Tuesday, March 26, 2019

Your best cycling days may still be ahead

As parents, we think that if there is anything our children have, it’s time. After all, they are still young; there is time for them to succeed, find love, and stay out of trouble. It’s okay if they are a bit overweight, prefer French fries to salad and video games to soccer games; when they are older all that will change, and they will be fine.

They may succeed, find love, and stay out of trouble — but increasingly, research says that if they are overweight with poor eating and exercise habits, they will stay that way.

A study recently released in the journal Pediatrics followed about 500 10th graders for four years and found that less than 9% of them got the recommended 60 minutes of moderate-to-vigorous physical activity every day — and while they got a bit more exercise in 11th grade, the numbers went steadily down afterward, especially those who didn’t go to a four year college or who went to college but lived at home.

Overweight children are simply more likely to turn into overweight adults — that is becoming abundantly clear. Currently two-thirds of U.S. adults are overweight; a third of them are obese. And what is also becoming abundantly clear is that overweight adults are very likely to stay overweight. A study of almost 200,000 obese men and women in the United Kingdom, published in 2015 in the American Journal of Public Health, found that the probability of achieving a normal weight was about 1 in 210 for men and 1 in 124 for women. Even just losing weight was tough: among the most obese, the odds of losing 5% of body weight were 1 in 8 for men and 1 in 7 for women.

A lot has to do with biology; more and more, we are beginning to understand how the actual chemistry of our bodies can be changed by our diets, in good and bad ways. A lot has to do with our lifestyles and what we come to think of as normal. We are remarkably sedentary as a culture, portion sizes have grown, and we eat far too many processed foods. A lot, sadly, has to do with the growing divide between rich and poor; having access to healthy foods and both the opportunity and time for exercise, is clearly tied to income.

And all of this, every last bit of it, starts in childhood — as early as infancy, even before birth. The best and most effective way to fight obesity is to prevent it — or, if we can’t do that, to catch it early.

That’s why we need to stop thinking that our children will have time to slim down and get healthy—and stop thinking that it’s up to them, not us.

We need to take action as a country and create more access to healthy foods and exercise generally. We need to take a much harder look, too, at how our food is produced and sold. But as parents and communities, we need to be much more proactive than we currently are. It should really bother us that less than 9% of youth get enough exercise. We should be alarmed, actually — alarmed enough to turn off the screens and get them moving. It doesn’t have to be an organized sport or going to a gym; just playing outside or going for a walk could make a huge difference.

I think that’s what bothers me the most as a parent and a pediatrician: how little this bothers us. We are growing not just overweight, but complacent; we are accepting a new normal that is setting our children up for heart disease, diabetes, cancer and other health problems. We are accepting that our children may have shorter lives than ours. It was February, and clinic was teeming with respiratory infections of all kinds: mostly the common cold, but also bronchitis, pneumonia, and sinus infections. The patients were coming in usually thinking that they needed antibiotics for their sinus infection, or another respiratory infection.
The first patient on my schedule was a healthcare provider with “sinus infection” written down as her main issue.* She’d had about two weeks of nasal and sinus congestion which she blamed on a viral upper respiratory infection (URI, also known as the common cold). Her two young kids had been sick with colds all winter, so she wasn’t surprised to have these symptoms, along with endless postnasal drip and a cough.

Her congestion had improved a bit at one point, and she thought that she was finally getting better. But then, the day before her appointment, she awoke with throbbing pain between her eyes, completely blocked nasal passages, and, more concerning to her, green pus oozing from her left tear duct. She had body aches, chills, and extreme fatigue. “Do I maybe need antibiotics?” she asked.
Most sinus infections don’t require antibiotics

Ah, sinus infections. The New England Journal of Medicine rpublished a clinical practice review of acute sinus infections in adults, that is, sinus infections of up to four weeks. The need for an updated review was likely spurred by the disconcerting fact that while the vast majority of acute sinus infections will improve or even clear on their own without antibiotics within one to two weeks, most end up being treated with antibiotics.

It is this discrepancy that has clinical researchers and public health folks jumping up and down in alarm, because more unnecessary prescriptions for antibiotics mean more side effects and higher bacterial resistance rates. But on the other hand, while 85% of sinus infections improve or clear on their own, there’s the 15% that do not. Potential complications are rare, but serious, and include brain infections, even abscesses.
But sometimes, antibiotics for sinus infections are needed

So how does one judge when it is appropriate to prescribe antibiotics for a sinus infection? There are several sets of official guidelines, which are all similar. When a patient has thick, colorful nasal discharge and/or facial pressure or pain for at least 10 days, they meet criteria for antibiotic treatment. If a patient has had those symptoms, but the symptoms seemed to start improving and then got worse again, then even if it’s been less than 10 days, they meet criteria for antibiotic treatment. (That’s referred to as a “double-worsening” and is a common scenario in bacterial sinus infections.)

The authors, however, also suggest that doctors discuss “watchful waiting” with patients and explain that most sinus infections clear up on their own in one to two weeks, and it’s a safe option to hold off on antibiotics. The symptoms can then be treated with a cocktail of over-the-counter medications and supportive care, like nasal saline irrigation, nasal steroid sprays, decongestants, and pain medications.

Of course, many patients expect and demand antibiotics for sinus infections, and even those who are open to watchful waiting may hear about the rare but possible complications of things like, oh, brain abscess, and opt to treat.

In the case of my patient above, she met criteria for treatment. She weighed the watchful waiting option against the potential risks of antibiotics for her sinus infection, and chose the prescription. I can tell you from very close follow-up that she improved quickly, though in truth, we will never really know if she would have gotten better anyway.

*This is a real case, details recalled as accurately as possible, based on my own experience as a patient with a sinus infection, originally posted here. Are you reading this while standing at your desk? There’s a good chance that you are — standing desks are all the rage.

These desks allow you to work at your “desk job” while standing rather than sitting in a chair. They can be custom built (for thousands of dollars) or you can convert a regular desk into a standing desk at no cost by elevating your computer — one of my colleagues simply placed his computer on a stack of books. Sales of standing desks have soared in recent years; in many cases their sales have far outpaced those of conventional desks.

Personally, I love the idea — rather than sitting all day staring at a computer screen, surely it would be better to be standing (while staring at a computer screen). But, I also love the idea of studying some of the assumptions surrounding standing desks. A common one is this: certainly it takes more effort — and extra calories — to remain upright rather than sit, and over a course of days or weeks those extra calories would add up to something significant. But is it true that a standing desk can help you avoid weight gain or even lose excess weight?

That’s just what researchers publishing in the Journal of Physical Activity and Health tried to answer. (Yes, there is such a journal.) They fitted 74 healthy people with masks that measured oxygen consumption as a reflection of how many calories they burned while doing computer work, watching TV, standing, or walking on a treadmill. Here’s what they found:

    While sitting, study subjects burned 80 calories/hour — about the same as typing or watching TV
    While standing, the number of calories burned was only slightly higher than while sitting — about 88 calories/hour
    Walking burned 210 calories/hour.

In other words, use of a standing desk for three hours burns an extra 24 calories, about the same number of calories in a carrot. But walking for just a half hour during your lunch break could burn an extra 100 calories each day.

Prior reports of the calories burned by standing versus sitting suggested a much higher calorie burn rate for standing, but this new study actually measured energy expenditure and likely represents a more accurate assessment.
Reasons to stand by your standing desk

While the new study suggests that a standing desk is unlikely to help with weight loss or avoiding weight gain, there may be other reasons to stand while you work. Advocates of standing desks point to studies showing that after a meal, blood sugar levels return to normal faster on days a person spends more time standing. And standing, rather than sitting, may reduce the risk of shoulder and back pain.

Other potential health benefits of a standing desk are assumed based on the finding that long hours of sitting are linked with a higher risk of

    cardiovascular disease
    cancer (especially cancers of the colon or breast)
    premature death.

But “not sitting” can mean many different things — walking, pacing, or just standing — and as the new study on energy expenditure shows, the health effects of these may not be the same. For most of these potential benefits, rigorous studies of standing desks have not yet been performed. So, the real health impact of a standing desk is not certain.
If you’re going to stand at your desk…

Keep in mind that using a standing desk is like any other “intervention” — it can come with “side effects.” For example, if you suddenly go from sitting all day to standing all day, you run the risk of developing back, leg, or foot pain; it’s better to ease into it by starting with 30 to 60 minutes a day and gradually increasing it. Setting a timer to remind you when to stand or sit (as many experts recommend) can disrupt your concentration, reduce your focus, and reduce your efficiency or creativity. You may want to experiment with different time intervals to find the one that works best for you.

It’s also true that certain tasks — especially those requiring fine motor skills — are more accurately performed while seated. So, a standing desk may not be a good answer for everyone who sits a lot at work.
What’s next?

We have seen dramatic changes in the work environment in recent years. These include open floor plans and inflatable exercise balls instead of chairs, as well as standing desks. I have colleagues who have installed a “treadmill desk” that allows them to work on a computer or video conference while walking on a treadmill. There are advantages, and perhaps some risk, that come with each of these changes. But, before we accept them as better — or healthy — we should withhold judgment until we have the benefit of more experience and, ideally, well-designed research. I loved riding my bicycle as a kid, and whizzing along wooded roads with friends on crisp autumn days. For me, the images of blurred leaves and sunshine are still fresh, as are the feelings of freedom, joy, and the wind on my skin. Now, only an occasional bike ride with my children reminds me how much I love cycling.

But there are plenty of reasons to go for a ride, no matter what your age. “It’s fun, it’s socially oriented, and it gets you outside and exercising,” says Dr. Clare Safran-Norton, a physical therapist at Harvard-affiliated Brigham and Women’s Hospital. Plus, cycling is an aerobic activity, it’s easy on the joints, and it helps build muscle and bone.
Back in the saddle

Hopping on a bicycle sounds easy enough, but it can be a little more challenging as we get older, with stiff joints that may make it hard to swing a leg over the top tube of a two-wheeler.

Fortunately, bike manufacturers are responding to meet riders’ needs. One option is the step-through bike, a two-wheeler with a low or absent top tube. “I get emails from people who tell me they’re riding for the first time in 20 years,” says Tony Biria of Biria Bicycles, which in 2002 introduced a bicycle to the U.S. with a top tube that’s just six inches off the ground. Beach cruisers and comfort bikes are also popular among older cyclers. All three of these bike types feature high-rise handlebars that enable you to sit upright; wide tires for a smooth ride; shock-absorbing seat posts; and lower top tubes.

Other bike types include tricycles, which are helpful if you are less stable on your feet; and recumbent bikes that allow you to lean back and ride. “If you have spinal stenosis, a recumbent bike puts your spine in a flexed position and gives you pain relief. But if you have a herniated disk, the bike can make the disk bulge more,” says Dr. Safran-Norton.
Gear up

You can make cycling even safer and more comfortable with special equipment.

Cycling clothes have high-tech fibers that wick away moisture. They are usually neon-colored, with reflective material so you’ll be visible to drivers. Bike shorts have a thick pad or chamois to prevent chafing and provide cushioning.

Bicycle seats (called “saddles” in cycling lingo) are available with extra padding, in wide styles that support the pair of bones you sit on. Go even further with a saddle that relieves pressure on the perineum, the area between those bones, behind the genitals. It’s home to nerves and arteries that supply the lower body, and too much pressure here may cause numbness and tingling in the legs. Pressure-relieving saddles may have a “noseless” or horseshoe design.
Prepare before taking to the road

Getting a comfy bike and all the trimmings isn’t enough preparation to hit the road. You’ll want to consult your doctor first, especially if you have heart disease, arthritis, or thinning bones. “If you have osteoporosis, consider riding a tricycle, which is more stable than a two-wheeler, posing less of a fall risk. I’d advise that you don’t ride a bike if you’ve had a recent fracture. Another fall could make it worse,” says Dr. Safran-Norton.

When riding, remember that the seat height should allow a slight bend at your knee. “You don’t want a straight knee at bottom of the pedal stroke, because the bike could be too tall and you could fall off,” says Dr. Safran-Norton.

Other tips:

    wear a helmet
    don’t use clips to keep your feet on the pedals, which can make injuries worse if you fall
    don’t ride alone
    stick to bike paths instead of the street
    stay hydrated before, during, and after your ride
    and use sunscreen and sunglasses.

Minding these safety tips is crucial. Some evidence suggests that bicycle injuries among people over age 45 have risen dramatically since 1998. But as long as you take precautions, cycling is still considered a safe way to exercise, get around, and have fun.

And remember that having fun is really what this is all about. If you enjoy exercising, you’ll be more likely to do it. In the case of cycling, it may even make you feel like a kid again.

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