to each other.  Capitalism, and the medical services created and rendered therein, cannot succeed in a socialistic society requiring limitation of liberty under the guise of "medical equality."
 
Our medical system is broken.  We have allowed our government to create programs like Medicare and Medicaid, socialistic programs, trying to create equality and limiting our liberty.  We are now dependant upon these medical insurance programs created and expanded 50 years ago under progressive presidencies and congress.  We, the children and grandchildren of these leaders, must now deal with the consequences of socialistic action.
 
May we recognize our real rights, and may we pick leadership to help us solve these problems and learn to more effectively pursue life, liberty and happiness.

Tuesday, April 20, 2010

My Two Cents on Healthcare

I have had multiple patients ask me what my "take" on our current health care issue is and how I think it will affect the practice of medicine and my office.  So many patient's have asked me this question, that I figure I would just blog my thoughts here for all to read. 

Interestingly, I got spamed an e-mail today from Lori Heim, MD, president of the American Academy of Family Physicians, stating how wonderful this new "Obamacare" is and what a great "step forward this is for healthcare."  Let me give you my impressions on how "wonderful" this really is.

In order to understand Healthcare reform as it stands today, it is important that we look at three specific issues.  First, lets take a look at history, at some societies that have taken paths similar to ours.  Muselini, Stalin, Mao and others have shown that there are five steps in leading a society to socialism.  Those steps are 1) to take over the financial institutions, 2) take over major industry, 3) take over healthcare, 4) take over gun control and 5) control immigration.  Our great but sleeping country has allowed the first three of those steps to occur in the last year.

The banks were bought by Obama's Czars under the guise of "bail out money," car manufacturing, the largest private industry in our country, is now under the thumb and major ownership of our government by the same method. Now healthcare is under the control of the Obama Administration.  In this healthcare plan, Obama has succeeded in creating 159 new buerocratic agencies to oversee your doctor in rendering healthcare to you.  And to top this off, this new plan that Nancy Pelosi was so sure you and I would love will only raise our income tax by 9.7% by 2012.  That's right a 10% tax hike for a buerocraticly driven healthcare system.  Healthcare is not the goal, socialism is the goal, and healthcare control is just one of five steps in that direction.  Watch the news for control of guns and immigration as the next steps.

Second, Obama told us that this health care plan would pay for itself.  That's because the cost of this $940 billion (yes, that billion with a "b") plan at the time it was voted on was offset by the fact that the Medicare paycut, that would cost $930 billion to fix, had already taken place.  The Obama Administration used the money from the pay cut to balance the new healthcare plan.  The media just sucked this right up and never said a word about it. 

Interestingly, they tried to throw the physicians a bone by saying, "Hey, well will give you a 10% raise for seeing medicare patients."  That won't help because they have already cut reimbursement to physicians by 21.5%.  This cut is occuring because Bill Clinton, in his wisdom at the end of his presidency, decided to balance the budget by cutting reimbursement by 5% every year starting in 2002 for 10 years.  Medicare currently only reimburses physicians payment rates equivalent to the 1986 economy.  (You look around and see if there are any other industries functioning that haven't had a pay raise in 30+ years) We as physicians have never had a pay raise since.  Congress has "deferred" this pay cut each year but never fixed it. Congress missed deferring it this year on April 1st because of Obama's push to "fix healthcare instead."

As of Monday, congress again retroactivly deferred this cut until May 30th, however, patient's seen from April 1st to April 18th will be paid at the cut rate.  Medicare will "try to ensure that these are corrected" but have you ever tried to get Medicare to correct a payment error?  Good luck! You're more likely to get the IRS to waive your taxes this year.

Third, the balance of the pay cut will continue to rise each year.  As of September 1st, this pay cut will increase to 26.5%. 

Let me explain to you what this means.  If the 21.5%  pay cut occurs May 30th, I will have to lay off three of my employees and drop my personal health insurance and insurance for my remaining staff just to keep my doors open.  As an employer, the 10% personal income tax my employees pay starting in 2012 is matched by the business they work for, that means that my employer taxes go up by 10% per employee.  Commercial health care sets their rates on the Medicare reimbursement, so with in 6 months of the pay cut ALL insurance will cut their rates too.  A 21.5% pay cut to physcian's offices and a 10% increase  per employee payroll tax will put me out of business.  Good thing I have kept my shovels around, I may be digging diches soon.

Unless this is fixed, 2012 will see thousands of physician offices closing their doors.  There are already not enough primary care physicians and the need will drastically increase to cover the additional 30 million people "Obamacare" claims it will cover.  This means healthcare shortages will occur beyond what this country has ever seen.  You thought wait times to get in to see your doctor were bad, wait until 2012.

Our wonderful Republican party has done nothing but vote no.  In fact, Arizona's Senator Kyle, Senator McCain and House Representative Franks all voted "no" on Monday's Medicare deferrment.  I have been watching their voting each week for the last year.  When questioned in a recent town hall meeting by multiple physicians as to what the Republican Party was doing to create legislation that would fix the problem, all Senator McCain could say was "we are determined to vote down Obamacare."  Great line Senator McCain! That's all you've been doing for the last year.

So, as a physican with 40% of my practice Medicare based, healthcare reform is "wonderful." It fills my mind "full of wonder" as to what type of work I will be doing in 2012, and wondering where my patient's will find care.

I suggest two things to you.  First, pray, and pray sincerely.  The only way out of this fiasco is by the hand of divine intervention.  Second,  watch closely for and vote for congressional leadership that understands these issues.   That's what I'll be doing.

Sunday, April 18, 2010

HCG & Weight Loss Fads

A number of patient have heard and asked me about Human Chorionic Gonadotropin (HCG). It is a hormone normally secreted by the trophoblastic cells of the placenta during pregnancy. It was first described as a treatment for obesity in conjunction with a very low calorie diet by Dr. A. Simeons in 1954.  Dr. Simeons reported weight loss success combining HCG with a very low calorie diet.  Multiple subsequent studies revealed that this method has been ineffective and that there has been no significant effect of HCG over placebo.  It appears that the weight loss occuring in these patients was due to the very low calorie diet used at the time and not the HCG; however, it has also since been shown that the diet used by Dr. Simeons was deficient in protein content based on current standards accepted in the bariatric (weight and metabolism specialist) community. 

The American Society of Bariatric Physicians released a position statement on HCG including the following summary and conclusions:
"Numerous clinical trials have shown HCG to be ineffectual in producing weight loss. HCG injections can induce a slight increase in muscle mass in androgen-deficient males. The diet used in the Simeons method provides a lower protein intake than is advisable in view of current knowledge and practice. There are few medical literature reports favorable to the Simeons method; the overwhelming majority of medical reports are critical of it. . .
Conclusions:
It is the position of the American Society of Bariatric Physicians that:
1. The Simeons method for weight loss is not recommended.
2. The Simeons diet is not recommended.
3. The use of HCG for weight loss is not recommended."
(http://www.asbp.org/resources/uploads/files/HCG%20Position%20Statement.pdf)

It is important that you consult your doctor before you begin any weight loss program and that you are aware of the recent data on current fads like the use of injectible and subligual HCG.

Dr. Nally is a member of the American Society of Bariatric Physicans and adheres to the metabolic and weight managment guidelines set forth by this medical society.