Only 7% of the 60 Million with Prediabetes Are Aware

Measuring glycated hemoglobin levels may be an appropriate means of catching patients with prediabetes....

Ronald Ackerman, MD, MPH, of Indiana University, and colleagues reported in Preventive Medicine that, HbA1c testing yielded similar probabilities for developing diabetes and heart disease as those estimated by using the 2003 American Diabetes Association definition for prediabetes. "The A1c test may provide a badly needed, clinically practical indicator of the composite risk for incident diabetes and cardiovascular disease," they wrote.

Fasting plasma glucose and two-hour plasma glucose, two commonly used tests for assessing diabetes and prediabetes, are limited because they require a patient to return on a separate day after an overnight fast and remain in the office for 2-3 hours which is a potential barrier to test completion, the researchers said.

Measuring HbA1c is easier -- it requires only one blood draw. In June 2009, the International Expert Committee, which represents several major diabetes groups, recommended using HbA1c to diagnose diabetes.

The recommendations of the committee have stirred up some controversy, still, the researchers said, only about 7% of patients with prediabetes -- who are thus at risk for later diabetes and heart disease -- are aware of their status.

To estimate the risks of developing diabetes and cardiovascular disease for adults with different HbA1c levels, Ackerman and colleagues assessed data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006.

Among adults who met the 2003 ADA definition for prediabetes, the probabilities for developing Type 2 disease over 7.5 years and cardiovascular disease over 10 years were 33.5% and 10.7%, respectively.

The researchers found that using HbA1c alone -- with a range of 5.5% to 6.5% defining prediabetes -- would identify a population with comparable risks for diabetes and heart disease (32.4% and 11.4%, respectively).

But using a slightly higher cutoff -- beginning at 5.7% -- would identify increased risks of 41.3% for diabetes and 13.3% for heart disease.

These risks are comparable to those seen in patients enrolled in the Diabetes Prevention Program, which had an enrollment criteria of both elevated fasting plasma glucose and impaired glucose tolerance, the researchers said.

Thus, they concluded, using a bottom cutoff of 5.7% for diagnosing prediabetes may be more appropriate.

Either way, they said, HbA1c measurement "should be considered a means of identifying greater numbers of patients at risk for diabetes and heart disease" -- especially because "of its practical nature and wide availability."

The study was limited by its use of cross-sectional data, and it may be lacking in generalizability. For instance, a greater number of African Americans would be identified as having prediabetes than if using fasting plasma glucose or two-hour plasma glucose testing, the researchers noted.

Prevent the five most common running injuries

It doesn’t matter if you’re just beginning to run or you’re a marathon veteran: running injuries can happen to anyone. And when a runner gets hurt, plantar fasciitis, Achilles tendinitis, iliotibial band syndrome (ITBS), shinsplints, or runner's knee usually is the diagnosis. Allison Lind, a physical therapist in New York City, developed an exercise program that will make you less vulnerable to these five injuries. Do them together as a prerun routine.

1. Prevent ILIOTIBIAL BAND SYNDROME with side-leg raisers Prevent ITBS by strengthening the gluteus medius muscle near the hip. When it's weak, another upper-leg muscle overcompensates and pulls on the ITB, causing pain along the outside of the leg, down to the knee.

Lie on your side with your hips and legs stacked. Lift your top leg up, keeping it straight, but point your toes inward and toward the ground to isolate the gluteus medius. Hold for 30 seconds, then release. Roll over so your opposite leg is on top, and repeat. Do three sets on each leg, working up to one minute per set.

2. Prevent SHINSPLINTS with heel walking and big-toe raisers Prevent shinsplints by strengthening the muscles that attach to the shinbone. A. Walk in place barefoot for one minute with your forefeet off the ground. Do three sets. B. Lift the big toe of one foot as high as you can, lower, repeat 10 times. Switch feet. Do three sets.

3. Prevent RUNNER'S KNEE with half-squats on a downward slope Prevent runner's knee, or patellofemoral pain syndrome, by strengthening the quads to keep the kneecap aligned. Stand facing down a hill or on a decline board. Squat halfway between the start position (straight leg) and a full squat (90 degrees). Do three sets of 10. Too easy? Try single-leg squats.

4. Prevent ACHILLES TENDINITIS with calf drops Prevent Achilles tendinitis by strengthening the calves.Stand barefoot with the balls of your feet on a step. Rise up on your toes with both feet. Shift your weight to one foot; lower down on that foot. Rise up on both, lower on one. Do three sets of 10 on each side.

5. Prevent PLANTAR FASCIITIS with arch raisers Prevent plantar fasciitis by strengthening foot muscles. Stand barefoot on one leg. Imagine your foot is a tripod and place even pressure on your big toe, pinkie toe, and heel. Ground these three points as you "scrunch up" your arch. Hold for 30 seconds; repeat three times.

Current Insights On Conservative Care For Heel Pain

A Two-Pronged Approach to Treatment
To develop an effective treatment plan, one should consider using what I refer to as a “two pronged” treatment approach for the patient. This approach considers treating the symptoms and treating the cause. Treating the symptoms of pain and inflammation would include any combination of: nonsteroidal anti-inflammatory drugs (NSAIDs); cortisone injection; physical therapy; or cryotherapy. Treating the cause would include any combination of: taping; orthotics; shoe recommendations or modifications; night splints; cross training; and/or modification or restriction of activity.

Too often, a treatment plan will address only one of these areas. For example, the patient receives an injection, which does nothing to address the cause of the heel pain.

I have found taping to be a valuable tool in treating heel pain but it appears to be a lost art. Taping can be therapeutic as well as diagnostic in determining if a patient could benefit from functional orthotics. I like to say, “Orthotics are only as good as the shoes that you put them in.” If shoes are worn out or not recommended for your patient, orthotics will not be as effective in controlling the foot.
The biomechanical exam and gait evaluation are critical to addressing the underlying cause. You need to determine what diagnostic studies are needed to confirm your diagnosis, especially if it does not appear to be your classic plantar fasciitis injury.

Is Stretching Beneficial For Patients With Heel Pain?
To stretch or not to stretch — that is the question. All too often we will recommend stretching to patients for treating heel pain in the acute phase of the injury. Unfortunately, stretching often starts before the area has healed sufficiently. Stretching should not begin until the rehabilitation phase of the injury, after the healing phase has occurred. If stretching starts too early, it creates a vicious cycle and can prolong the healing of the injury.
There is also quite a bit of controversy over the value of stretching so the jury is still out. However, I tend to be a believer in the benefit of stretching both in recovering from an injury as well as helping to prevent injuries. When addressing stretching, one should specifically focus on stretching the calf muscles as well as the plantar fascia for both sides. It should be a gradual approach with slow, long, static stretching that builds up gradually over time as the patient can tolerate. One should avoid rapid, violent stretching (ballistic). I will usually recommend a pre-activity stretch after a brief warm-up and a post-activity stretch after cooling down.

How Cross Training Can Keep Heel Pain Patients Active
Cross training is a very important aspect of the treatment plan. It is important that patients are able to keep up their level of fitness while recovering from heel pain. Ideally, you can have them use pool therapy, bike or elliptical training to stay in shape and avoid stressing their foot.

Limiting or restricting activity is often difficult, especially for the athlete. One should address the intensity and frequency of activity, especially when it comes to those participating in youth sports. Fortunately, children are often involved in varied activities anyway so cross training is helpful in the treatment plan for youth injuries. Cross training is an essential part of the treatment plan for dealing with high school, college and professional athletes.
It is important to realize that exercise prescription is a major part of dealing with the treatment of heel pain. Prescribing exercise and tailoring it to a specific patient is a talent you should develop. Proper exercise prescription can greatly assist in motivating patients to be actively involved in the treatment and help ensure that their fitness level does not drop off significantly. Improper exercise can prolong the recovery time and increase the rehabilitation period. Return to activity guidelines should be clear to the patient with reasonable goals and expectations.

Current Insights on Conservative Care for Heel Pain

Heel pain in children is commonly caused by calcaneal apophysitis or Sever’s disease. This is a traction apophysitis at the calcaneus due to the pull of the Achilles tendon insertion and the origin of the plantar fascia. Typically, the child is involved in a youth sport or activity, such as soccer, baseball, track or basketball, which involves a lot of running and jumping.

Usually, the condition will resolve on its own over time but it is helpful to treat symptoms in the active child using many of the aforementioned treatments such as taping, proper shoe recommendations, ice, stretching (not during acute episodes), etc. I like to apply a low Dye strapping with a closed basket weave on the heel. This has worked very well in allowing children to participate in their activity relatively pain free.

Institute a stretching exercise program for the Achilles tendon and plantar fascia when the child is not in a pain cycle. Addressing footgear is also critical in allowing the child to return to activity and reduce symptoms.

During the exam, the child with calcaneal apophysitis will have a positive squeeze test with medial and lateral compression over the heel with localized tenderness. The activity level is based on response to treatment and minimizing pain with activity.

Keys to Ensuring a Good Fit with Athletic Shoes
• Measure both feet standing on a Brannock device.
• Have patients try on shoes in the afternoon or evening due to swelling.
• Have patients wear similar weight socks or orthotics for activity.
• Have patients try on shoes a half size larger to compare fit.
• Do the basic three shoe tests to evaluate quality.
• Tell patients there should be at least one finger width from the end of the longest toe to the end of the shoe.
• Have patients wear new shoes indoors first to make sure they are comfortable.
• The shoe should not require a break-in period.
• Educate patients on knowing when to replace shoes and the differences among shoe brands.

Treating heel pain can be a real challenge. It is very important to get a detailed history from the patient as to the etiology of the heel pain. The vast majority of heel pain results from overuse. When acute injuries become chronic, one should identify and address biomechanical causes. Evaluating the patient’s training, shoe gear and any previous treatment is essential to a successful treatment plan.

Commonly, the diagnosis points to plantar fasciitis. However, remember there are many causes of heel pain and your differential diagnosis could include a calcaneal stress fracture, nerve entrapment/neuritis, calcaneal apophysitis, calcaneal bone cyst, Reiter’s syndrome or a possible tumor. A good history and exam will help pinpoint a diagnosis and direct a subsequent treatment plan.
Heel pain in the athlete is commonly caused by an increase in the intensity and frequency of activity. Often the athlete is adding running to the workout routine and for cross-training workouts. A good history will include the following key points: sudden or gradual onset of pain, localized or diffuse pain, pain intensity (scale of 1-10), duration of pain and what relieves the pain. The patient history also includes any prior history of problems, any previous treatment, any changes in training intensity and frequency, and any changes in athletic footwear.
The problem with using the pain scale is getting the patient to understand the relative number as most patients will say it is a 10. It is sometimes difficult to determine if the pain is mechanical or neurological in nature. Commonly, the pain is insidious in nature and there is no incidence of trauma.

Current Insights On Conservative Care For Heel Pain

Pertinent Tips For Performing Corticosteroid Injections
Corticosteroid injections can be helpful as part of the treatment plan you offer to the patient. I tell the patient the injection can help with the pain and inflammation. This can also be a good alternative for a patient who cannot take NSAIDs.
I inject at the medial aspect at the transition area of the dorsal to plantar skin. This approach can avoid the fat pad inferiorly and the calcaneus superiorly.
I always offer ethyl chloride to help minimize the pain. I penetrate the skin quickly and then slowly inject the heel. It is important to explain to patients that they will feel the cold spray, then a stick and a little burning or discomfort. I will usually inject dexamethasone phosphate or Kenalog (Bristol-Myers Squibb) with bupivacaine. I will do up to three injections depending on how the patient responds to the initial injection but usually one or two injections is sufficient to calm down the heel pain.

I stress that a corticosteroid injection is not a cure, just part of the treatment plan. If the patient does not respond to the injection series, I would consider an oral corticosteroid, such as a Medrol dosing pack. It is pointless to repeat steroid injections when there is little or no response in reducing symptoms. I typically do not offer cortisone injections in the acute phase. Also, I warn the patient of a possible steroid flare-up following the injection, which usually resolves in a short period of time. Be sure to caution the patient to reduce activity following a corticosteroid injection as it can mask the pain during activity and make the condition worse.

Can Physical Therapy Have An Impact?
Physical therapy can be beneficial in the treatment process and the earlier it begins, the better. There are many modalities that one can prescribe such as icing, massage, ultrasound, iontophoresis, stretching and strengthening exercises.
Remember that physical therapy is a prescription so you need to order the frequency and duration of therapy, and establish specific goals. Physical therapy needs to be at least two to three times per week to be effective. I will usually reassess the patient at three- to four-week intervals. If physical therapy is not helping patients after several weeks, reassess the plan. If patients are progressing well, I will often continue their therapy.
The major goals of physical therapy are to decrease pain and increase function. Patients need to understand treatment expectations. I also like to make sure patients receive home exercises to do so they take an active role in their treatment. It is important to work closely with a physical therapist and athletic trainer in the treatment of heel pain.

What You Should Know About Taping
Taping should be the key ingredient in treating heel pain that is mechanical in nature. As I said earlier, taping is becoming a lost art but it is therapeutic as well as diagnostic. When one properly applies a low Dye strapping, it can provide dramatic relief of symptoms. Physicians can apply this strapping with accommodative padding, such as a cobra pad or medial longitudinal arch pad. I will typically offer taping to all of my heel pain patients who have a biomechanical cause of the pain, which one typically sees with plantar fasciitis. I always check to make sure the patient has not had any trouble with taping in the past.

I use a pre-tape spray. Using 1-inch anchors and 2-inch strips, I apply the strips in an overlapping fashion from lateral to medial, causing an anti-pronation force. I will apply another anchor and then repeat another series of overlapping straps. Then I apply a retention strap on the dorsum of the foot to secure the tape job.
Ideally, the tape job can last several days. Sometimes I will do a criss-cross strapping under the arch if the patient has a cavus foot type and that will tend to provide better support. Although the tape will stretch some in a short time, the proprioceptive feedback benefit will last much longer.
I allow the patient to take a brief shower and then use a hair dryer to help dry out the tape job. Since I use porous cloth athletic tape, it holds up pretty well for several days to a week if needed. If you are taping the patient multiple times for several weeks, an under-wrap or pre-wrap will help protect the skin.
Taping restricts excessive motion but allows for functional movement. Taping is not a substitute for rehabilitation but rather an adjunct therapy. If patients respond well to taping, it is a good indication that functional orthotics will be a benefit for them. Usually, if the patient does not respond to a low Dye strapping, the problem is most likely not plantar fasciitis.

What About Functional Orthoses And Night Splints?
Functional orthotics can greatly benefit patients who have had heel pain and chronic plantar fasciitis. Typically, I will put them in a flexible orthotic with a deep heel cup, wide plate and rearfoot post. A medial heel skive of 2 to 4 mm is also helpful in patients with extreme pronation. A plantar fascial groove may be needed for patients who have a tight plantar fascia to prevent irritation of the medial arch. The easiest way to check is to maximally pronate the foot and dorsiflex the hallux as a tight medial band will be prominent. Sometimes one can use a cobra pad to help increase the medial arch height and decrease pronatory forces. A prefabricated sports orthotic can also be helpful in the interim but usually the patient will require a prescription custom orthotic because of the benefits of a heel cup and rearfoot posting providing more support. I typically do not use orthotics in acute or sub-acute cases, or with patients who have not postively responded to taping.
Try to avoid the trap of fitting the orthotic to the shoe. I will usually have patients wait to get any new footwear until they have their orthotics to help ensure a good fit. Then I will have patients bring in their new footwear and check for fit and control with the orthotic. I always advise the patient with heel pain to avoid flip-flops or sandals due to lack of support and cushioning. It is surprising how often a patient will be in flip-flops when he is she is being treated for a foot problem.

Night splints are also a good alternative for treatment to help retain the plantar fascia tension by providing constant force. However, patients may not tolerate the night splints for a prolonged period of time. One can set the night splints for positioning with dorsiflexion commonly from 5 to 15 degrees. This reduces the effect of post-static dyskinesia by reducing the effect of shortening of the plantar fascia and intrinsic muscles of the foot.

Emphasizing The Value Of Proper Footwear And Fit To Combat Heel Pain
Proper footwear is essential for the patient with heel pain. Often, part of the cause of heel pain is an improper shoe for that patient. Usually, the proper athletic shoe will be a great benefit. There are many brands and models of shoes out there so it is best to give your patients some qualitative guidelines. Most patients find they have gravitated to a particular brand that tends to fit their foot. However, it is often not the best model or size for them.
Depending upon the foot type and biomechanics, patients will typically need guidance toward one of the following shoes: motion control, stability or cushion shoes. I typically do a shoe exam that checks for heel counter rigidity, midfoot torsion stability and forefoot flexion of the shoe. Ideally, a removable sock liner or inner sole will allow for easy placement of an orthotic and allow the heel area of the orthotic to sit flat in the shoe.
Typically, a pes cavus foot type will do best in a cushion or neutral type of shoe. A pes planus/hyperpronated foot type will need a moderate to maximum motion control shoe. A normal foot type will usually do well with a stability or mild motion control shoe. One needs to address the shoes before even getting to the orthotic stage. At this point, there is no evidence that toning shoes or rocker bottom shoes provide any benefit for dealing with heel pain. The American Academy of Podiatric Sports Medicine has a helpful section on its website (www.aapsm.org) on athletic footwear recommendations, which can help the practitioner keep current on models and styles.
Have patients try on shoes in the afternoon or evening when their feet will be the largest. Measure patients with a Brannock device while they are standing. Use the measurements as a guide or reference only as different brands can run relatively different sizes. One can also use the shoe fit test to trace the foot and then the shoe, and compare for overlap. Patients should be wearing a similar style of sock. If they have an orthotic device, they should have it in the shoe. There should be a finger width between the end of their longest toe and the shoe. I always have them try on a half size bigger shoe to compare the fit.
I do not recommend breaking in shoes as this tends to break in the feet. Have patients wear the new shoes indoors for a day or two to make sure they feel comfortable. I will then repeat the three-point shoe exam with them to help make sure it is the proper shoe for them. Most patients do best in a running shoe as they offer the best support and cushioning (see “Keys To Ensuring A Good Fit With Athletic Shoes” above).

In Conclusion
A two-pronged approach is helpful in treating heel pain. Most heel pain will respond well to conservative care using this approach. Make sure to address biomechanical issues, footwear considerations and return to activity principles. I rely on taping and athletic footwear prescription as the gold standards of my approach to heel pain. Cross training and exercise prescription are also critical to successful rehabilitation. Stretching programs can be helpful, especially in children with calcaneal apophysitis or plantar fasciitis.
When the patient is not responding to conservative treatment measures, consider additional diagnostic tests to identify the cause and rule out some of the other differential diagnoses of heel pain. Extracorporeal shockwave treatments or surgical repair may be necessary. Consider post-treatment orthotics and proper footwear to prevent further problems.

Can Diabetes Affect Your Mood?

Q: My husband has type 2 diabetes, which is now being controlled by medicine. I find that he is sometimes particularly irritable or even mean, which is very out of character for him. Is this common with type 2 diabetes, or with high or low readings?

— Amanda

A:It is great that you are seeking a better understanding of your husband’s illness. Diabetes is a disease that not only affects individuals but also those close to them. As a result, those who have good family support in the care of their diabetes do much better in managing their illness.

There are a few reasons for behavioral changes like those you see in your husband among people with diabetes. One is the effect of abnormally low glucose levels in the bloodstream. The other reason is depression, which can be triggered by the diagnosis of diabetes, the burden of daily management, and fear of complications.

Low glucose levels can cause symptoms including impaired judgment, anxiety, moodiness, belligerence, fatigue, apathy, confusion, dizziness, blurred vision, and a lack of coordination. I would advise your husband to check his sugar levels at the times when he is irritable. If his mood is indeed due to low glucose levels, the symptoms will improve if he raises his blood sugar, for example, by drinking orange juice or taking glucose tablets. It is also important to consult with his doctor to adjust his medicines or dietary intake.

On the other hand, your husband’s irritability can be a manifestation of depression. Many people with depression are undiagnosed and thus do not receive the necessary counseling and treatment. Also, depression symptoms vary from person to person, which can make it difficult to diagnose. Signs such as lack of sleep, overeating or lack of appetite, poor concentration, and other symptoms help in the diagnosis of depression.

In any case, depressed individuals have difficulty with the demands of daily diabetes care. This turns into a cycle of poor glucose control leading to depression, and depression causing further glucose abnormality.

There are other reasons that can cause behavioral changes like those you describe. Your husband’s doctor might shed better light on these possibilities.

Carbohydrates in the Diabetes Diet

Carbs count in a diabetes diet because they directly affect blood glucose levels. If you're not producing enough insulin to regulate those levels, serious medical issues can develop. When you have diabetes, following a careful diabetes diet is a key aspect of diabetes management, and controlling carbohydrate intake is an essential part.

Along with proteins and fats, carbohydrates are one of the three major components of food. Your body converts carbohydrates into glucose, which your cells burn for energy. Since glucose is transported to cells through your bloodstream, eating carbohydrates will cause your blood glucose level to increase.

Because carbohydrates directly affect your blood sugar level, eating too many carbs — or the wrong sort of carbs — can undo whatever other actions you’re taking to keep your diabetes in check.

How Carbs Affect Different Diabetes Types

It's important to control your carbohydrate intake no matter which of the three major forms of diabetes you have:

Type 1 diabetes. If you have this type of diabetes, you cannot produce insulin, a hormone that helps cells use glucose. That means you must take insulin and other medication to regulate blood sugar. A healthy diabetes diet with controlled carbohydrate intake will make it easier to predict when you will need to administer insulin and how much to use.Type 2 diabetes. People with type 2 diabetes have developed a resistance to insulin, often due to obesity or poor diet. By maintaining steady blood sugar levels through carb counting, you may be able to reduce the amount of insulin or medication you need or avoid taking the drugs altogether.Gestational diabetes. If you develop diabetes during pregnancy, you need to count carbs because unchecked blood sugar levels can damage the fetus as well as your own body. Diabetes Management: Carbs and the Diabetes Diet

There are three main types of carbohydrates:

Sugars, often called simple carbohydrates, are converted quickly to glucose. Think of them as dry wood in a fire, burning fast and hot.
Starches, often called complex carbohydrates, are formed by long chains of sugars and take longer for your body to break down into glucose. Think of them as big logs that burn slowly in a fire.
Fiber is present in different amounts in all plant-based foods, especially in whole grains (starches). It’s great for digestive health, but because it isn’t digested the way the other two types of carbs are, fiber grams don’t count in your carb totals.
People with diabetes need to count all the starch and sugar carbohydrates they take in every day as part of their diabetes management plan. The American Diabetes Association recommends that diabetics eat around 45 to 60 grams of carbohydrates per meal, although you should consult with your diabetes care team to determine the right amount of carbohydrates to fit your needs and lifestyle.

Most of your carbohydrates should come in the form of starchy carbohydrates, which will convert into glucose more slowly and help your blood sugar remain steady. Healthy choices include whole grains, beans, and lentils, and starchy vegetables like peas, corn, and potatoes. Avoid refined starches like white flour or white rice, as they tend to burn as fast as sugars.

Some of your carbohydrates still can come in the form of sugars, particularly if they are natural sugars in healthy foods like low-fat dairy products, fruits, or vegetables. Just avoid added sugars such as table sugar and the high-fructose corn syrup and other types of sugars you’ll find in sodas, sweets, and other processed foods.

To keep track of your carbohydrates, you need to read the nutrition facts label included on most packaged foods. Check out the serving size to figure out how much constitutes one serving, and then scan down to find the total amount of carbs contained in a serving. Usually, the label also will show how many of those carbs are sugars and how many are dietary fiber, which helps to slow the release of sugar. Always read the ingredient label closely because product names can be deceiving — for instance, you may find a number of different forms of sugar in a processed food that isn’t even a sweet.

You need to be a part-time detective to find out all the facts about carbs, but your undercover work will make it much easier to manage diabetes.

By Dennis Thompson Jr.
Medically reviewed by Lindsey Marcellin, MD, MPH

10 States With the Deadliest Eating Habits

Americans are fat and getting fatter by the year. Recent data reported in medical journal Lancet showed that BMI (Body Mass Index), a recognized measurement of obesity, is higher on average in America than in any other nation.

The obesity problem, however, is international. The report in Lancet states that "In 2008, 9.8 percent of the world's male population were obese, as were 13.8 percent of women. In 1980, these rates were 4.8 percent and 7.9 percent." U.S. eating habits and diets have been exported, many experts say. Nations which before had relatively lean diets which were high in grains and fruits now consume many more soft drinks and hamburgers.

This trend toward poorer diets has caused obesity to be the most written-about health problem in the United States. Fat Americans are more likely to have diabetes, coronary artery disease, strokes and certain forms of cancer. Less well reported are links between obesity and dementia, obesity and postmenopausal estrogen receptors, and obesity and social status. Thin people, apparently, are more likely to be chief executives and billionaires. The problem of obesity is so acute that the number of studies about its causes and solutions grows by the day. The journal Health Affairs reported last year that overall obesity-related health spending reached $147 billion in the U.S., about double what it was a decade earlier.

Like so many other issues where data are collected in the public sector and the information is used to solve problems nationwide, the problems are local. 24/7 Wall St. looked at a number of factors which cause unhealthy diets and resulting obesity. These include income, access to healthy food sources, the ability to pay for healthy food, the concentration of fast food outlets, and the consumption of fruits, vegetables, sugar, fat and soft drinks. The levels of healthy eating defined with these parameters varies wildly from state-to-state. That means there is not likely to be any one set of solutions created and funded at the federal level to solve the problem. Just as education results and their causes are hyper-local, so are the habits that cause unhealthy diets and their results. That makes the problem harder to solve. Congress cannot mandate how many McDonald's can be built within any hundred square mile area, or, if it could, McDonald's would object.

The data on poor eating habits and obesity are abundant and unusually well-researched. Congress funded a nationwide report which was called "Access to Affordable and Nutritious Food -- Measuring and Understanding Food Desserts and Their Consequences." The information contained in this report includes the number of households who do not have access to cars and probably find it difficult to go to grocery stores frequently. The USDA keeps in-depth statistics on concentration of grocery stores. The Census Bureau tracks fast food expenditures per capita. The U.S. Department of Health and Human Services follows consumption of fruits and vegetables. 24/7 made its state rankings based on grocery stores per 1,000 residents, amount spent on fast food per capita, gallons of soft drinks purchased per capita and pounds of sweet snacks purchased per capita. We also took into account information provided about poverty levels, obesity and other factors directly related to unhealthy diets.

It is worth mentioning again how complex and local the obesity and eating habit problem is. This does not mean that the problems are insoluble, but nearly so. The issue of fat Americans is one that almost needs to be addressed house-to-house.

10. New Mexico

Grocery Stores Per 1,000 Residents: 0.26 (23rd)
Amount Spent on Fast Food Per Capita: $737 (8th most)
Gallons of Soft Drinks Purchased Per Capita: 58 (12th least)
Pounds of Sweet Snacks Purchased Per Capita: 111 (13th least)

New Mexico's worst rankings occur in two metrics. It has the 44th-greatest percentage of households without a car that are more than 10 miles from a supermarket or grocery store and the 44th-greatest percentage of population that has low income and is more than 10 miles from a supermarket or grocery store, according to the United States Department of Ag1riculture. These metrics are significant because they suggest a lack of access to affordable and nutritious food. Residents may rely on fast food restaurants and convenience stores instead. New Mexico has the eighth-greatest amount of money spent on fast food per capita among all the states considered.

9. Arizona

Grocery Stores Per 1,000 Residents: 0.17 (47th)
Amount Spent on Fast Food Per Capita: $761 (4th most)
Gallons of Soft Drinks Purchased Per Capita: 60 (21st least)
Pounds of Sweet Snacks Purchased Per Capita: 109 (11th least)

Arizona has the second-fewest grocery stores per person, with only 0.17 for every 1,000 people. This illustrates a major restriction on healthy food access for one of the country's fastest growing states. One of the ways in which residents of Arizona are supplementing their diets is with fast food. Arizonans spent an average of $760.50 each on fast food in 2007, the fourth-greatest amount among the states.

8. Ohio

Grocery Stores Per 1,000 Residents: 0.18 (45th)
Amount Spent on Fast Food Per Capita: $622 (20th least)
Gallons of Soft Drinks Purchased Per Capita: 70 (11th most)
Pounds of Sweet Snacks Purchased Per Capita: 122 (10th most)

Because a large part of Ohio's poor population is located in major urban centers like Cleveland and Cincinnati, the state ranks well in regards to access to grocery stores among the poor. However, the state ranks third-worst in store availability across all income classes at 0.18 locations per 1,000 people, compared to 0.6 in first place North Dakota. Ohio's population has the 11th-greatest consumption of soft drinks, and top-10 highest consumption of both sweet snacks and solid fats. As a result of these poor diets, Ohio has an adult diabetes occurrence of over 10%, which is the 11th-worst rate in the country.

7. South Dakota

Grocery Stores Per 1,000 Residents: 0.5 (4th)
Amount Spent on Fast Food Per Capita: $547 (9th least)
Gallons of Soft Drinks Purchased Per Capita: 64 (23rd least)
Pounds of Sweet Snacks Purchased Per Capita: 122 (8th most)

South Dakota has the fifth-smallest population in the country, and yet, it is the 17th-largest state in terms of geographic area. As a result, many residents have limited access to affordable and nutritious food. In fact, South Dakota has the greatest percentage of households with no car and which are more than 10 miles from a supermarket or grocery store, as well as the greatest percentage of low-income households which are more than 10 miles from a supermarket or grocery store. Only 10.1% of adults in South Dakota consume the U.S. Department of Health and Human Services' recommended two or more fruits and three or more vegetables per day, compared to the national average of 14%. This is the fifth-worst rate in the nation.

6. Nevada

Grocery Stores Per 1,000 Residents: 0.23 (29th)
Amount Spent on Fast Food Per Capita: $939 (most)
Gallons of Soft Drinks Purchased Per Capita: 58 (10th least)
Pounds of Sweet Snacks Purchased Per Capita: 114 (19th least)

Nevada spends the most per capita on fast food -- nearly $940 per person per year. This is roughly 25% more than Texas, the second-worst state, and well more than twice what Vermont residents spend. As might be expected, the state ranks in the bottom 10 for both households with no cars and low-income populations, defined as people with income less than 200 percent of the federal poverty thresholds, and proximity to grocery stores. Nevada's obesity and diabetes rates, are above average.

5. Oklahoma

Grocery Stores Per 1,000 Residents: 0.25 (24th)
Amount Spent on Fast Food Per Capita: $676 (15th most)
Gallons of Soft Drinks Purchased Per Capita: 69.8 (8th most)
Pounds of Sweet Snacks Purchased Per Capita: 103.2 (3rd least)

The rate of household-level food insecurity, including households with food access problems as well as households that experience disruptions in their food intake patterns due to inadequate resources for food, is 15.2% in Oklahoma. The national rate is 13.5%. Oklahoma also has the third-lowest rate of adults who meet the recommended two fruit/three vegetable daily intake, with only 9.3% of adults doing so. Perhaps this is part of the reason Oklahoma's obesity rate is 31.4%, the fifth-worst in the country.

4. Kansas

Grocery Stores Per 1,000 Residents: 0.35 (7th)
Amount Spent on Fast Food Per Capita: $610 (19th least)
Gallons of Soft Drinks Purchased Per Capita: 64 (23rd most)
Pounds of Sweet Snacks Purchased Per Capita: 121 (12th most)

Kansas has some of the easiest access (seventh-best) to stores where cheap and healthy food is available. It is clear, however, that most residents do not take advantage of this, as the state has one of the worst diets in the country. Residents consume the 12th-most sweet snacks per person as well as the 12th-most solid fats -- more than 20 pounds per person. The state ranks 28th in adult diabetes and 31st in obesity -- 28% of the state's adults are considered overweight.

3. Missouri

Grocery Stores Per 1,000 Residents: 0.26 (22nd)
Amount Spent on Fast Food Per Capita: $623 (21st least)
Gallons of Soft Drinks Purchased Per Capita: 65 (18th highest)
Pounds of Sweet Snacks Purchased Per Capita: 121 (17th most)

Missouri does not rank especially poor in any of the metrics considered, however it does rank badly in about almost every one. It has the 11th-lowest rates of adults eating the recommended amount of fruits and vegetables, the eighth-greatest rate of food insecurity, and relatively high rates of soft drink, sweet snack and solid fats consumption. Missouri has the ninth-worst rate of obesity among adults, with 30% having a body mass index greater than 30.

2. Alabama

Grocery Stores Per 1,000 Residents: 0.21 (37th)
Amount Spent on Fast Food Per Capita: $649 (23rd most)
Gallons of Soft Drinks Purchased Per Capita: 77 (4th most)
Pounds of Sweet Snacks Purchased Per Capita: 113 (16th least)

Alabama residents consume 77 gallons of soft drinks per capita per year, the fourth-highest amount in the country. This is roughly 33% more than Oregon, which consumes the least. Soft drinks like cola have more sugar per ounce than nearly any other food we regularly consume, and it is clear that soda has helped contribute to Alabama's poor health outcomes. The state has the seventh-highest obesity rate and, predictably, the second-worst diabetes rate. More than 12% of the state's adult population has the disease.

1. Mississippi

Grocery Stores Per 1,000 Residents: 0.21 (34th)
Amount Spent on Fast Food Per Capita: $588 (17th least)
Gallons of Soft Drinks Purchased Per Capita: 82 (most)
Pounds of Sweet Snacks Purchased Per Capita: 113 (17th least)

Mississippi has the worst eating habits in the country. Only 8.8% of the adult population eats the recommended amount of daily fruits and vegetables, the lowest rate in the country. Residents consumed just under 82 gallons of soft drinks per capita in 2006, the greatest amount reported. Furthermore, the state has the third-highest rate of household-level food insecurity, with 17.1% of households being affected. It is perhaps unsurprising, then, that the state has the highest rates of both adult diabetes (12.8%) and adult obesity (34.4%).

by Charles B. Stockdale, Douglas A. McIntyre and Michael B. Sauter
Wednesday, February 9, 2011

Researchers Uncover Potential Breakthrough Cure for Type 1 Diabetes

"We've all been brought up to think insulin is the all-powerful hormone without which life is impossible, but that isn't the case," says Dr. Roger Unger from UT Southwestern Medical Center....

In this published study, UT Southerwestern Medical Center researchers obtained normal blood sugars when they prevented the release of glucagon from the liver and the release of insulin from the beta-cells.

The new findings suggest that Type 1 diabetes could be converted to an asymptomatic, non-insulin-dependent disorder by eliminating the actions of a specific hormone.

As we have learned from the thousands of diabetes studies and the coming and going of cures for diabetes, there are many mechanisms and reactions involved in the conversion of glucose to energy, so caution needs to be taken with the results of this study, until it can be duplicated especially in human subjects.

Scientists at UT Southwestern Medical Center studied the hormone glucagon, which prevents low blood sugar in healthy people and causes high blood sugar in people with Type 1 diabetes. When glucagon was suppressed in mice, the hormone insulin became unimportant. Glucose tolerance returned to normal.


These findings in mice show that insulin becomes completely superfluous and its absence does not cause diabetes or any other abnormality when the actions of glucagon are suppressed. Glucagon, a hormone produced by the pancreas, prevents low blood sugar levels in healthy individuals. It causes high blood sugar in people with Type 1 diabetes.

Dr. Unger, professor of internal medicine and senior author of the study stated that, "We've all been brought up to think insulin is the all-powerful hormone without which life is impossible, but that isn't the case." "If diabetes is defined as restoration of glucose homeostasis to normal, then this treatment can perhaps be considered very close to a 'cure.'"

Insulin treatment has been the gold standard for Type 1 diabetes (insulin-dependent diabetes) in humans since its discovery in 1922. But even optimal regulation of Type 1 diabetes with insulin alone cannot restore normal glucose tolerance. These new findings demonstrate that the elimination of glucagon action restores glucose tolerance to normal.

Normally, glucagon is released when the glucose, or sugar, level in the blood is low. In insulin deficiency, however, glucagon levels are inappropriately high and cause the liver to release excessive amounts of glucose into the bloodstream. This action is opposed by insulin, which directs the body's cells to remove sugar from the bloodstream.

Dr. Unger's laboratory research previously found that insulin's benefit resulted from its suppression of glucagon.

In Type 1 diabetes, which affects about 1 million people in the U.S., the pancreatic islet cells that produce insulin are destroyed. As a countermeasure to this destruction, Type 1 diabetics currently must take insulin multiple times a day to metabolize blood sugar, regulate blood-sugar levels and prevent diabetic coma. They also must adhere to strict dietary restrictions.

In this study, UT Southwestern scientists tested how mice genetically altered to lack working glucagon receptors responded to an oral glucose tolerance test. The test -- which can be used to diagnose diabetes, gestational diabetes and prediabetes -- measures the body's ability to metabolize, or clear, glucose from the bloodstream.

The researchers found that the mice with normal insulin production but without functioning glucagon receptors responded normally to the test. The mice also responded normally when their insulin-producing beta cells were destroyed. The mice had no insulin or glucagon action, but they did not develop diabetes.

"These findings suggest that if there is no glucagon, it doesn't matter if you don't have insulin," said Dr. Unger, who is also a physician at the Dallas VA Medical Center. "This does not mean insulin is unimportant. It is essential for normal growth and development from neonatal to adulthood. But in adulthood, at least with respect to glucose metabolism, the role of insulin is to control glucagon.

"And if you don't have glucagon, then you don't need insulin."

Dr. Young Lee, assistant professor of internal medicine at UT Southwestern and lead author of the study, said the next step is to determine the mechanism behind this result.

"Hopefully, these findings will someday help those with Type 1 diabetes," Dr. Lee said. "If we can find a way to block the actions of glucagon in humans, then maybe we can minimize the need for insulin therapy."

Dr. Unger said anything that reduces the need for injected insulin is a positive.

"Matching the high insulin levels needed to reach glucagon cells with insulin injections is possible only with amounts that are excessive for other tissues," he said. "Peripherally injected insulin cannot accurately duplicate the normal process by which the body produces and distributes insulin. If these latest findings were to work in humans, injected insulin would no longer be necessary for people with Type 1 diabetes."

Dr. May-Yun Wang, assistant professor of internal medicine at UT Southwestern, and researchers from the Albert Einstein College of Medicine also contributed to the work. The study was supported in part by the VA North Texas Health Care System, the American Diabetes Association and the National Institutes of Health.

Diabetes January 26, 2011 vol. 60 no. 2 391-397

Walk Your Way to Fitness

A regular walking workout can benefit your overall health. Find out why fitness walking is so important and how you can get started. If you’re like most people, you walk just under three miles every day in the course of your normal activities. Now it’s time to get a little more purposeful. The Centers for Disease Control and Prevention, the American College of Sports Medicine, and the Surgeon General all agree that at least 30 minutes of brisk physical exercise is good for your health, and walking is one of the easiest forms of exercise to get.

Some of the many benefits of a regular walking workout include:

Cardiovascular health. Fitness walking strengthens your heart, improves your circulation, and lowers your blood pressure. A study published in The New England Journal of Medicine evaluated 73,743 postmenopausal women enrolled in the Women's Health Initiative Observational Study and found that women who walked briskly 2.5 hours every week reduced their chance of heart disease by 30 percent.Bone health. As a weight-bearing exercise, walking can stop some of the bone loss of osteoporosis and may slow down arthritis.Weight loss. A regular walking workout burns calories. If you walk 4 miles four times a week, you can walk off about a half-pound of fat every month. Weight loss combined with a healthy diet can also decrease your risk of type 2 diabetes.Mental health. Studies show that fitness walking reduces stress and improves your overall sense of emotional well-being. A regular walking workout can help you enjoy deeper, more restful sleep, which may decrease your risk for anxiety and depression. How to Start Your Walking Workout

The speed and distance of your walking workout are not as important as the time you spend walking at a brisk pace. If you have any health issues talk to your doctor first and find out what is a safe pace for you. Start gradually and walk only as far and as long as is comfortable. Follow these fitness walking guidelines:

Work up to at least 30 minutes of brisk walking a day.
Warm up by walking at your normal pace for about 5 minutes and then pick up the pace for about 15 minutes.
While you walk, swing your arms and maintain good posture.
Take long strides, but don't strain yourself.
Slow down at the end of your walk and do some gentle stretching.
Every week you should try to add about 5 more minutes to the brisk part of your walking workout until you can get it to over 30 minutes.

By Chris Iliades, MD
Medically reviewed by Christine Wilmsen Craig, MD

Is There a 'Safe' Blood Sugar Level?

Q: What is the "safe" blood sugar level? I have heard several opinions from other diabetics, and I am very confused. I was told that it was 154 about a year ago, and my doctor didn't recommend daily monitoring. At one time on a morning fasting, my level was 74.

— Theresa,

A: Yes, there is a safe blood sugar level. It is the optimum range that safely provides the body with adequate amounts of energy. For the average person, it is 70 to 105 mg/dl in a fasting state. (Diabetes is diagnosed when the fasting blood glucose level is at or above 126 mg/dl.)

Glucose values vary depending on the time of day, your activity level, and your diet. Your sugar level of 154 mg/dl, which is high, may not have been determined while you were fasting. If it had been, a physician would have repeated the test. Your doctor did, and your level was determined to be normal at 74 mg/dl.

In this case, daily monitoring is probably not necessary. If your levels are elevated in the future, you will be diagnosed with diabetes. Treatment can include lifestyle modification, diet, and exercise. If these strategies are not adequate to control your blood glucose level, your physician may prescribe oral medicines or insulin. Having a laboratory examination during your yearly physical and maintaining a healthy lifestyle are adequate for now.

Why is it important to keep your glucose level within a normal range? An excess of glucose in the bloodstream causes various chemical changes that lead to damage to our blood vessels, nerves, and cells. Each cell in the body has a function that requires energy, and this energy comes primarily from glucose. The energy allows you to perform various tasks, including talking and walking. It allows your heart to beat and your brain to produce chemicals and signals that help you think, breathe, regulate your internal temperature, and digest and absorb food. The body is a veritable industrial complex! But this complex is also quite delicately balanced. The very cells that process glucose and convert it to energy can be damaged by excess glucose. Imagine a car engine being damaged when it is flooded with gasoline.

A lack of glucose is also extremely detrimental to the body and can have serious consequences — including death. Without a source of energy to fuel the vital functions of the body, these functions cease.

Good luck with your blood glucose management, and don't hesitate to ask your doctor about ways to maintain and improve your health.

Warding Off Muscle Cramps As We Age

If you're over 65, you probably know what a "charley horse" is. You may have gotten them during strenuous exercise as a younger person. But in older age, muscle cramps can be unlike any you've ever had before. That's because like so many other things in our bodies, our muscles and nerves wear out and function less effectively as we age.

"A cramp is a sudden painful contraction of a muscle that becomes rock hard," says Dr. Robert Miller, a neurologist who specializes in muscle cramps at the California Pacific Medical Center and teaches at University of California, San Francisco. "The muscle goes into a spasm and squeezes all the little nerve endings inside the muscle, and creates pain, and definitely ... gets your attention until you do something about it."

Uncontrollable Muscle Spasms

For Ken Holladay, 71, his muscle cramps started off mild and irregular. At first, he got them once every few weeks, but then they started to get more frequent. Eventually, they occurred every single night — often twice, between 2 a.m. and 6 a.m. It was a painful version of a charley horse, only it was in his feet and toes: "The big toe was at 90 degrees to the bottom of the foot; put your foot on the floor, and this big toe would be pointing straight up toward the ceiling; and I don't believe you can voluntarily pull a big toe that high."

Keeping Your Feet Happy
But as it turns out, your muscles can, all on their own. Holladay says that one time his toe actually curled down, "and I leapt out of bed to try and get rid of the pain and landed on that toe and broke the toe, broke the bone underneath that big toe, broke the toenail off." It was terrible, he says.

And since the cramps typically occurred twice every night, it was impossible to get a good night's sleep or feel well-rested during the day. But that's not what drove Holladay to seek treatment. What really scared him, he says, was the possibility that, as he got older, he might become bedridden due to disease or injury. If that happened, Holladay says, he wouldn't be able to get out of bed and walk, stretch and flex his muscles. He would just have to lie there, in terrible pain.

It was too scary a thought.

Searching For Treatment
So, Holladay went searching for help and treatment. First his doctor had to determine whether the spasms were an indicator of any other muscle or nerve degenerative disease, like ALS. With that established, Holladay tried a number of potential treatments: acupuncture, and then prescription quinine, which has since been taken off the market as a treatment for muscle cramps due to concerns about side effects. Neither one worked.

Finally he drove over an hour to see Dr. Yuen So, director of the neurology clinic at Stanford University. As it turned out, So and colleagues had just finished an evidence-based review of treatments for muscle cramps. Unfortunately, they turned up little. There were hundreds of studies but no conclusive or compelling evidence that any particular treatment would work for all or even most patients.

Dr. Hans Katzberg headed the review. Katzberg says some treatments held promise, including a certain type of calcium channel blocker used to treat blood pressure, as well as Vitamin B complex. Even with them, however, results were not convincing. "We were surprised to find out how little is documented in the treatment of cramps," says So. "A lot we do in medicine is based on anecdotal experience, and in this case, a lot of the treatments we use fall into the unproven category."

For Holladay, So ended up prescribing an anti-seizure medication. The meds worked.

"After a week or two, no cramps. After a month or two, no cramps," Holladay says. It was miraculous, he says, and he can't speak highly enough of the neurology department at Stanford or of Dr. So.

Keeping Spasms At Bay
Even though things eventually worked out for Holladay, that's not the case for many patients who suffer severe nighttime muscle cramps. According to UCSF neurologist Miller, older people are at greater risk for cramps simply because of their age. Nerves control muscles, and nerves just wear out.

"As we age, there are changes in both nerves and muscles. Muscles get more weak and small. And nerves undergo some decay, with the tissue becoming thin. And when that happens, the connections that the nerves make to the muscle become less secure."

And cramps occur at the place where nerves meet muscle, says Miller. When the brain sends the signal for the muscle to move, "the signal does have to cross through tiny nerve twigs, or nerve terminals." Excessive signaling, excessive irritability — which may result from thinning and weakened nerves — seems to be the generator for cramping.

At 68, Miller is a candidate for cramps himself. But he keeps them at bay, he says, by eating a banana a day and drinking lots of water. The banana provides electrolytes with its magnesium, potassium and calcium. The water provides fluid. Fluid and electrolytes, says Miller, while not proved to decrease muscle cramps, do seem to help by keeping nerve pathways healthy.

And Miller also benefits from stretching, doing weekly yoga and daily bike riding. Every day, he traverses San Francisco's hills for a total of two hours back and forth to work, "stretching my calf muscles and hamstring muscles by standing up on the pedals and stretching first one and then the other." Stretching is a tried-and-true cure for muscle cramps by pretty much any sufferer's description, says Miller, despite the lack of scientific evidence.

Charles Woodson, Donald Driver suffer injuries, but Super Bowl XLV victory helps ease the pain

ARLINGTON, Tex. - Charles Woodson waited eight long years to get a second chance to win a Super Bowl and he hated having to stand on the sidelines and watch it happen. "It was very hard to watch," Woodson said afterward. "But not anymore."

The agony of injuries was replaced by the unrestrained joy of a long-awaited championship for the 34-year-old Woodson and 36-year-old Donald Driver, both of whom were knocked out of Super Bowl XLV in the first half. Woodson broke his collarbone. Driver suffered a high ankle sprain.

Both of them were standing helplessly on the sidelines when the Packers finally put away the Steelers, 31-25.

"It was very hard," Driver said. "I went in at halftime and the doctor told me that we were going to try to tape it up and see if I could go. I couldn't jump on it anymore and he told me I was done, even though I felt like I could still go. He said, 'No good.'

"Sometimes you have to follow what the doctor says. I followed the doctor's orders."

While Driver, the Packers' receiver, was trying to finagle his way back onto the field, Woodson already knew he was out. So the cornerback and captain instead delivered some inspirational words.

"I told the guys before they went back out, they understand how much I wanted it," Woodson said. "I was pretty emotional so I didn't get a whole lot out, but just to tell them to get it done. And they did."

Woodson was still in pain after the game, but he said, "I'm a champ, so it doesn't matter. World champion. That's what it's all about."

RINGING IT IN
How confident were the Packers? On Saturday, coach Mike McCarthy had the team fitted for its championship rings.

"It's a pretty quiet process," Packers guard Daryn Colledge said. "It's a ring fitting like you probably did for your own wedding ring. I think it just sets that mental mind-set that you've got to go out there and you've got something to accomplish."

BAD IDEA
Before Rashard Mendenhall's fourth-quarter fumble swung the momentum back to the Packers, Steelers coach Mike Tomlin nearly did so when he decided to have Shaun Suisham try a 52-yard field goal with 4:29 left in the third quarter and the Steelers trailing 21-17.

He missed badly, wide left, giving the Packers the ball near midfield. The Steelers dodged the bullet when the Packers were forced to punt. "That was a terrible decision by me in hindsight," Tomlin admitted. "That wasn't even close."

NUMBERS GAME
The NFL announced the attendance as 91,060, including those outside the stadium in the Party Plaza. It also took the unusual step of announcing there were 12,159 "credentialed" people at the game, including media, workers and league officials. That brought the "total" to 103,219.

No word on whether that included the 400 unlucky people who bought $800 tickets to the game, but were left without seats because several sections of temporary seating weren't completed in time.

PACK GETS THE JUMP
The Packers have scored first in all five Super Bowl appearances.... The Packers had 50 rushing yards - second-fewest ever for a Super Bowl-winning team. The St. Louis Rams had just 29 in Super Bowl XXIV. ... Had the Steelers rallied from a 21-3 deficit, it would've been the largest comeback in Super Bowl history. The record is 10 points, twice, including by the New Orleans Saints last year.

PAIN REIGNS
Steelers rookie wide receiver Emmanuel Sanders was carted off the field in the second quarter with a foot injury. He was placed in a walking boot and didn't return. Pittsburgh cornerback Bryant McFadden (hip) and right tackle Flozell Adams (left shoulder) left the game for a short time in the first half before returning.

HAVING THEIR PHIL
In what is fast becoming a ritual for the Steelers, Mike Tomlin had his team listen to a CD of Phil Collins' "In the Air Tonight" on Saturday night to visualize its goals, as Tomlin had before the AFC title game. Asked about Tomlin's message, one player told the NFL Network, "Nothing much actually. Phil Collins runs the meeting."

The Packers, on the other hand, had motivational speaker Kevin Elko address them on Saturday night.

The Growing Problem of Childhood Obesity

With childhood obesity starting at ever-younger ages, it's never too soon to educate kids about a healthy diet. Learn about creating an obesity-fighting diet for your children at home and at school. Childhood obesity is a growing problem. Figuring out how to help your children eat a healthy diet and avoid obesity may be challenging, especially in the face of favorite high-calorie snacks, finger foods, and sugary drinks. But the stakes are high: A recent study of 3,098 children between 3 and 6 years old showed that excess weight causes an increase in heart disease risk factors even in toddlerhood.

“Obesity has increased from 5 percent in the 1970s to 12.4 percent today in preschoolers ages 2 to 5. In children ages 6 to 11, it went from 4 percent to 17 percent and the 12- to 19-year-olds, from 6 to 17.6 percent,” says Leah Holbrook MS, RD, clinical instructor of family medicine and Heart Links project coordinator for the department of family medicine at SUNY Stony Brook in Stony Brook, N.Y.

It’s never too soon to stress healthy eating — recent research suggests that the trend toward obesity may begin as early as the first six months of life.

Childhood Obesity: Helping Children Lose Weight at Home

You may be tempted to turn to popular commercial diets for guidance, but Holbrook advises caution. Children and teens are still growing, so the calorie or nutrition restrictions in commercial adult diets may not be good options for younger bodies, Holbrook says. A guide to healthy diets can be found at the USDA’s My Pyramid for Kids. But if you are not sure how to apply those ideas, Holbrook advises talking to your doctor.

Holbrook offers these tips to help fight childhood obesity:

Toss the sweet drinks. Sugary drinks such as soda, sweet tea, juice, and sweetened milk are a major source of unnecessary calories in the diet. Offer plain, low-fat milk or water instead.

Eat at home more. “When you eat out, you almost always get more calories and fat than if you eat at home,” says Holbrook, who adds that there is also a lot of value in spending time together making and eating meals.

Exercise together. A family walk, bike ride, or romp in the park can help set a healthy tone for everyone. Children should have an hour of physical activity a day, says Holbrook.

Talk to kids about healthy food choices. Educate your children about healthy diet issues such as correct portion sizes and why whole-grain crackers, fruits, vegetables, and low-fat dairy snacks are better than cookies, candy bars, or potato chips — and follow through by keeping these healthy snacks available at home.

Consider other family issues. If you are struggling with stress and parenting overall, you may need to ask for help. A recent study of 2,400 toddlers and their mothers showed a 50 percent greater risk of obesity among children whose mothers who said they were often too overwhelmed to express love or make sure their child got necessary medical care.

Childhood Obesity: Helping Children Lose Weight at School

It is equally important for parents to make their concerns known at the school or daycare facility where their children eat one or more meals, plus snacks, every day. Policy changes that require healthier foods in the cafeteria and vending machines at these locations have been shown to help children control their weight, according to Holbrook.

“Parents are really integral in making these policies work. If they are not supportive of these policies, the school districts won’t pursue them. And as long as the adults are on board, the kids don’t seem to mind,” says Holbrook.

If your school system or daycare provider is slow to change, you may have to work with your child to create healthy, filling brown-bag lunch and snack options for them to take to school. But with information and support, you and your children can fight obesity.

By Madeline Vann, MPH
Medically reviewed by Christine Wilmsen Craig, MD

Motivating a Teen With Type 1 Diabetes

Q: My 16-year-old son is having difficulty staying motivated to consistently take care of his diabetic needs like checking his blood sugar often and keeping a log book. His doctor hospitalized him at the start of school to establish better control — his first hospitalization since diagnosis with type 1 10 years ago. He is active in sports, likes to stay up late, eats only 15 to 30 carbs for breakfast, and is on a regimen of Lantus twice daily and Humalog for meals and highs (injections, no pump.) His last A1c was 10.3. Do you have suggestions for helping him be motivated to care for himself?
— Janelle

A:
That's a tough situation indeed. Many of my colleagues who care for teenaged patients have similar moments of exasperation. As you know so well, the teen years are filled with layers of complexities for kids themselves and their families. There are many issues that become priorities in any teenager's life, among them the challenges presented by their own growth and development. These issues become even more complicated for a teenager with diabetes.

Adolescence is a time of great change, and with physical growth come greater insulin requirements. And with rebellion, experimentation and the need for peer acceptance comes greater non-adherence. In addition, while trying to find and assert their own identity, teens become less reliant on mom and dad. The challenge for parents is equally great and the solutions, unfortunately, are usually time-consuming and labor-intensive.

Your son is doing certain things for which he should be congratulated, including getting involved in sports, carbohydrate counting and injecting his insulin several times a day. These are feats that many of my adult patients do not accomplish. Motivating your son further might require one or more of the following:

1.Understanding his attitude towards frequent glucose checks and his coping and problem-solving skills will help you in identifying specific ways to help him change his behavior.

2.Assessing his knowledge-base about the need to check his sugar levels and his knowledge of glucose and insulin balance during athletic engagements can identify gaps, which can be easily addressed.

3.Understanding his priorities and academic responsibilities and showing empathy to these daily challenges can help you provide a structure that is conducive to checking blood glucose levels and diabetes self-management.

4.Exploring the barriers of checking his sugar level at school, as well as the challenges he might face from his peers about having diabetes, doing frequent glucose checks and injecting insulin, might uncover issues that he finds difficult to discuss. Since you live in a small town, there might not be many other kids living with diabetes. Perhaps your son can connect with other kids with diabetes via the Internet for peer support. A good place to start is the American Diabetes Association.

5.More importantly, understanding your communication pattern with your son and assessing its effectiveness will help you find a happy medium between too much involvement and too little engagement. Empathy is important, but so is leaving him room to make his own decisions. In other words, asking him how he can meet the challenge of good glucose control might also be more effective than telling him to make a specific change in his behavior.

6.When exploring these areas, you should enlist the help of your son's doctor as well as a psychologist or diabetes educator in your area. In addition, if you find that there are barriers at school that prevent your son from checking glucose, you should involve the school and teachers. Some teens like taking leadership roles in teaching others about diabetes, advocating for students with diabetes and organizing groups. This gives them the motivation for also managing their diabetes better. Teachers can be recruited to stage such a forum for your son and perhaps other teens. Other possible venues you might explore include religious organizations, social clubs, and community fitness centers.

Finally, this might be time to consider the insulin pump, which many teens like because it allows them better control. I wish you much luck and hope you will write back with further questions or to tell us how you and your son are doing.

Exploring The Potential Of Procedures That Address Venous Ulcer Etiology

The complexity of venous ulcerations leads to prolonged healing and doubt. Clinicians have traditionally treated venous wounds with debridement, multi-layer compression dressings and skin grafts.

Most of the literature focuses on various topical ointments, the use of allogenic grafting, compression therapies, etc. Unfortunately, there is little research on addressing the etiology of venous wounds. Understanding and treating the etiology in all aspects of medicine is imperative in order to achieve a successful result.

Venous insufficiency is a condition in which veins do not adequately return blood back to the central system. In the lower extremity, both the superficial and deep vein systems of the legs utilize valves to ensure cephalad flow. The deep vein system also uses muscular contraction to assist in pumping the blood upward. A perforating vein is a vein that penetrates a fascial plane and may connect the superficial venous system to the deep vein system or connect greater saphenous veins to small saphenous veins.

Over time, various risks factors such as heredity, hormones, pregnancy and prolonged standing cause the smooth muscle in the vein’s wall to relax. When this occurs, there is an inability of the vein valves to approximate. In the legs, the normal flow opposes gravity. However, with insufficiency, the blood refluxes and backflow occurs to the ankles. In severe cases, blood pooling leads to edema, hyperpigmentation, loss of skin turgor and ulceration. An ulcer can also occur after a varicose vein opens and causes bleeding.

Consider a patient who presents with a venous ulceration. In most cases, these patients receive wound care and compression therapy. One does not usually perform an ultrasound. Ultrasound is crucial in finding out where the insufficiency lies and which veins lead to the ulceration. It is imperative that the physician or registered vascular technician evaluates both the deep vein and superficial vein systems for reflux. Just scanning the deep vein system for a thrombus would be incomplete and will not identify the pathology involved.

Direct attention to the lower extremities while the patient is standing. Evaluate the deep vein system, including the femoral, popliteal, tibial and peroneal veins, and look for the presence of a thrombus and reflux. In the superficial system, test the greater and small saphenous veins as well as anterior and posterior circumflex and perforating veins.

In general, one should utilize the following guidelines to identify insufficiency in the superficial system: a greater saphenous vein larger than 0.4 cm in diameter, longer than 0.5 seconds of reflux and a small saphenous or perforating vein larger than 0.3 cm in diameter and 0.5 seconds of reflux. If varicosities are present, one can follow the varicosities towards their tributary. This is called vein mapping.

With the presence of a venous ulcer, the ultrasonographer will be able to scan over the ulcer and trace it back to the insufficient vein. The ulcer is usually a direct extension from a superficial varicosity. However, the underlying etiology is a result of insufficiency of the superficial, deep or perforating vein system. By addressing the insufficient vein either through ultrasound guided chemical ablation or endovenous ablation, venous ulcerations heal on an average of four weeks barring that no infection is present.

Key Insights On Ultrasound Guided Chemical Ablation

Ultrasound guided chemical ablation is a treatment in which one injects a sclerosant into the refluxing vein. The two most common sclerosants are sodium tetradecyl sulfate (Sotradecol, Angiodynamics), which recently received FDA approval, and polidocanol (Asclera, Merz). Traditional saline injections are not strong enough to treat large veins and should be reserved for cosmetic spider and reticular veins only.

With ultrasound guidance, inject liquid sclerosant or foam sclerosant (sclerosant mixed with air or CO2) into the insufficient vein. Foam has become widely accepted for its advantages. Foam solution makes more contact with the vein wall due to increased surface area properties, disperses quicker and stays in the vein longer than liquid. Furthermore, one can easily visualize and follow the solution on ultrasound during treatment. With sclerotherapy treatment, the chemical damages the vessel wall. The vein hardens and the body breaks it down. Larger and deeper veins will harden, thicken and shrink but may not disappear altogether.

One does not directly inject the ulceration but rather the insufficient vein along its course. If one performs ultrasound chemical ablation alone, it will take a few treatments before treatment addresses the veins at the ulceration site. Accordingly, this method usually occurs after an ablative procedure. Only perform this treatment on the superficial and perforating vein systems. Do not inject the deep venous system.

A Closer Look At Endovenous Laser Ablation

Endovenous laser or radiofrequency ablation is a procedure that closes the long segment of the insufficient vein. First access the insufficient vein under the guidance of ultrasound. Through the access needle, insert a guide wire. Remove the needle and place a dilator and sheath over the wire and into the vessel. Remove the wire and the dilator, and leave the sheath in the vein. Proceed to instill a fiber optic laser or catheter for radiofrequency. Confirm the placement of the fiber or cathode exiting the end of the sheath. Be sure to avoid superficial/deep vein junctions by at least 1.5 inches.

Then deliver anesthetic agents mixed with saline, creating what is known as a sea of tumescence. After administering adequate anesthetic, remove the sheath along with the laser and/or catheter while delivering laser energy or radiofrequency. One must apply enough laser energy or radiofrequency to the vein in order to create appropriate closure and stop the flow through the insufficient portion. After the procedure, the patient wears compression stockings and bandages over the ulceration for approximately one week.

Follow-up with the patient includes the use of post-procedure ultrasound to confirm the success of the procedure (namely ensuring there is no deep thrombus) and mapping the vein to the ulcerated site.

Perform traditional debridement and have the patient wear compression dressings for two weeks. After the two-week period, if the ulceration has not already healed, ultrasound guided chemical ablation may close any remaining branches of veins that have reflux flow. Do not inject sclerosant directly through the ulceration. It is imperative to treat any and all vessels leading to the ulceration but it is not necessary to treat all superficial vein structures if insufficiency is not present.

Over the course of therapy, the ulceration will decrease in size and the vessels will become hardened. Perform injections every three to four weeks. Four to six sessions may be needed to complete the course of therapy. On ultrasound, these vessels will not be able to compress and there is no filling on color flow Doppler.

Final Thoughts

It is important to note that once an individual has venous insufficiency, it does not go away and may in fact affect other veins. Other veins may become insufficient due to increased load and hypertension, and new vessels can develop. This process is called neovascularization. It is necessary to perform maintenance and follow-up care to ensure a new ulceration does not develop.

Performing procedures to improve and control the chronic venous insufficiency should be the focus of venous ulcer healing. Depending on the size and healing potential of the patient, the wound healing time is significantly shorter. This positively affects all aspects of patient care including increased patient adherence, decreased risk of infection, decreased healthcare costs and more efficient medical care.