Lawrence J. Cheskin

Evidence for exacerbation of irritable bowel syndrome during menses

Many women report that bowel symptoms are associated with menstruation, but neither the prevalence of these complaints nor their physiological basis is known. This study aimed to estimate prevalence, to determine whether patients with irritable bowel syndrome are more likely to make such complaints, and to determine whether bowel complaints during menstruation are attributable to psychological traits such as increased somatization. To estimate prevalence, 369 clients of Planned Parenthood of Maryland were asked whether gas, diarrhea, or constipation occurred during menstruation. These subjects were compared with women referred to a gastroenterology clinic and found to have irritable bowel syndrome or functional bowel disorder (abdominal pain plus altered bowel habits but not satisfying restrictive criteria for irritable bowel syndrome). Thirty-four percent of 233 Planned Parenthood clients who denied symptoms of irritable bowel syndrome or functional bowel disorder reported that menstruation was associated with one or more bowel symptoms. Gastroenterology clinic patients with irritable bowel syndrome were significantly more likely to experience exacerbations of each of these bowel symptoms, but especially increased bowel gas. Self-reports of bowel symptoms during menstruation were not associated with psychological traits or with menses-related changes in affect.

Constipation in the elderly living at home. Definition, prevalence, and relationship to lifestyle and health status.

The prevalence of self‐reported constipation and the factors which contribute to it were investigated in a door‐to‐door survey of 209 people aged 65 to 93. Thirty percent of men and 29% of women described themselves as constipated at least once a month. However, elderly people define constipation differently than do their physicians: only 3% of men and 2% of women in the community sample reported that their average stool frequency was less than three per week, the customary medical criterion for constipation. The primary symptom which elderly people used to define constipation was having to strain in order to defecate. Multiple factors were found to influence self‐reports of constipation. The amount of liquids consumed was significantly related to longest period without a bowel movement in men, but fiber and liquids were not related to self‐reported constipation in either sex. The number of chronic illnesses and the number of nonlaxative medications were significantly related to constipation in women but not men, and the number of psychological symptoms correlated significantly with self‐reports of constipation in both men and women. Age was not significantly related to self‐reported constipation in men or women over the age of 65.

Impact of weight loss on Health-Related Quality of Life

To examine the effect of treatment-induced weight loss on Health-Related Quality of Life (HRQL), 38 mildly-to-moderately overweight persons recruited to participate in a study to examine the efficacy of a lifestyle modification treatment program completed a sociodemographic questionnaire, the Beck Depression Inventory (BDI), the Medical Outcomes Study Short-Form Health Survey (SF-36, as an assessment of HRQL), and underwent a series of clinical evaluations prior to treatment. After baseline evaluations, participants were randomly assigned to either a program of lifestyle physical activity or a program of traditional aerobic activity. Participants again completed the SF-36 and BDI after the 13-week treatment program had ended. Weight loss averaged 8.6 ± 2.8 kg over the 13-week study. We found that weight loss was associated with significantly higher scores (enhanced HRQL), relative to baseline, on the physical functioning, role-physical, general health, vitality and mental health domains of the SF-36. The largest improvements were with respect to the vitality, general health perception and role-physical domains. There were no significant differences between the lifestyle and aerobic activity groups on any of the study measures. These data indicate that, at least in the short-term, weight loss appears to profoundly enhance HRQL.

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high‐income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi‐experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2–18 in high‐income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta‐analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity‐related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity‐only interventions delivered in schools with home involvement or combined diet–physical activity interventions delivered in schools with both home and community components. SOE was moderate for school‐based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school‐based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics‐oriented interventions.

Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence

Buprenorphine is a partial μ‐opiate agonist and κ‐opiate antagonist with established efficacy in the treatment of opiate dependence. Its efficacy for cocaine dependence is uncertain. This study evaluated buprenorphine for the treatment of concomitant cocaine and opiate dependence.

A controlled comparison of buprenorphine and clonidine for acute detoxification from opioids

We compared the short-term efficacy of a high-dose, 3 day regimen of buprenorphine to a standard 5-day course of clonidine in attenuating the signs and symptoms of the acute opioid abstinence syndrome during rapid detoxification from heroin in 25 men and women admitted to a closed inpatient research ward for this randomized, double-blind, parallel-group trial. Among the 18 completers, there were no significant differences between the buprenorphine and clonidine groups on five subjective and six physiological measures. However, clonidine lowered blood pressure and buprenorphine provided more effective early relief of withdrawal symptoms.

Naltrexone alters subjective and psychomotor responses to alcohol in heavy drinking subjects.

Preclinical studies support endogenous opioid system involvement in alcohol reinforcement and consumption; however, recent clinical trials and human laboratory studies have provided mixed findings of the effects of naltrexone (a non-selective opioid antagonist) on alcohol responses. This study used a within-subject design (n = 23) to investigate naltrexone effects (0, 50 and 100 mg qd) on subjective and psychomotor responses to alcohol (none, moderate, high) in heavy drinkers. Before alcohol administration, subjects reported decreased desire to drink alcohol when maintained on 50 mg compared with placebo naltrexone. Following alcohol administration, active naltrexone significantly increased subjective ratings of sedative, and unpleasant/sick effects and decreased ratings of liking, best effects and desire to drink. Naltrexone generally did not alter subjective or objective indicators of drunkenness. Finally, high doses of naltrexone and alcohol interacted to produce the greatest decreases in liking and best effects. Findings support the role of endogenous opioids as determinants of alcohols effects and suggest that naltrexone may be particularly clinically useful in those treatment patients who continue to drink heavily.

A systematic review of home-based childhood obesity prevention studies

BACKGROUND AND OBJECTIVES: Childhood obesity is a global epidemic. Despite emerging research about the role of the family and home on obesity risk behaviors, the evidence base for the effectiveness of home-based interventions on obesity prevention remains uncertain. The objective was to systematically review the effectiveness of home-based interventions on weight, intermediate (eg, diet and physical activity [PA]), and clinical outcomes. METHODS: We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library from inception through August 11, 2012. We included experimental and natural experimental studies with ≥1-year follow-up reporting weight-related outcomes and targeting children at home. Two independent reviewers screened studies and extracted data. We graded the strength of the evidence supporting interventions targeting diet, PA, or both for obesity prevention. RESULTS: We identified 6 studies; 3 tested combined interventions (diet and PA), 1 used diet intervention, 1 combined intervention with primary care and consumer health informatics components, and 1 combined intervention with school and community components. Select combined interventions had beneficial effects on fruit/vegetable intake and sedentary behaviors. However, none of the 6 studies reported a significant effect on weight outcomes. Overall, the strength of evidence is low that combined home-based interventions effectively prevent obesity. The evidence is insufficient for conclusions about home-based diet interventions or interventions implemented at home in association with other settings. CONCLUSIONS: The strength of evidence is low to support the effectiveness of home-based child obesity prevention programs. Additional research is needed to test interventions in the home setting, particularly those incorporating parenting strategies and addressing environmental influences.

Encouraging Patients To Become More Physically Active: The Physician's Role

The healthful effects of regular exercise are recognized by most physicians and many adults. Physical activity decreases the incidence of coronary artery disease, serum lipid abnormalities, hypertension, and type 2 diabetes mellitus and increases longevity. Unfortunately, awareness of these facts by both the public and health care professionals has not translated into a more active population. Of adults in the United States, only 22% are currently active enough to derive health benefits from their physical activity, 53% are somewhat active but not active enough to derive health benefits, and 25% are completely sedentary [1]. The American Heart Association [2] recently added sedentary lifestyle to its list of controllable risk factors. The American College of Sports Medicine and the Centers for Disease Control and Prevention (CDC) suggest that all Americans should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week [3]. The National Institutes of Health (NIH) recently issued similar recommendations [4]. However, the NIH stressed that persons currently meeting this standard can derive additional health and fitness benefits by becoming more physically active or participating in more vigorous activities. Getting Patients Moving Getting patients moving is always a challenge. The subject of physical activity should be broached with sedentary patients at the first office visit. Say, for example, It must be hard to stay physically active with all the time you need to spend at a desk job. This beginning can lead easily to information on the patients attitudes and beliefs about exercise and whether he or she wants to begin an exercise program. Many sedentary patients would like to become more active but do not know how to begin. Obtain a history of exercise habits and sports participation over a lifetime. This can help identify the type of activity to suggest. For example, a former varsity athlete who enjoyed regular exercise and training may feel comfortable with a traditional prescription for structured exercise in a health club. Conversely, a program of increased lifestyle activity may initially be more appropriate for a sedentary, middle-aged patient with no formal exercise history. It is also helpful to identify the persons current exercise pattern (that is, the exercise pattern over the past 3 to 6 months) and barriers to participation (Table 1). Characterizing social preferences may also help tailor the exercise prescription. For example, some enjoy the solitude of walking or jogging; others enjoy the camaraderie of an exercise class. Table 1. Principles of Exercise Prescription for the Apparently Healthy Adult, Based on Current Levels of Physical Activity It is common for the press to emphasize stories about the exercise-related tragedies of elite athletes who succumb to sudden cardiac death. Thus, it is important to address patient fears related to exercise [5]. Patients should understand that, in reality, regular physical activity is associated with a decreased risk for heart disease. Furthermore, the risk for sudden death with moderate-intensity activity is considerably less than the risk with more intense vigorous exercise [1]. It is important for physicians to state clearly the medical importance of physical activity. Patients may perceive that physicians who do not address the need to exercise are condoning a sedentary lifestyle. On the other hand, a clear statement that addresses the health benefits and importance of increasing physical activity conveys the message that sedentary habits are bad habits. Once the stage is set, it is best to establish small, attainable initial goals with the patient. For example, after establishing baseline levels of physical activity, a first step is to recommend increased lifestyle activity. The prescription should be very specific, achievable, and realistic (for example, walk five blocks and walk up three extra flights of stairs each day) and should be developed in discussion with the patient. Writing the recommendation on a prescription pad may increase the likelihood that the recommendation will be followed. At follow-up visits, ask patients if they have successfully met their goals. Any increase is a step in the right direction and should be praised. With time and encouragement, many persons find that what they were initially doing largely to please others (such as the physician) becomes rewarding and self-reinforcing as they perceive improvements in physical fitness, energy level, mood, and health. Effects of Physician Advice Helping patients change modifiable risk factors is a difficult task for health care providers [6-8]. Because patients respect their physicians advice, a succinct message from a physician can be a potent catalyst in motivating change [9, 10]. Fully 80% of Americans cite their physician as their primary source of information about health [11], and the average adult makes 2.7 visits to a physician per year; thus, the physician has multiple opportunities to intervene and encourage patients to adopt healthier lifestyles [12]. The U.S. Preventive Services Task Force [9] recommends that physicians advise patients to engage in a program of regular physical activity tailored to their individual health status and lifestyle [9]. Although the conviction that physician counseling to increase physical activity may have a significant effect on public health is widespread, only limited empirical evidence supports it [9]. One major study, the PACE (Physician-Based Assessment and Counseling for Exercise) program, was developed to provide specific counseling protocols matched to the patients level of activity and readiness to change. Long and colleagues [13] found that 3- to 5-minute counseling sessions increased physical activity among patients treated in the primary care setting. Eighty percent of providers in the PACE trial reported that their patients were receptive or very receptive to activity counseling. More than 50% of providers perceived that their patients became more active after the intervention. In one randomized trial [10], increases in the duration (but not the frequency) of physical activity were reported a month after physician activity counseling [10]. Patients in this trial were also asked to report their level of agreement with the following statement: If my doctor advised me to exercise, I would follow his/her advice. Thirty-five percent of patients strongly agreed and 58% agreed with this statement, whereas only 7% disagreed and less than 1% strongly disagreed. Investigators in a multicenter cohort study assessed changes in several health-related behaviors 1 year after a preventive intervention by primary care physicians. Surveys conducted before and after the intervention showed that study patients with behavioral risks who had the intervention were more likely than matched controls to report positive changes with regard to exercise adoption, use of seatbelts, weight loss, and reduction of alcohol intake [14]. Although physicians generally believe that most patients should exercise, many of those who counsel their patients about health-habit modifications address smoking and body weight more frequently than they address inactivity [15]. For example, Rosen and coworkers [16] reported that although 64% of primary care physicians prescribed exercise for their high-risk patients, only 29% regularly counseled all patients about the importance of regular activity. Patients often interpret a lack of advice to become more active as an endorsement of the view that physical activity is not important. Recommendations about Physical Activity Early guidelines specified that aerobic exercise would offer little benefit if it were not done at moderate to high intensity in a steady state for 20 to 60 minutes three or more times per week [17]. These rigorous recommendations were designed to achieve optimal improvements in physical fitness. Persons currently exercising at this level should be encouraged to continue because this activity is likely to maximize both health and fitness benefits. However, the current low rate of volitional participation in exercise may be due in part to the misunderstanding that exercise must be vigorous and uninterrupted in order to provide health benefits [3]. Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure [18]. Physical fitness is related to, but distinct from, physical activity. It is defined as a set of attributes that people have or achieve that relates the ability to perform physical activity [18]. Fit persons have a lower risk for cardiovascular disease [19, 20]. In 1989, Blair and colleagues [19] demonstrated that adults with low cardiorespiratory fitness had much higher rates of all-cause and cardiovascular mortality than did those who were moderately fit. Smaller but additional reductions in death rates were seen in persons who were the most fit. Thus, physical activity need not be vigorous or extensive to produce substantial health benefits. Recent reports document that the health benefits of increasing activity can be accrued at exercise intensities significantly lower than previously thought [18-20]. These findings prompted the NIH [4], the CDC and the American College of Sports Medicine [3], and the Surgeon General [1] to revise exercise guidelines. It is now suggested that sedentary persons who wish to become more physically active should accumulate 30 minutes or more of moderate-intensity physical activity each day as an alternative to traditional programmed exercise. In 1993, Paffenbarger and colleagues [21] reported the effects of changes in physical activity and other lifestyle characteristics on mortality in 10 269 Harvard University alumni. Men who were initially sedentary but had started to participate in moderately vigorous sports by 1977 had a 23% lower risk for death than di

Self-efficacy, attendance, and weight loss in obesity treatment

Self-efficacy is an important predictor of treatment outcomes for a variety of addictive behaviors. However, little research is available regarding its predictive value in obesity treatment. We assessed the predictive validity of the 20-item version of the Weight Efficacy Lifestyle Questionnaire (WEL) in a consecutive sample of 109 obese adults seeking outpatient treatment at a university-based weight-management center. Although the WEL demonstrated a stable factor structure and sound psychometric properties, it failed to correlate with either program attendance or weight loss. We concluded that self-efficacy judgments (as measured by the WEL) are not predictive of short-term obesity treatment outcomes.