Eastside Family Health Center: July 2011

Friday, July 29, 2011

Obesity

As many are aware, obesity is a major issue in America and the problem is getting worse. More than 33% of Americans are obese ( defined as a BMI > 30 ). More than 64% of Americans are overweight (BMI>25).

It costs America approximately 100 billion dollars a year to treat obesity and the complications that arise from it. This is in addition to hidden costs, such as days missed from work and early death( less taxes).

There are several well documented health hazards with obesity, such as diabetes, heart disease, stroke, cancer, arthritis, liver disease, sleep apnea, and depression. The risks increase with the degree of obesity.

The most practical means of measuring obesity is the body mass index. This is calculated by dividing the weight in kilograms by the height in meters( kg/m).

BMI Categories : 25-29 overweight; 30-34 obese; 35-39 moderately obese; 40-49 severely obese; >50 super ( morbidly) obese.

Well, what to do? The hallmark solution will forever be diet and exercise, but for most people there has only been limited success and not for a lack of desire or effort. Surgery has come into medical community acceptance over the last several years due to studies showing the improvement in obesity complications.

Weight loss surgery (called bariatric from Greek word baros meaning weight) works by either malabsorption or restriction. Restriction procedures limit the amount of calorie intake by reducing the stomachs reservoir capacity or via creation of a blind stomach outlet. Gastric banding is a purely restrictive procedure. This limits solid food intake by restricting the stomach size as its only mechanism of action. The small intestine must then absorb nutrients. The weight loss with purely restrictive procedures is more gradual.

Malabsorptive procedures work by shortening the length of the small intestine. This is done by shortening of the small bowel or by diverting around it. Examples include jejunoileal bypass or duodenal switch operation. The weight loss can be huge, but the complications many such as protein loss or micronutrient deficiencies.

The famous Roux-en-y gastric bypass is both restrictive and malabsorptive. In this operation you are left with a small stomach pouch; however, the small bowel is rerouted favoring additional weight loss via dumping and mild malabsorption.

So, does surgery work? It does, especially for those with BMI >40. The mean weight loss percent of excess weight loss was 61%. Diabetes completely resolved in 77% and either improved or resolved in 84%. Also look at these results: high cholesterol improved 70%; high blood pressure improved 62%; sleep apnea resolved 86%; reflux improved as well as urinary incontinence. Because of these data, I am now a fan of weight loss surgery.

The amazing thing is that there is now data showing a decrease is overall mortality. The reduction of the complications of obesity reduces overall mortality by 29%. As always, if one can reduce BMI by diet and exercise this is the safest way. Otherwise talk to your doctor about weight loss surgery. There are several different types of surgery; an expert in the field will need be consulted.

Let’s review some of the indications for surgery intervention: Be motivated! Have a BMI>40. Or, have a BMI>35 with co-morbidities(other diseases or complications) such as diabetes, blood pressure, apnea, severe arthritis, heart condition etc. and having failed non-surgical programs.

The most common surgical technique is the laparoscopic gastric banding. The upper stomach is banded by a tight, adjustable soft silicone ring connected to an infusion port placed under the skin.

The port can be accessed with ease via a syringe and needle. The band is adjusted to deal with weight loss as well as nutritional issues. Data shows an expectation of about 40-75% weight loss at two years. But note! It is easier to cheat with the lap band! So, a comprehensive approach is needed as well as good motivation.

The decision to proceed with a surgery for obesity is a serious one as there are many potential complications. For this reason it is necessary to follow protocols.

We also have the BMI Calculator on our website. Check it out here: Eastside Family Health.

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Dr. Frank Marinkovich owns and operates Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.

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Wednesday, July 27, 2011

Non-Sciatic Sciatica

Piriformis Syndrome

This is an interesting disorder that is one cause of sciatica, other than a herniated disc in the low back. The sciatic nerve is compressed by the piriformis muscle causing an irritation of the sciatic nerve with numbness in the buttocks running down the lower thigh into the leg. When someone has these symptoms the biggest thing to rule out is a herniated disc of the spine. So, if there is sciatica but no clear spinal signs, think piriformis muscle inflammation.

piriformis distribution

What causes it? In approximately 17% of the population the sciatic nerve passes through the piriformis muscle rather than underneath it. This is the supposed cause of this syndrome (non-disc related sciatica). Also anatomically, weak gluteal (buttock) muscles, which may occur with a lot of desk type jobs that involve much sitting( hip flexion with accompanying shortening and tightening of the hip flexors). With weak gluts, other muscles have to compensate such as the hamstrings, adductor muscles( inner muscles of the thighs), and the piriformis. This results is hypertrophy of the piriformis with the resultant syndrome.

Other causes could include overuse injury such as strenuous use of the legs( anyone do the STP bike ride lately?) such as biking or rowing. Also, runners, who engage in forward type of activities as well, are susceptible to developing this syndrome. So, it is important to perform lateral (side) type of stretching to balance out the legs. If not properly stretched, the legs can develop overly tight adductors and out of proportion weak abductors. The piriformis muscle becomes large and sciatic nerve impingement is inevitable. The key is to keep the outside muscles of the hip, called abductors in proper stretch to take the strain off of the piriformis.

Interestingly, not only does the spasm of the piriformis cause sciatic nerve symptoms but the pudental nerve may also be irritated. This nerve controls the muscles of the bowel and bladder. The syndrome may present with loss of bowel and urine function as well as saddle anesthesia( numbness around the anus).

Some other potential causes of the syndrome include a falling injury, tight SI joints( sacro-iliac, or low back joints), over pronation of the foot, or sitting on a wallet.

How is it diagnosed? Diagnosis is largely clinical, i.e. there not really any good or reliable imaging tests for this syndrome. Presentation includes pain in the buttock, back of the thigh and lower leg made worse with prolonged sitting, activity or walking.

What is treatment? Treatment is conservative including avoiding such activities as running, biking or rowing for a while. Also, muscle relaxants , anti-inflammatories as well as physical therapy or massage to stretch and strengthen. If these do not work, see your doctor to consider an imaging study to rule out other pathology. Treatment for weak abductors and tight adductors include stretching and strengthening of these muscles. It is possible to see results after just a few days.

the piriformis stretch

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Tuesday, July 12, 2011

The Case of the Jumping Legs: Restless Legs Syndrome

Do you have jumpy legs or legs that just need to move? Well, you may have a syndrome called restless legs (RLS). These are marked by a spontaneous movement of the legs. This usually only occurs at rest and are relieved by movement. Sleep disturbance, such as sleep apneas, is commonly associated. This is not the same as leg cramps.

Who has this? This is a very common problem, as up to 15% of Americans have it. More women than men have it; the prevalence of RLS increases with age. Sometimes it may occur in children and at times is misdiagnosed as growing pains.

What is the cause? The cause is usually unknown; however, there appears to be a genetic link, in other words a family history. There is a hypothesis that the neurotransmitter called dopamine is associated with this disorder. In fact, this hypothesis is the basis of how we treat it with medicine. There is also an increased incidence of restless legs in patients with Parkinson’s disease.

RLS may also be associated with iron deficiency, chronic kidney disease, pregnancy, movement disorders, diabetes, varicose veins, and rheumatism. There is some association with low thyroid and obesity.

What are some of the symptoms? Clinically, patients describe a sensation of crawling, creeping, pulling, itching, or stretching all deep in the leg rather than the skin. Pain is usually absent. Symptoms typically worsen at the end of the day and are maximal at night, usually within 15 minutes of getting into bed. In severe cases, symptoms may occur earlier in the day while the patient is seated. This makes sitting at a desk or meetings or in a movie theatre difficult. In milder cases, one may be fidgety.

So, how do you diagnose RLS? Here are the criteria by the International Restless Leg Study Group: an urge to move when in bed or periods of inactivity( sometimes other body parts are involved as well such as the arms or even the entire body); the urge is partially or totally relieved by movement such as walking or stretching. Supportive criteria include family history or a positive response to RLS medication.

What is the treatment? Some cases require the use of meds, but before that here are some these simple measures to try: stretching exercises of the posterior leg muscles before going to bed; use of iron replacement ( have your iron checked first); stop mental activating activities such as video games before going to bed; avoid caffeine; and lose weight. If these don’t work, there are some pretty successful medications your doctor can discuss with you.

Below is an example of stretching exercise to try:

Stand facing the wall, feet together, about two feet from the wall. Heels on the floor, lean forward to the wall, stretching the posterior leg muscles. Hold for 10-30 seconds. Repeat x5. Twice daily.

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