What will my third trimester appointments be like?
Medical Minute with Dr. Grisham
What will my second trimester appointments be like?
Medical Minute with Dr. Grisham
What will my first trimester appointments be like?
Medical Minute with Dr. Grisham
More Positive Findings for that Magic Pill: Exercise
We have known for a long time that exercise has tremendous benefits. From the classic positive effects on health risks like high cholesterol to more recent benefits such as the possibility that exercise during pregnancy may actually result in smarter offspring (summarized in one of my previous articles), the benefits to exercise seem to have no bounds.
We learned from the classic Framingham Heart Study that patient characteristics such as high blood pressure, high cholesterol, smoking and obesity increased their risk of having cardiovascular disease. We also know that exercise can improve a patient’s blood pressure, cholesterol or body mass index, thus decreasing their cardiovascular risk. But what happens if a patient does exercise but still has all of those risk factors? Is exercise wasted on that person?
A recent study out of Curtin University in Australia suggests those who exercise, even those with persistent blood pressure, cholesterol and/or waistline issues are more likely to live longer than those who are sedentary. In this study, the researchers divided a group of patients into three separate categories based on activity level. The three categories were basically in the range of 1) Couch Potato 2) Some Activity 3) Regular Exercise. Not surprisingly, the Couch Potatoes were twice as likely to have died from a cardiac event than those in the Some Exercise group and six times more likely to have died than those in the Frequent Exercise group. What was surprising, however, is that even when controlling for the various cardiovascular risk factors among the groups, those patients with significant issues with their blood pressure, cholesterol and or waistline still received benefit from the exercise.
The encouraging thing here is that even if your cholesterol, weight or blood pressure numbers are not normalizing, you can feel assured that your efforts are still paying dividends. Patients suffering from hypertension, hypercholesterolemia and weight control issues were much more likely to be alive in 15 years if they exercised, despite their health issues. The old saying, “speed kills”, perhaps should be replaced with, “sedentary kills”.
If you are sedentary, consult with your physician to make certain you are healthy enough to begin an exercise program. If so, make a pledge to yourself and your health: “I am choosing to live a healthy lifestyle today.” Good luck! Good health!!
Supplements: Do Not Waste Your Money or Your Health
It has been my standard practice to steer patients away from over-the-counter health supplements and vitamins. I have always found it perplexing how many of these patients will readily shun any prescription product as the spawn of Satan but if the latest snake oil is presented to them in a plastic bottle with the inscription, “all-natural”, on the side of it, they will readily accept and ingest that product as ingestible gospel. Never mind that for a prescription medication to become accepted and sold in the medical market in the United States it must pass rigorous multi-level trials costing millions of dollars; it is that plastic bottle stamped, “all-natural”, the contents of which are not tested by anyone, EVER, that is accepted by these patients as safe and effective.
The supplement industry is a multibillion dollar industry. It fits very well in this no ownership, no responsibility society in which we live. Many people in the United States would prefer to simply “take a pill” to obtain the desired effect or benefit they seek. This is so much easier and more efficient that actually doing something the “right” way to gain the desired benefit. As such, this industry meshes very well with the mindset of this populace. Want to lose weight? Take this pill. Want bigger muscles? Take that pill. Want to perform better in the bedroom? And on and on it goes. In reality, most of the time, these pills do not have the ability to facilitate the changes their marketers promise and if they do, it is likely that the pills contain a banned and or dangerous, illegal product.
Many people are unaware that there is no FDA for over-the-counter supplements and vitamins, no one to assess quality control. It is well-documented that during numerous random lab testing these products often do not contain the ingredients that they claim and what is worse is they often contain many ingredients which are not reported and not desirable. If the bottles do actually contain any of the ingredients that they claim are in their product, the pills vary greatly not only from bottle to bottle but within the same bottle from pill to pill.
Unlike prescription medications, which, again, are rigorously tested and evaluated for safety prior to going to market, these supplements are presumed to be safe without any testing. What is more frustrating and disheartening is that, strangely, the burden of proof is then on the FDA to prove that a product is unsafe. A company here in my hometown of Dallas has been in the news again lately for consistently placing products on store shelves which contain banned substances linked to high blood pressure, increased heart rate and deaths. Ingredients like DMAA and aegeline which have been deemed unsafe by the FDA. Please see the excellent article by Seema Yasmin, M.D. at this link, which describes the games that are played by unscrupulous supplement companies to place these unsafe products on the market to line with a blatant disregard for public health. The health risks are enormous.
There are no short cuts. Proper diet, rest and exercise are the best foundation. If you require a medication for an illness or affliction you are much smarter and safer going with a rigorously tested product. Does the FDA make the right decision every time? Of course, not! Sometimes products are later found to have risks or issues not previously known and products are recalled. However, the supplement industry is the wild, wild, west. It is sheer insanity to think for a moment that a completely unregulated product, produced by cowboys riding nothing but a profit motive race horse, is going to be safer than a rigorously tested medication. Slapping “all-natural” on the side of a bottle has absolutely no recognized regulated meaning. It has no value, no credentials.
Do yourself a favor. Do not waste your time and health on these products. You will be better, safer, healthier and, perhaps, a little wealthier, too.
Finally, a Safe Diet Pill?
A new year has begun and t’is the season of new year’s resolutions. More often than not, the most common resolution pertains to weight loss. Whether it is a stated resolution to exercise more, eat less or eat better, this is the time of year when a large percentage of the nation begins paving the road with good intentions. Health clubs are packed, yoga studios are jammed and those who exercise regularly throughout the year look forward to February when the majority of the new year’s resolution people will be gone, having fallen back into their old habitual lifestyle.
The fact of the matter is, most people have a really difficult time mustering the discipline to maintain a healthy diet and regular exercise regimen. More often than not, they would prefer to simply take a pill and have the weight magically fall off. They would do just about anything to lose the weight. How far would you go? Would you eat another person’s feces to lose weight? What?!?!?!?! Sound crazy? A recent study out of Washington University in St. Louis has some extremely compelling evidence that ingesting the feces of thin people might just do the trick.
The role of bacteria in diet and various disease states has long been an area of interest. So researchers at Washington University led by Jeffrey Gordon, M.D. devised a study in which they located sets of twins, one obese and one thin. They then transferred the gut bacteria from the twins to mice that had been raised in a sterile environment and therefore had no bacteria of their own. Mice who were colonized by the thin twin’s bacteria remained thin and the mice colonized by the obese twin’s bacteria became obese. Truly amazing! This occurred despite the fact the mice were given the same diet.
The question many people are asking themselves is, “Can I really be overweight simply because my gut has the wrong bacteria?” Quite possibly, yes. But let us look further at the research from Dr. Gordon and his team. The researchers then decided to see what happened when they took three different groups of mice and put them together. They combined the thin mice with the thin twin bacteria, the obese mice with the obese twin bacteria and “sterile” mice not colonized by either of the twins’ bacteria in an environment together. Mice housed together consume one another’s fecal material and, therefore, all of the mice from the different groups would be colonized with both the thin and the obese twins’ bacteria.
Their findings were nothing short of incredible. All three populations of mice gastrointestinal tracts were taken over by the thin twin’s bacteria. The thin mice stayed thin, the sterile mice stayed thin and the obese mice became thin and stopped showing the negative metabolic effects of obesity. Fantastic!!! So now, all one has to do is colonize yourself with the gut bacteria of thin people and overweight people can become thin, too, correct? Not so fast. There has to be some accountability somewhere, right?
The researchers took the study one step further. The mice diets in the original study were very low in fat. So they decided to run a similar experiment where by they placed the fat mice with the thin mice and fed them a low fat diet very high in fruits and vegetables and in the other group they placed the fat and thin mice together and fed them an unhealthy diet high in fat and low in fruits and vegetables. The obese mice which were fed the unhealthy diet remained colonized with the obese twin’s bacteria and remained obese. The obese mice were only colonized by the thin twin’s bacteria when they consumed the healthy diet, high in fruits and vegetables. So it appears that even in this incredible case, it remains encumbent upon those wishing to lose weight that they choose their diet responsibly.
This research is extremely exciting and holds great promise. Consuming the fecal material of others sounds crazy but it is not without precedent in the field of medicine. There exists an awful type of bacterial infection which occurs in patients who have been on multiple antibiotics and or antibiotics for a prolonged period. These patients can become infected with a bacterium named Clostridium difficle. Although there is an antibiotic which can treat this infection, patients with difficult C. difficle infections improved more rapidly when given feces from healthy individuals.
Researchers caution that there is still much to learn and that their preference would be to find the by-products of the bacteria responsible for these changes and, perhaps, give those to patients rather than feces or the bacteria from the feces themselves; having said that, the possibilities are very exciting. Perhaps, some day, soon those who struggle with obesity, may be able to couple a pill with a diet high in fruits and vegetables and become thin. This would allow them to live happier and healthier lives and potentially save billions of dollars in a healthcare system strained by the destructive pathology of obesity associated illness. In the meantime, this doctor, still recommends regular exercise and a responsible diet. Happy New Year!
Maternal Exercise Makes Baby Smarter
As the end of 2013 rapidly approaches, I would like to return to a familiar theme that is central not only to my practice of medicine but also to my personal health; that is, the tremendous benefits of regular exercise. At every annual exam of every patient, I inquire as to what they are doing for exercise. Many, if not most, are not doing anything consistently and some, nothing at all. I pose this question every year to every patient because I believe it is incredibly important to the health of each individual, their families and to society as a whole.
The benefits to cardiovascular health and weight control are well-known. Increased cognition in individuals who exercise has also been well-documented; but is it possible that exercise during pregnancy can make your offspring smarter? A fascinating study out of the University of Montreal demonstrates that this may actually be the case.
These researchers divided a group of similar women in their first trimester of pregnancy into two separate groups one of which began an exercise program in the second trimester, the other remained sedentary. The exercising group exercised three times each week for a minimum of 20 minutes at a moderate level. For most, this exercise consisted of some variation of running.
Following delivery of these patients’ newborns, the researchers began testing the newborns almost immediately. This testing consisted of placing a cap on the heads of the newborn babies which allowed the researchers to analyze the electrical activity in the newborns’ brains that occurred in response to sounds which were played through in a loop. The lead researcher Elise Labonte-LeMoyen, PhD., explained that these sounds normally produce characteristic spikes in the electrical activity of immature brains but that these spikes diminish as brains mature and are able to process information more efficiently.
In Dr. Labonte-LeMoyen’s study, those newborns born to the exercising mothers had a more blunted electrical response to the auditory stimuli than did the babies born to the sedentary moms; thus indicating that their brains were more mature. This is truly amazing! The mechanism through which maternal exercise is able to facilitate this effect is not known, but the researchers hypothesize that chemicals released during maternal exercise are transferred via uteroplacental bloodflow to the baby’s bloodstream and on to their nervous systems.
This is obviously an exciting area of research and there is much more to learn. However, if the well-known personal benefits to regular exercise are not enough to motivate you to start a regular exercise program, maybe the thought of having your child attend Harvard will provide that motivation! I hope to see you out on the running trails!!!
Synthetic Vaginal Mesh: Friend or Foe?
Synthetic vaginal mesh has received a great deal of press of late, most of it negative. Is this justified? Is there a place for the use of synthetic mesh in the repair of pelvic organ prolapse? If you question most experts in the field I think the answer is, overwhelmingly, yes. I certainly think so. But it is not quite that simple. There are many related questions which much be asked and answered before one can reach a conclusion. The more important question from a patient’s perspective should be, “Is synthetic mesh right for me?”
I have always been a mesh minimalist. There are so many medical and surgical products introduced to the market, many of which have no benefit to the patient. I assess any new surgical product with a skeptical eye. Does the product add anything new, is it beneficial to patients, is it cost effective? These are all very important questions which should be answered affirmatively before I will consider incorporating a new product into my practice.
The issue with synthetic mesh goes much deeper and has many other variables. I do believe it provides a benefit to the right patient when placed by a qualified surgeon. The problem with mesh over the years has been multifactorial. You have had numerous companies jumping on the mesh bandwagon manufacturing “copy-cat” mesh kits and then trying to place them in the hands of every Dr. Tom, Dick or Harry with a pulse.
This is a major problem. Firstly, there are too many gynecologists who were never properly trained in basic “bread and butter” gynecologic surgery, never mind in the field of advanced pelvic reconstructive surgery. There are surgeons who, as their obstetric practices have died- off, have tried to reinvent themselves as pelvic reconstructive surgeons and are self-proclaimed experts in the field spending a great deal of money advertising themselves as such. Patients beware.
These procedures require specialized training and a real understanding of the pelvic anatomy. Not something many gynecologic residency programs offer. When synthetic mesh is placed in a patient by unqualified hands it can be very dangerous. It is under these circumstances that synthetic mesh began to find itself on the receiving end of bad press and the watchful eye of the FDA, and rightly so. However, when placed by a qualified surgeon in the right patient it provides a very nice option for patients suffering from symptomatic pelvic organ prolapse.
The key for me is to discuss the risks and benefits of each option with a patient and let them decide which option, given these risks and benefits, they feel is most appropriate for them. One of the greatest positives about using synthetic mesh in these repairs is…that it lasts forever; one of the biggest negatives…, it lasts forever. This long term durability is a strength and a weakness. This is why each individual patient must decide for themselves if the benefits outweigh the risks. If not, they may wish for their surgeon to use a biologic mesh whose material provides a “scaffolding” for their body to create new native support tissue. But if you were to return and biopsy the area, say 6 months later, there would be no evidence that the biologic mesh was ever there. Each scenario has its risks and benefits.
It is very important that a patient be counseled on her options and to let her decide which option is best for her with her physician’s assistance. Then, only a qualified pelvic surgeon should do the repair and place the mesh, whether biologic or synthetic or, perhaps, perform a repair with no mesh at all.
As I mentioned before, I have always been a mesh minimalist. When a patient decides that synthetic mesh would be best for her, I always prefer to use the least amount of synthetic material, placed in just the right place to achieve the desired support of the pelvic structures.
Every approach has it positives and negatives and any repair can eventually fail and the symptoms can return. But synthetic mesh does have something to offer patients who suffer from these conditions.
The American Urogynecologic Society, the leading non-profit organization dedicated to the treatment of pelvic floor disorders, recently published a very important position paper on the subject that is definitely worth a read, a link to which is provided here. Because of the environment that had developed with copy-cat companies and unqualified surgeons, this increased scrutiny was warranted, but not to the degree that a beneficial product should be completely removed from our surgical repertoire. Just remember: right product, right procedure, right patient, right surgeon. Do not settle for anything less.
Surgical Injustice – Robotic Surgery Revisited
Not usually being one to say, “I told you so”, when it comes to the role of robotic surgery in modern medicine and more specifically gynecologic surgery, it must be stated, “I told you so.” Three years ago I wrote an article regarding my concerns over the use and misuse of robotic surgery and how I was concerned that a marketing force was driving patients to a surgical approach which was not the BEST approach for them or, even worse, not indicated, at all.
In the article, I listed examples of how this technology was being advertised and employed improperly. I discussed concerns over longer operative times, greater complication rates, increased anesthesia exposure, steep surgeon learning curves, enormous expense and use of the more invasive technology not because of indication but for physician enjoyment or to log training cases.
Again, my expertise lies in gynecologic surgery, and it is in this area that I can say the robot is being inappropriately advertised and utilized. The least invasive approach to the majority of these procedures is through the vagina. To suggest otherwise, demonstrates either a lack of knowledge of the subject matter or worse, a deliberate attempt to deceive patients.
Finally, our own regulatory body has spoken out on this issue, when, in March, the president of the American College of Obstetrics and Gynecology, James T. Breeden, M.D. stated, among other things that, “…there is no good data proving that robotic hysterectomy is even AS GOOD as-let alone better-than existing, and far less costly, minimally invasive alternatives.” My only question is, “What took so long?”
I encourage you to read Dr. Breeden’s, “Statement on Robotic Surgery.” It is informative, to the point and echoes many of the same concerns I voiced three years ago in the article.
Recently, I was asked to assist another surgeon in what was posted as a Laparoscopically-assisted vaginal hysterectomy. When I arrived at the operative suite and learned that the case was actually a robotic hysterectomy, I informed the surgeon I would be unable to assist. I could not and cannot, in good conscience, participate in this practice in gynecologic surgery. In what other specialties might similar concerns exist? It saddens me to see this practice in medicine today.
A Primer on Exercise and Pregnancy
It is unfortunate that many pregnant women choose to forsake exercise and physical training in favor of more sedentary behavior. A large number of myths surround the perceived frailty of pregnant females. These fallacies prevent women from understanding the importance of exercise during their term. For instance, many women believe that abdominal exercises will induce labor or harm the baby. In truth, core exercises strengthen the abdominal musculature which provides support to the uterus during pregnancy. These types of exercises can also strengthen pelvic floor muscles, which can provide many benefits in addition to playing a supportive role during and after pregnancy.
Another common myth surrounds fetal nutrient delivery and limitations imposed by exercise. Some women incorrectly believe that exercising will rob their child of calories or other nutritive properties. The female body will always prioritize energy and alimental needs towards the fetus. Pregnant women that exercise should take care to increase their nutritional status appropriately, but there is no reason to fear exercise-induced fetal malnutrition.
One of the worst and most widespread myths involves previous fitness status and pregnancy exercise. Many women believe that, since they never worked out before, beginning an exercise program while pregnant will produce adverse effects. Although attempting to achieve the best shape of your life is out of the question, consistent, low-intensity exercise holds numerous benefits for both mother and child regardless of your past exercise history. Decreased incidence of gestational diabetes, back pain, excess weight gain and postpartum depression are only a few of the benefits gained when pregnant women exercise. The reduction in gestational diabetes alone is worth the small amount of effort and time required.
However, the right kind of exercise is just as important as understanding exercise’s significance. Complex exercises and sports are barred during pregnancy for obvious reasons, but other, seemingly-innocuous activities can be troublesome. Remember, always obtain approval from your OBGYN before engaging in any exercise program, diet or supplemental addition during pregnancy. Further, know your limitations when performing exercise and don’t expect personal bests or records during your pregnancy. The point of exercise when carrying a child is not strength, beauty or skill, but improved health for child and mother.
Every pregnant woman of good health with an uncomplicated pregnancy should consider walking for a minimum of 15 minutes a day. This exercise should be continuous and at a comfortable pace. Walking is the most basic of aerobic exercises and serves to improve circulation of the cardiovascular and lymph system. Swollen feet are a common occurrence during pregnancy, yet few women recognize the palliative effect that walking can have on edema. Walking is also very relaxing and has been shown to improve mood. For those who would like to walk longer, a maximal limit of 45 minutes is recommended. Brisker paces should be set at your medical provider’s discretion.
Swimming is a great alternative for those who may prefer nonambulatory options. Pregnant women who may not be comfortable walking or performing other exercises are often quite capable of swimming. Water-based aerobics classes provide similar amounts of exercise with an equivalent decrease in exercise-mediated joint stress. Pregnant women who choose to swim or exercise in water should always be accompanied in case of emergency.
Sporting activities hold great promise for pregnant women due to their high enjoyment potential. Many women find their generally non-competitive attitude allows them to take greater pleasure in friendly games. Modestly-competitive activities also reduce feelings of exertion, which tends to makes exercise more tolerable. However, your pregnancy and fitness status will play a role in determining what kind of sport in which you can participate. Sports such as tennis, basketball and soccer should be avoided due to the possibility of falling and collisions.
Women in general will often overlook weightlifting when considering exercise choices. This tends to stem from the perception that weightlifting will lead to “bulky” muscles and masculinizing effects. Many women consider the body type of professional female bodybuilders to be a common side effect of female weight training, but this is simply not the case. Pregnant women can benefit significantly from the metabolic cascades elicited during “toning type” weight training. Moreover, very little joint stress will be incurred during weight training when proper form is kept and adequate exercise choices are made.
Determining if and how you can exercise while pregnant is the most important point to take home. Physical fitness is just as important for the mother as it is for the child. Every expectant mother should better their own health and fitness in order to best ensure a safe delivery and healthy child.
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Recent Posts
- What will my third trimester appointments be like?
- What will my second trimester appointments be like?
- What will my first trimester appointments be like?
- More Positive Findings for that Magic Pill: Exercise
- Supplements: Do Not Waste Your Money or Your Health
- Finally, a Safe Diet Pill?
- Maternal Exercise Makes Baby Smarter
- Synthetic Vaginal Mesh: Friend or Foe?
- Surgical Injustice – Robotic Surgery Revisited
- A Primer on Exercise and Pregnancy