http://www.fitsugar.com Happy healthy you. en http://www.fitsugar.com/204593 <a href="http://www.fitsugar.com/204593"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They Sleep--Well:</b> They snooze 2 more hours per week, compared with overweight people, says a study from Eastern Virginia Medical School. Researchers theorize that a lack of shut-eye is linked to lower levels of appetite-suppressing hormones like leptin and higher levels of the appetite-boosting hormone ghrelin.</p> <p><i>Emulate Them:</i> Break it down: Two extra hours of sleep a week is only 17 more minutes a day--a lot more manageable, even for the most packed of schedules. Start there and slowly work toward 8 hours of snooze time a night--the right amount for most adults.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="http://fitsugar.com/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204593#comment sleep prevention 8 secrets 8 secrets of naturally thin people Fri, 20 Apr 2007 03:00:00 -0700 FitSugar http://www.fitsugar.com/204593 http://www.fitsugar.com/204591 <a href="http://www.fitsugar.com/204591"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They're Movers And Shakers:</b> On average, slim people are on their feet an extra 2 1/2 hours per day--which can help burn off 33 pounds a year, according to a study from the Mayo Clinic in Rochester, MN.</p> <p><i>Emulate Them:</i> Try a reality check. Studies have shown that people often overestimate how active they really are, says Gallagher. Most people actually spend 16 to 20 hours a day just sitting. Wear a pedometer on an average day, and see how close you get to the recommended 10,000 steps. Your day should combine 30 minutes of structured exercise with a variety of healthy habits, such as taking the stairs instead of the elevator or mopping the floor with extra vigor. To see how many calories your activities burn, see the exercise calculator at www.caloriecontrol.org.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204591#comment prevention 8 secrets 8 secrets of naturally thin people Thu, 19 Apr 2007 02:00:00 -0700 FitSugar http://www.fitsugar.com/204591 http://www.fitsugar.com/204584 <a href="http://www.fitsugar.com/204584"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 Secrets of Naturally Thin People</a> one by one.</p> <ul> <li><b>They Have A Self-Control Gene:</b> Researchers at Tufts University found that the biggest predictor of weight gain among women in their 50s and 60s was their level of disinhibition, or unrestrained behavior. Women with low disinhibition (in other words, a finely tuned sense of restraint) had the lowest body mass index. High disinhibition (i.e., low restraint) was linked to an adult weight gain of as much as 33 pounds.</p> <p><i>Emulate Them:</i> Prepare for moments when your disinhibition is likely to be higher--such as when you're in a festive atmosphere with a large group of friends. If you're at a party, tell yourself you'll take one of every fourth passed hors d'oeuvre. If you're out at dinner, order an appetizer portion and share dessert. Or if you're stressed--another low-restraint moment--make sure you have a source of crunchy snacks (like fruit or carrot sticks) at the ready.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204584#comment prevention 8 secrets 8 secrets of naturally thin people self control gene Tue, 17 Apr 2007 13:30:00 -0700 FitSugar http://www.fitsugar.com/204584 http://www.fitsugar.com/204580 <a href="http://www.fitsugar.com/204580"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They're Creatures Of Habit:</b> Any dietitian will tell you that a varied diet is good--but too much variety can backfire, says Katz, author of The Flavor Point Diet. Studies have shown that too many tastes and textures encourage you to overeat, he explains. "Thin people have what I call a food groove--the majority of their meals consist of well-planned staples," says Beck. "There are a few surprises thrown in, but for the most part, their diets are fairly predictable."</p> <p><i>Emulate Them:</i> Try to be as consistent as possible with your major meals--have cereal for breakfast, a salad at lunch, and so forth. It's okay to add grilled chicken to the salad one day and tuna the next, but by sticking to a loosely prescribed meal schedule, you limit the opportunities to overindulge.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204580#comment prevention 8 secrets 8 secrets of naturally thin people creatures of habit Mon, 16 Apr 2007 11:45:00 -0700 FitSugar http://www.fitsugar.com/204580 http://www.fitsugar.com/204575 <a href="http://www.fitsugar.com/204575"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They Eat More Fruit:</b> Lean people, on average, have one more serving of fruit and eat more fiber and less fat per day than overweight people, reports a 2006 study published in the Journal of the American Dietetic Association.</p> <p><i>Copy Them:</i> Start tinkering. Examine your diet for ways to add whole fruits (not juices) to your meals and snacks. Aim for two or three servings per day. Sprinkle berries in your cereal or on your yogurt. Add sliced pears to your turkey sandwich, or bake an apple for dessert. Keep a bowl of fruit on your kitchen table or desk to motivate you to think fruit first, vending machine never.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204575#comment prevention 8 secrets 8 secrets of naturally thin people eat more fruit Fri, 13 Apr 2007 03:30:00 -0700 FitSugar http://www.fitsugar.com/204575 http://www.fitsugar.com/204570 <a href="http://www.fitsugar.com/204570"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They Don't Use Food To Cure The Blues:</b> It's not that thin women are immune to emotional eating, says Kara Gallagher, PhD, a weight loss expert based in Louisville. But they tend to recognize when they're doing it and stop.</p> <p><i>Emulate the Naturally thin:</i> Add the word 'Halt' to your vocabulary, says Gallagher. More than just a command (as in stop eating that entire sleeve of cookies), it's an acronym that stands for Hungry, Angry, Lonely, or Tired--the four most common triggers for emotional eating.</p> <p>If you're truly hungry, choose a balanced snack, such as a handful of nuts, to tide you over until your next meal. But if you're angry, lonely, or tired, seek an alternative calorie-free solution to your emotional need. Blow off steam by going for a run or just jumping around--the heartbeat boost will help dissipate your anger. Lonely? Call a friend, e-mail your kid, or walk to the park or mall. Being around others will make you feel more connected to your community (even if you don't bump into anyone you know). If you're tired, for heaven's sake, sleep!</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see secrets one and two <a href="/tag/8+secrets" >here</a>.</p> <p><a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204570#comment prevention 8 secrets 8 secrets of naturally thin people Thu, 12 Apr 2007 04:00:00 -0700 FitSugar http://www.fitsugar.com/204570 http://www.fitsugar.com/204558 <a href="http://www.fitsugar.com/204558"><img width=119 height=160 src='http://media.onsugar.com/files/users/1/12981/15_2007/naturally-thin-secrets.large.jpg'></div></a><p><span class="inline left"></span>We all want to know what those naturally thin people are doing to stay so um, naturally thin. Prevention has discovered that healthy thin people just don't think about food the same way as everyone else. In this 8 part series, I'll reveal <a href="http://www.prevention.com/article/0,5778,s1-4-151-647-7894-1,00.html" target="_blank">Prevention's 8 secrets of naturally thin people</a> one by one.</p> <ul> <li><b>They Realize Hunger Isn't An Emergency:</b> Most of us who struggle with extra pounds tend to view hunger as a condition that needs to be cured--and fast, says Judith S. Beck, PhD, author of the new Beck Diet Solution. "If you fear hunger, you might routinely overeat to avoid it," she says. Thin people tolerate it because they know hunger pangs always come and go, buying them some time.</p> <p><i>Emulate the Naturally Thin:</i> Pick a busy day to purposely delay lunch by an hour or two. Or try skipping an afternoon snack one day. You'll see that you can still function just fine. Then next time you feel those grumbles, you'll hold off before making a beeline for the fridge.</li> </ul> <p>More secrets revealed this week. Did you miss any? You can see all the secrets <a href="/tag/8+secrets" >here</a>.<br /> <a href="http://creative.gettyimages.com/source/home/home.aspx" target="_blank">Source</a></p> http://www.fitsugar.com/204558#comment prevention naturally thin 8 secrets 8 secrets of naturally thin people Wed, 11 Apr 2007 02:30:00 -0700 FitSugar http://www.fitsugar.com/204558 http://www.fitsugar.com/2331195 <a href="http://www.fitsugar.com/2331195"></a><div id="health_topic"> <div id="health_topic_left"> <div class="left_nav_block"> <h3>In This Report</h3> <ul> <li class="indent"><a href="#adamHeading_2" rel="section">Highlights</a></li> <li class="indent"><a href="#adamHeading_3" rel="section">Introduction</a></li> <li class="indent"><a href="#adamHeading_4" rel="section">Blemishes</a></li> <li class="indent"><a href="#adamHeading_5" rel="section">Risk Factors</a></li> <li class="indent"><a href="#adamHeading_6" rel="section">Prevention</a></li> <li class="indent"><a href="#adamHeading_7" rel="section">Treatment</a></li> <li class="indent"><a href="#adamHeading_8" rel="section">Resurfacing Treatments</a></li> <li class="indent"><a href="#adamHeading_9" rel="section">Implant Procedures</a></li> <li class="indent"><a href="#adamHeading_10" rel="section">Plastic Surgery</a></li> <li class="indent"><a href="#adamHeading_11" rel="section">Resources</a></li> <li class="indent"><a href="#adamHeading_12" rel="section">References</a></li> </ul> </div> </div> <div id="health_topic_right"> <div id="health_topic_from_adam"> HEALTH GUIDE REFERENCE FROM A.D.A.M </div> <div id="health_topic_content"> <h3 id="adamHeading_2">Highlights</h3> <p><strong>Smoking and Skin Damage</strong> </p> <ul> <li>The skin of smokers ages more rapidly than the skin of non-smokers, even in areas of the body not exposed to sunlight, according to a 2007 study. Women in the study who smoked also had much lower levels of vitamin E secretions in their skin. Vitamin E may protect the skin from sun damage.</li> <li>There may be an association between smoking and higher frequency of a type of acne (noninflammatory acne) in adult women, according to a European study.</li> </ul> <p><strong>Antioxidants and Your Skin</strong> </p> <ul> <li>A study in the <i>Journal of Nutrition</i> found that a combination of antioxidants and trace elements supplementation raises the risk of skin cancer in women, but not in men.</li> </ul> <p><strong>Ultraviolet Radiation</strong> </p> <ul> <li>Overall, exposure to ultraviolet radiation from sunlight (radiation referred to as UVA or UVB) accounts for about 90% of the symptoms of premature skin aging.</li> <li>UVB primarily affects the outer skin layers. It is most intense when sunlight is brightest. People receive slightly over 70% of their yearly UVB dose during the summer.</li> <li>UVA penetrates more deeply and efficiently. The intensity of UVA rays is less dependent on the time of day and season of the year than that of UVB rays.</li> </ul> <p><strong>Vitamin D</strong> </p> <p>A report analyzing studies of vitamin D supplementation found that people who take vitamin D supplements live longer than those who do not. People who avoid sunlight are at risk for vitamin D deficiency. </p> <h3 id="adamHeading_3">Introduction</h3> <p>As you age, your skin undergoes progressive changes: </p> <ul> <li>The cells divide more slowly, and the inner layer of skin (the dermis) starts to thin. Fat cells beneath the dermis begin to shrink. In addition, the ability of the skin to repair itself decreases with age, so wounds heal more slowly. The thinning skin becomes vulnerable to injuries and damage.</li> <li>The deeper layer of the skin, which provides scaffolding for the surface skin layers, loosens and unravels. Skin then loses its elasticity (ability to stretch). When pressed, it no longer springs back to its initial position. Instead, older skin sags and forms furrows.</li> <li>The sweat- and oil-secreting glands atrophy (waste away), leaving the skin without a protective layer of water and fat. The skin's ability to stay moisturized then decreases, and it becomes dry and scaly.</li> <li>Frown lines (those between the eyebrows) and crow's feet (lines that spread from the corners of the eyes) appear to develop because of permanent small muscle contractions. Habitual facial expressions also form characteristic lines.</li> <li>Gravity makes the situation worse, contributing to the formation of jowls and drooping eyelids. Eyebrows, surprisingly, move up as a person ages, possibly pulled up by forehead wrinkles.</li> </ul> <p>Wrinkles can have a profound impact on self-esteem. The stigma attached to looking old is evidenced by the more than $12 billion Americans spend each year on cosmetics to hide the signs of aging. Our society places a premium on youthfulness, and age discrimination in the workplace, although illegal, has stalled many people's careers. Indeed, the emotional consequences of aging explain in large part why the cosmetics industry and plastic surgeons thrive. </p> <p>The sun is the most important cause of prematurely aging skin (a process called photoaging) and skin cancers. Overall, exposure to ultraviolet radiation from sunlight (radiation referred to as UVA or UVB) accounts for about 90% of the symptoms of premature skin aging. Most of these effects occur by age 20: </p> <ul> <li>Even small amounts of UV radiation trigger the processes leading to skin wrinkles.</li> <li>Long-term repetitive exposure to sunlight adds up, and likely is responsible for the vast majority of unwanted consequences of aging skin, including basal cell and squamous cell cancers.</li> <li>Intense exposure to sunlight in early life is an important cause of melanoma, a particularly aggressive type of skin cancer.</li> </ul> <p><i>Initial Damaging Effects of Sunlight.</i> Ultraviolet radiation penetrates the layers of the skin. Both UVA and UVB rays cause damage leading to wrinkles, lower immunity against infection, aging skin disorders, and cancer. They appear to damage cells in different ways, however. </p> <ul> <li>UVB is the main cause of sunburns, and primarily affects the outer skin layers. UVB is most intense at midday when sunlight is brightest. People receive slightly over 70% of their yearly UVB dose during the summer. We receive only 28% during the remainder of the year. Window glass filters out UVB.</li> <li>UVA penetrates more deeply and efficiently. The intensity of UVA rays is less dependent on the time of day and season of the year than that of UVB rays. For example, you receive only about half of your yearly UVA dose during the summer months, with the balance spread over the rest of the year. Window glass does NOT filter out UVA.</li> </ul> <p>Both UVA and UVB rays cause damage to the body, including genetic injury, wrinkles, aging skin disorders, and skin cancers. Exactly how they cause this damage is not yet fully understood. </p> <p><i>Processes Leading to Wrinkles.</i> Even small amounts of UV radiation trigger the processes that can cause wrinkles: </p> <ul> <li>Sunlight damages collagen fibers (the major protein that gives structure to the skin). Sunlight also causes damage to elastin, a protein in the skin that normally maintains springiness and strength of tissue beneath the skin.</li> <li>In response to this sun-induced elastin accumulation, the body produces large amounts of enzymes called <em>metalloproteinases</em>. One study indicated that when people with light to moderate skin color are exposed to sunlight for just 5 - 15 minutes, the metalloproteinase levels in their body remain high for about a week.</li> <li>The normal function of these <em>metalloproteinases</em> is generally positive -- to remodel the sun-injured tissue by producing and repairing collagen. This is an imperfect process, however, and some of metalloproteinases produced by sunlight actually <em>degrade</em> (break down) collagen. The result is an uneven formation (<em>matrix</em>) of disorganized collagen fibers called <em>solar scars</em>. Repetition of this imperfect skin rebuilding causes wrinkles.</li> <li>An important event in this process is the over-production of <em>oxidants</em>, also called free radicals. These are unstable molecules that are normally produced by chemical processes in the body, a process called <em>oxidation</em>. Environmental damage, however, causes an overproduction of oxidants. Excessive amounts of oxidants damage the body's cells and even alter their genetic material. Oxidation may contribute to wrinkling by activating the specific metalloproteinases that degrade connective tissue.</li> </ul> <p>In addition to sunlight, other factors may hasten the formation of wrinkles: </p> <p><em>Cigarette Smoke</em>. Smoking produces oxygen-free radicals, which accelerate wrinkles and aging skin disorders, and increase the risk for non-melanoma skin cancers. Studies also suggest that smoking and subsequent oxidation produce higher levels of metalloproteinases, the enzymes associated with wrinkles. </p> <p><i>Air Pollution.</i> Ozone, a common air pollutant, may be a particular problem for the skin. One study reported that it might deplete the amount of vitamin E in the skin. This vitamin is an important antioxidant. </p> <p><i>Rapid Weight Loss.</i> If weight loss occurs too rapidly, the volume of fat cells that cushion the face are also decreased before chemicals in the skin can react. This not only makes a person look gaunt, but can cause the skin to sag. </p> <h3 id="adamHeading_4">Blemishes</h3> <p>This report covers three types of blemishes: Liver spots, purpura, and seborrheic keratoses (or warts). </p> <p>Liver spots (known as lentigos, or sun-induced or pigmented lesions) are flat brown spots on the skin. They are almost universal signs of aging. Occurring most noticeably on the hands and face, these blemishes tend to enlarge and darken over time. The extent and severity of the spots are determined by a combination of skin type, sun exposure, and age. These spots are harmless, but should be distinguished from lentigo maligna, which is an early sign of melanoma. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Liver spots or age spots are a type of skin change that are associated with aging. The increased pigmentation may be brought on by exposure to sun, or other forms of ultraviolet light, or other unknown causes.</div> </div> </div> <p><i>Treating Liver Spots.</i> Liver spots do not require treatment, although some people are distressed by their appearance. Treatments may include the following: </p> <ul> <li>Trichloroacetic acid (a chemical peel).</li> <li>Tretinoin (Retin A) alone or in a combination with Mequinol (Solagé). Tretinoin is related to vitamin A, and is also effective in treating wrinkles.</li> <li>Gentle freezing with liquid nitrogen (cryotherapy).</li> <li>Laser treatment. Specific lasers, such as the Nd:YAG, are effective in eliminating 80% of liver spots in one treatment. It may be more effective than cryotherapy and have fewer side effects.</li> <li>Bleaching creams -- these are commonly available but are not as satisfactory as peels, and high concentrations can sometimes cause permanent loss of skin color.</li> </ul> <p>Purpura occurs when tiny capillaries (blood vessels) break and leak blood into the skin. In older people, the condition (called senile or actinic purpura) is usually caused by fragile blood vessels. The capillaries appear as flat purplish patches. These patches are called petechiae when they are smaller than 3 mm (about a tenth of an inch). When they are greater than 3 mm, they are referred to as ecchymoses. Patients typically complain of a rash, which may appear reddish at first but gradually change color, turning brown or purple. </p> <p><i>Treatment.</i> Although there is no specific treatment for purpura, patients are advised to avoid trauma, including vigorous rubbing of the skin, which may be sufficient to damage the capillaries. Emollients that soften the skin may be helpful. Some doctors also recommend vitamin C, but its effectiveness is unproven. </p> <p>Seborrheic keratoses, (also called seborrheic warts), are among the most common skin disorders in older adults. Their cause or causes are unknown. They usually appear on the head, neck, or trunk and can range in size from 0.2 - 3 cm (a little over an inch). They are well defined and appear to be pasted onto the skin, but their appearance can vary widely: </p> <ul> <li>They can be smooth with tiny, round, pearl-like formations embedded in them.</li> <li>They can be rough and warty.</li> <li>They can be brown or black.</li> </ul> <p>Seborrheic keratoses sometimes look like melanoma, since they can have an irregular border, but they are always benign. A dermatologist can tell the difference between them, although experts warn that melanomas may "hide" among these benign lesions and go unnoticed without close inspection. In general, seborrheic keratoses have a uniform appearance while melanomas often have a smooth surface that varies in height, color density, and shading. In some cases, keratoses may cause itching or irritation. They can be easily removed with surgery or freezing. Vitamin D3 ointment is also showing promise in clinical trials. </p> <h3 id="adamHeading_5">Risk Factors</h3> <p><i>Exposure to Sun in Childhood.</i> It is estimated that 50 - 80% of skin damage occurs in childhood and adolescence from intermittent, intense sun exposure that causes severe sunburns. In spite of this now well-known effect, many people still believe that a tan in children signifies health. And even though many parents are concerned about sun exposure, they still rely too much on sunscreen and not enough on protective clothing. </p> <p><i>The Elderly.</i> Most people over 70 have at least one skin disorder. Many have three or four. Everyone experiences skin changes as they age, but a long life is not the sole determinant of aging skin. Family history, genetics, and behavioral choices all have a profound impact on the onset of aging-skin symptoms. </p> <p>Of all the risk factors for aging skin, exposure to UV radiation from sunlight is by far the most serious. Indeed, the vast majority of undesirable consequences of aging skin occur in individuals who are repetitively exposed to the sun, including the following: </p> <ul> <li>Outdoor workers, such as farmers, fishermen, construction workers, and lifeguards</li> <li>Outdoor enthusiasts</li> <li>Sunbathers</li> <li>People who regularly attend tanning salons or use tanning beds (One study indicated that regular use significantly increases the risk for non-melanoma skin cancers. Fair-skinned women under age 50 may be at particular risk.)</li> </ul> <p>Experts have devised a classification system for skin phototypes (SPTs) based on the sensitivity to sunlight. It ranges from SPT I (lightest skin plus other factors) to IV (darkest skin). People with skin types I and II are at highest risk for photoaging skin diseases, including cancer. It should be noted, however, that premature aging from sunlight can affect people of all skin shades. </p> <table border="1" cellpadding="3" cellspacing="0"> <tr> <td valign="top" colspan="2" /></tr> <tr> <td valign="top"> <p><b>Skin Type</b> </p> </td> <td valign="top"> <p><b>Tanning and Burning History</b> </p> </td> </tr> <tr> <td valign="top"> <p>I </p> </td> <td valign="top"> <p>Always burns, never tans, sensitive to sun exposure </p> </td> </tr> <tr> <td valign="top"> <p>II </p> </td> <td valign="top"> <p>Burns easily, tans minimally </p> </td> </tr> <tr> <td valign="top"> <p>III </p> </td> <td valign="top"> <p>Burns moderately, tans gradually to light brown </p> </td> </tr> <tr> <td valign="top"> <p>IV </p> </td> <td valign="top"> <p>Burns minimally, always tans well to moderately brown </p> </td> </tr> <tr> <td valign="top"> <p>V </p> </td> <td valign="top"> <p>Rarely burns, tans profusely to dark </p> </td> </tr> <tr> <td valign="top"> <p>VI </p> </td> <td valign="top"> <p>Never burns, deeply pigmented, least sensitive </p> </td> </tr> </table> <p>The common belief is that women are at greater risk for wrinkles than men. Some evidence suggests, however, that given the same risk factors, men and women in the same age groups have comparable risks for skin photoaging. In a French study, the evidence of moderate-to-severe photoaging was observed in the following: </p> <ul> <li>Twenty two percent of women and 17% of men ages 45 - 49</li> <li>Thirty six percent of women and 38% of men by age 54</li> <li>Nearly half of both men and women by age 60</li> </ul> <p>Some studies report that men are more likely to develop non-melanoma skin cancers. </p> <p>Heavy smokers are almost five times more likely to have wrinkled facial skin than nonsmokers, according to one study. The skin of smokers in areas of their bodies not exposed to sunlight also seems to age more rapidly, compared to non-smokers in the same age group, according to a 2007 study. In fact, heavy smokers in their 40s often have facial wrinkles more like those of nonsmokers in their 60s. </p> <p>Studies of identical twins have found smokers to have thinner skin (in some cases by as much as 40%), more severe wrinkles, and more gray hair than their non-smoking twins. Even worse, cigarette smokers are more prone to skin cancers, including squamous cell carcinoma and giant basal cell carcinomas. A European study found an association between smoking and higher frequency of a particular type of acne in adult women. The study also found that women who smoked had much lower levels of vitamin E secretions in their skin. Vitamin E is an antioxidant that may help protect the skin from sun damage. [See <em>In-Depth Report</em> #41: <a href="/2331119" >Smoking</a>.] </p> <h3 id="adamHeading_6">Prevention</h3> <p>The best long-term prevention for overly wrinkled skin is a healthy lifestyle. </p> <p><i>Eat Healthy.</i> A diet with plenty of whole grains, fresh fruits and vegetables, and the use of healthy oils (such as olive oil) may protect against oxidative stress in the skin. One study reported that people over age 70 years had fewer wrinkles if they ate such foods. Diet played a role in improving skin regardless of whether the people in the study smoked or lived in sunny countries. Benefits from these foods may be due to high levels of anti-oxidants found in them. </p> <p><i>Exercise.</i> Daily exercise keeps blood flowing, which brings oxygen to the skin. Oxygen is an important ingredient for healthy skin. </p> <p><i>Reduce Stress.</i> Reducing stress and tension may have benefits on the skin. </p> <p><i>Quit Smoking.</i> Smoking not only increases wrinkles, but smokers have a risk for squamous cell cancers that is 50% higher than nonsmokers' risk. Smokers should quit smoking to prevent many health problems, not just unhealthy skin. </p> <p>The following are some daily measures for skin protection: </p> <ul> <li>Don't wash your face too often with tap water. (Once a day is enough.) It strips the skin of oil and moisture. In addition, chlorinated water, particularly at high temperatures, poses special risks for wrinkles.</li> <li>Wash your face with a mild soap that contains moisturizers. Avoid alkaline soaps, especially with deodorant.</li> <li>Pat the skin dry and immediately apply a water-based moisturizer.</li> <li>Always apply sunscreen, even if going outdoors for short periods.</li> <li>Avoid drinking alcohol within 3 hours of bedtime. Alcohol increases the risk for leaks in the capillaries, which allows more water in and causes sagging and puffiness. Capillary leakage increases when one is lying down.</li> <li>Lie on the back when sleeping. This helps offset the effects of gravity.</li> </ul> <p>One of the most important ways to prevent skin damage is to avoid episodes of excessive sun exposure. The following are some specific guidelines: </p> <ul> <li>Use sunscreens that block out both UVA and UVB radiation. <em>However, do not rely only on sunscreen for sun protection.</em> Wear protective clothing and sunglasses in addition.</li> <li>Avoid exposure particularly from 10 a.m. to 4 p.m., when sunlight pours down 80% of its daily UV dose.</li> <li>Avoid reflective surfaces, such as water, sand, concrete, and white-painted areas. Clouds and haze are <em>not</em> protective and in some cases may intensify UVB rays.</li> <li>Ultraviolet intensity depends on the <em>angle</em> of the sun, not heat or brightness. So the dangers are greater the closer to the summer-start date. For example, in the Northern Hemisphere, UV intensity in April (2 months before summer starts) is equal to that in August (2 months after summer begins).</li> <li>The higher the altitude the quicker one sunburns. One study suggested, for example, that an average complexion burns in 6 minutes at an altitude of 11,000 feet at noon, compared with 25 minutes at sea level in a temperate climate.</li> <li>Avoid sun lamps and tanning beds or salons. They provide mostly high-output UVA rays. Some experts believe that 15 - 30 minutes at a tanning salon is as dangerous as a day spent in the sun. People should not be misled by advertising claims of "safe" tanning or promotions offering unlimited tanning.</li> </ul> <p><i>Sunscreens.</i> The use of sunscreens is complex, and everyone should understand how and when to use them. The bottom line is <em>not</em> that people should avoid sunscreens or sunblocks, but that they should always use them in combination with other sun-protective measures. </p> <p><i>Protective Clothing.</i> Wearing sun-protective clothing is extremely important and protects even better than sunscreens. Special clothing is now available for blocking UV rays and is rated using SPF ratings or a system called the UPF (ultraviolet protection factor) index, with 50 UPF being the highest. (According to one study, this is a very reliable indicator of protection.) The clothing is expensive, however. The following are some tips for everyone: </p> <ul> <li>Adults and children should wear hats with wide brims. Even wearing a hat, however, may not be fully protective against skin cancers on the head and neck.</li> <li>People should look for loosely fitted, unbleached, tightly woven fabrics. The tighter the weave, the more protective the garment.</li> <li>Washing clothes over and over improves UPF by drawing fabrics together during shrinkage. An easy way to assess protection is simply to hold the garment up to a window or lamp and see how much light comes through. The less the better.</li> <li>Everyone over age 1 should wear sunglasses that block all UVA and UVB rays.</li> </ul> <p><em>Chemical Tanners</em>. Some research suggests that melanin and dihydroxyacetone (DHA), the active ingredients in many self-tanning lotions, may help filter out UVA and UVB radiation and are therefore protective against sun damage More research is underway. A preliminary study funded by the National Cancer Institute found that people who received numerous daily injections of melanotan-1 (MT-1) before going in the sun or a tanning bed tanned more quickly and showed fewer signs of sun-related damage. MT-1 is a synthetic version of the hormone melanin, which helps produce the skin's natural pigment (color). </p> <p>In choosing a sunscreen, look at the ingredients. Preparations that help block UV radiation are sometimes classified as sunscreens or sunblocks, according to the substances they contain. In general, sunscreens contain organic formulas and sunblocks inorganic formulas. However, the term sunblock is used less and less as sunscreens increasingly contain both kinds of ingredients: </p> <ul> <li><i>Organic</i> formulas contain UV-filtering chemicals such as octocrylene, octyl salicylate, homosalate, and octyl methoxycinnamate (block UVB), avobenzone-Parsol 1789 (blocks UVA), cinoxate, ethylhexyl p-methoxycinnamate (blocks UVB and small amounts of UVA), oxybenzone, benzophenone-3 (blocks UVA/UVB). People should look for a wide-spectrum sunscreen that contains combinations of these ingredients and filter both UVA and UVB. Of note: para-amino benzoic acid (PABA), once a popular ingredient, is now used infrequently. PABA may actually break down in the presence of UV exposure and release harmful oxidants. In addition, many people have an allergic reaction to it. Some products contain PABA derivatives, such as padimate O or octyl dimethyl PABA. It is not known if they have the same effects.</li> <li>The Food and Drug Administration approved Anthelios SX in July 2006. This new sunscreen prevents sunburn and protects against ultraviolet A and B rays. The product contains ecamsule, an ingredient not previously marketed in the United States.</li> <li><i>Inorganic</i> formulas contain the UV-blocking pigments zinc oxide or titanium dioxide. Zinc and titanium oxides lie on top of the skin and are not absorbed. They prevent nearly all UVA and UVB rays from reaching the skin. Older sunblocks are white, pasty, and unattractive, but current products use so-called microfine oxides, either zinc (Z-Cote) or titanium. They are transparent and nearly as protective as the older types. Microfine zinc oxide may be more protective and less pasty-colored than microfine titanium oxide.</li> </ul> <p>Inexpensive products work as well as expensive ones with the same ingredients. Unfortunately, there are still no standards for sunscreens, and even those claiming UVA protection may offer very little. In one study, the average UVA protection from a wide range of brands was only 23%. In fact, the average protection of brands not making the claim was 37%! </p> <p>Organic formulas and inorganic microfine oxides do not protect against <i>visible</i> light, which is a problem for people who have light-sensitive skin conditions, including actinic prurigo, porphyria, and chronic actinic dermatitis. Inorganic sunscreens that protect against visible light and are still cosmetically acceptable are now available in Europe, but not yet in the US. </p> <p><em>Calculating the SPF.</em> The sun protection factor (SPF) on all sunscreen labels is a ratio based on the amount of UVB (not UVA) radiation required to turn sunscreen- or sunblock-treated skin red compared to non-treated skin. For instance, people who sunburn in 5 minutes and who want to stay in the sun for 150 minutes might use an SPF 30. The formula would be: 30 (the SPF number) times 5 (minutes to burn) = 150 minutes in the sun. </p> <p>Protection offered by sunscreens may be classified as follows: </p> <ul> <li>Minimal: SPF 2 to 11.</li> <li>Moderate: SPF 12 through 29.</li> <li>High: 30+. (Although some sunscreens claim SPFs higher than 30, the added protection at such higher levels is insignificant.)</li> </ul> <p><em>SPF Levels by Age Group.</em> Certain groups should have higher or lower SPFs depending on age and other factors: </p> <ul> <li>Although sunscreens are safe in most toddlers and children, they should not be the first and only lines of defense. In fact, experts are worrying that by relying too much on sunscreen and not providing other protective measures, parents may actually be increasing their children's risk for melanoma. All young children should be well covered with clothing, sunglasses, and hats as the first line of defense against sunburn. Children should be kept out of the sun during peak sunlight periods. Sunscreens should not be used on babies younger than 6 months without consulting a doctor.</li> <li>Older children and adults (even those with darker skin) benefit from using SPFs of 15 and over. Some experts recommend that most people should use SPF 30 on the face and 15 on the body.</li> <li>Adults who burn easily instead of tanning and anyone with risk factors for skin cancer should use at least SPF 30.</li> </ul> <p><em>Timing and Amount of Application.</em> You should apply sunscreen or sunblock liberally as follows: </p> <ul> <li>Adults should include sunscreen with a daily skin regimen, even if going outdoors for only a short time.</li> <li>Apply a large amount to all exposed areas, including ears and feet. To achieve protection as indicated by the sunscreen's SPF, experts recommend half a teaspoon each for the head, neck, and each arm and a teaspoon each for the chest area, the back, and each leg.</li> <li>Apply initially 30 minutes before venturing outdoors for best results. (This allows time for the sunscreen to be absorbed. Then reapply every 15 - 30 minutes while being in the sunlight.</li> <li>Also reapply each time after exercise or swimming. (Choose a waterproof or water-resistant formula even if activities don't include swimming. Waterproof formulas last for about 40 minutes in the water, whereas water-resistant formulas last half as long.)</li> <li>Insect repellents reduce sunscreen SPFs by up to one-third. Use higher SPFs and very liberal application when applying both.</li> </ul> <p><em>Possible Hazards of Sunscreens, Sun Avoidance, or Both.</em> When used generously and appropriately, sunscreen products and sun avoidance help reduce the severity of many aging skin disorders, including squamous cell cancers. There are certain concerns, however. </p> <p><i>Sunscreen Use May Not Protect Against Basal Cell and Melanoma Cancers and May Even Increase the Risk.</i> Although sunscreens help prevent squamous cell carcinomas and other skin disorders, sunscreens do not appear to provide protection against melanoma and some basal cell cancers. In fact, some studies have reported a <i>higher</i> association with sunscreen use and these skin malignancies, though not all studies report such negative results. </p> <p>The reasons for this possible increased risk are unclear, though some theories include the following: </p> <ul> <li>Until recently, many sunscreens blocked only or mostly UVB rays and not UVA, the more deeply penetrating rays now known to be especially dangerous. Past studies may not have reflected the effects of the broad-spectrum sunscreens now available, which block both UVA and UVB.</li> <li>People who apply sunscreens may feel safe and stay out longer during high sun-exposure hours than is safe. Even if a person doesn't sunburn, UVA rays can still penetrate the skin and do harm.</li> <li>People may not put on enough sunscreen. According to a 2002 study, people generally apply only 20 - 60% of the recommended amount, which can provide significantly less protection than the given SPF. (Of note, a 2003 study reported that when applied at the recommended amount, a broad-screen sunscreen prevents DNA damage from UV exposure. However, omitting it even once resulted in significant cell injury.)</li> </ul> <p><i>Sunscreen Use May Increase the Risk for Health Problems Related to Sunlight Deficiencies.</i> There is some major concern that underexposure to sunlight, due to the use of sunscreens or sun-avoidance measures, may produce other health problems, such as the following: </p> <ul> <li>Vitamin D Deficiency. Vitamin D is found in only a few foods, such as fortified dairy products and fish, but it is produced in the skin in response to UVB sunlight. A medical literature review published in the journal <em>Nutrition and Cancer</em> reported that UVB rays may outshine dietary supplements for building the body's vitamin D reserves. Without an appropriate mix of diet and supplements, vigorous sun protection measures may increase a person's risk for developing vitamin D deficiency. Vitamin D is important for prevention of rickets, osteoporosis, and some cancers, including melanoma. People who need to avoid sunlight and whose diet is low in foods that contain vitamin D should check with their doctor about taking supplements. People with darker skin are at higher risk for deficiencies from sun protection than those with whiter skin. Note: vitamin D is toxic in high doses. Most doctors recommend 200 IU a day (for young adults) to 600 IU a day (above age 70). Doses up to 2,000 IU a day are considered safe. A report analyzing studies of vitamin D supplementation found that people who take vitamin D supplements live longer than those who do not. The researchers looked at 18 studies. They found that participants who received vitamin D supplements were, on average, 7% less likely to die during the study they were in, compared with those receiving "sugar pills."</li> <li>Other Cancers. Although sunlight is implicated in skin cancers, it is also associated with lower risks for breast, prostate, ovarian, and colon cancers. Some protection against these cancers may be related to vitamin D production by sunlight.</li> <li>Depression. Many people suffer from SAD (seasonal affective disorder), a form of depression that generally occurs in winter and is associated with exposure to less sunlight.</li> </ul> <p>The bottom line is that some sunlight is important and even necessary for a healthful and high-quality life. Adults may benefit from daily moderate tanning (20 - 30 maximum minutes of exposure during lower-risk hours) over several days to slowly build up pigment in the skin. </p> <h3 id="adamHeading_7">Treatment</h3> <p>An increasing number of dermatology patients are looking for a way to improve the appearance of their skin. As a result, more and more products have become available to treat skin wrinkles and blemishes. From vitamins and supplements to exfoliants and chemical peels -- the options can be overwhelming. In some cases, more than one approach may be needed. </p> <p>Antioxidants are substances that hunt oxygen-free radicals, the unstable particles that can damage cells. Free radicals may also cause sun damage and even skin cancers. Exposure to sunlight depletes antioxidants in the skin, and therefore they must be replaced. </p> <p>Antioxidant ointments, creams, and lotions ("topical products") may help reduce the risk of wrinkles and protect against sun damage. Unlike sunscreens, they build up in the skin and are not washed away, so the protection may last. Selenium, coenzyme Q10 (CoQ10), and alpha-lipoic acid are types of antioxidants that come in topical form. Many are proving to be very beneficial for the skin. </p> <p><em>Vitamin A.</em> Vitamin A is important for skin health. UV radiation produces vitamin A deficiencies in the skin. Topical products containing natural forms of vitamin A (retinol, retinaldehyde) or vitamin A-related products called retinoids (tretinoin, tazarotene) may help repair skin damage due to sunburn and natural aging. </p> <ul> <li>Tretinoin (Retin-A). Tretinoin (known commercially as Retin-A) is the only topical agent approved for treating photoaging and is available in prescription form (Avita, Renova, Differin). The June 2004 issue of <em>Dermatology Surgery</em> reported that tretinoin (0.25% concentration) was an effective and well-tolerated treatment for photodamaged facial skin. This drug produces a rosy glow and reduces fine and large wrinkles, liver spots, and surface roughness. It also may help prevent more serious effects of ultraviolet radiation. Patients may apply tretinoin to the face, neck, chest, hands, and forearms, and should do so at least twice a week. Noticeable improvement takes 2 - 6 months. Because Retin-A increases a person's sensitivity to the sun, patients should apply just a tiny amount at bedtime, and wear sunblock during the day. Patients should also avoid overexposure to the sun. Almost all patients experience redness, scaling, burning, and itching after 2 or 3 days that can last up to 3 months. In women who experience irritation, a daytime moisturizer or low-dose corticosteroid cream, such as 1% hydrocortisone, may help. There is some concern that overuse of high-dose tretinoin may cause excessive skin thinness over time. Studies now suggest that low concentrations (as low as .02%) of tretinoin can produce significant improvements in wrinkles and skin color, with less irritation than the higher doses.</li> <li>Retinol. Retinol, a natural form of vitamin A, could not, until recently, be used in skin products because it was unstable and easily broken down by UV radiation. Stable preparations are now sold over the counter. In the right concentrations, retinol may be as effective as tretinoin, and studies indicate that it has fewer side effects. An animal study suggests that adding antioxidant creams (such as those containing vitamins C or E) may offer added protection against degradation of retinol, but not tretinoin. The Food and Drug Administration warns that over-the-counter retinol skin products are unregulated. The amount of active ingredients is unknown, and some preparations, in fact, may contain almost no retinol.</li> <li>Tazarotene. Tazarotene (Tazorac, Zorac, Avage) is a retinoid used for acne and psoriasis. It has now been approved for treating wrinkles, skin discoloration, and blemishes due to photoaging. One short-term study suggested that it may be as effective as tretinoin and even slightly better at high doses. At such high doses, however, it can cause very severe irritation. Redness and peeling may be reduced by administering tretinoin first to get the skin acclimated. A randomized study of 562 patients with facial photodamage found that a daily application of tazarotene 0.1% cream resulted in a minimum 1 grade improvement in fine and coarse wrinkling, uneven skin color, pore size, skin roughness, and overall photodamage. More research is needed to determine if it produces any long-lasting significant benefits.</li> </ul> <p>Warning: Pregnant women and those who may become pregnant should avoid any vitamin A derivative (a product related to vitamin A). For example, oral tretinoin causes birth defects, and women should avoid even topical Retin-A when pregnant or trying to conceive. </p> <p><i>Vitamin C.</i> Vitamin C, or ascorbic acid, is a very potent antioxidant. Most studies on the effects of antioxidants on the skin have used this vitamin. In laboratory studies, large amounts of vitamin C reduced skin swelling and protected immune factors from sunlight. It may even promote collagen production. Vitamin C by itself is unstable, but products that solve the delivery problem are now available (such as Cellex-C, Avon's Anew Formula C Treatment Capsules, Physician Elite, and others). More research is needed. </p> <p><i>Antioxidants Under Investigation for Skin Care.</i> Other antioxidants are also being investigated for their value in skin protection. Most available brands, however, contain very low concentrations of these antioxidants. In addition, they are also not well absorbed and have a short-term effect. New delivery techniques, however, may prove to offset some of these problems. </p> <ul> <li>Vitamin E. Studies suggest that topical vitamin E, particularly alpha tocopherol cream (a form of vitamin E), decreased skin roughness, length of facial lines, and wrinkle depth. Studies on mice have also reported reductions in UV-induced skin cancer with its use.</li> <li>Both green and black tea may provide some protection against skin cancers and photoaging. There is also some evidence that pomegranate and soy extracts may help rejuvenate aging skin.</li> <li>Aloe, ginger, grape seed extract, and coral extracts contain antioxidants and are promoted as being healthy for the skin, although evidence of their effects on wrinkles is weak.</li> </ul> <p>A small study found that taking vitamin C and E supplements by mouth -- at the same time -- may help reduce sunburn, although it doesn't work as well as sunscreen. Taking the vitamins separately did not have any effect. Vitamin C and E are also antioxidants. </p> <p>One of the basic methods for improving skin and eliminating small wrinkles is exfoliation (also called resurfacing), which is the removal of the top layer of skin to allow regrowth of new skin. Methods for doing this run from simple scrubs to special creams to intensive peeling treatments, including laser resurfacing. People with darker skin are at particularly higher risk for scarring or discoloration with the more powerful exfoliation methods. </p> <p><i>Abrasive Scrubs.</i> Scrub <i>gently</i> with a mildly abrasive material and a soap that contains salicylic acid to remove old skin so that new skin can grow. The motion should be perpendicular to the wrinkles. Use textured material or cleansing grains with microbeads. Organic materials, such as loofahs or sea sponges, may harbor bacteria. Avoid cleansing grains that contain pulverized walnut shells and apricot seeds, which can scratch skin on a microscopic level. Cleansing grains with microbeads don't have sharp edges and remove skin without cutting it. Exfoliation using scrubs, however, can worsen certain conditions, such as acne, sensitive skin, or broken blood vessels. </p> <p><i>Topical Alpha Hydroxy Acid and Similar Substances.</i> Alpha hydroxy acids (AHA) ease the shedding of dead skin cells and may even stimulate the production of collagen and elastin. Their natural forms are: </p> <ul> <li>Lactic acid (milk)</li> <li>Glycolic acid (sugar cane)</li> <li>Malic acid (found in apples and pears)</li> <li>Citric acid (oranges and lemons)</li> <li>Tartaric acids (grapes)</li> </ul> <p>Most alpha hydroxy acid products contain glycolic acid. Skin care products are also made from polyhydroxy acids (PHAs) and beta hydroxy acids (BHAs). Research suggests that PHA products may cause less skin irritation than AHA or BHA products. </p> <p>Acid concentrations in over-the-counter AHA preparations are 2 - 10%. One clinical study suggested that 8% concentrations showed modest skin improvement Some examples include Avon's Anew Intensive Treatment (8% glycolic), Pond's Age Defying Complex (8%), Elizabeth Arden's Alpha-Ceramid Intensive Skin Treatment (3 - 7.5%), and BioMedic's home product (10%). Prescription strength creams contain at least 12% glycolic acid, and glycolic acid peels of 30 - 70% concentration may be administered in a doctor's office at weekly or monthly intervals. </p> <p>Response to AHA varies, and the treatment is not without risk, particularly in high-concentration products. Side effects from over-the-counter creams, prescription products, and professional AHA peels can include burns, itching, pain, and possibly scarring. Studies also suggest that AHA may increase susceptibility to sun damage, even at concentrations as low as 4%. Such effects can persist up to a week after a person stops using the product. Experts advise that people purchase products with AHA concentrations of 10% or less. Chemical peels of up to 60% are available without prescription on the Internet. Such concentrations are not recommended, except under a doctor's supervision. If any adverse effects occur, stop using the product immediately. Always avoid sunlight or use proper sun protection when using these products. </p> <p><i>Copper Peptides.</i> Certain copper-containing compounds may protect skin <em>and</em> help repair it. Note: copper is a toxic metal. When using products containing copper, buy only those that contain peptides (small protein fragments) that bind to copper. Most studies have been conducted on the copper peptide glycyl-l-histidyl-l-lysine:copper (II) or GHK-Cu. It is currently used in a number of products (such as CP Serum, Neutrogena's Visibly Firm, ProCyte's Neova). </p> <p><i>Furfuryladenine.</i> Furfuryladenine (Kinetin, Kinerase) is a naturally occurring growth hormone found in plant and animal DNA. It has antioxidant and anti-aging properties. Some small laboratory studies suggest that furfuryladenine may delay the onset and decrease the effects of aging on skin. However, there are no well-conducted human studies to support this suggestion. </p> <p><i>Vitamin K.</i> Microsponge-based vitamin K is said to clear bruises spider veins, and other small blood vessel damage. Vitamin K is important for blood clotting. </p> <p>Moisturizers help prevent dryness, bruising, and tearing. They have no effect on wrinkles by themselves. Moisturizers should be applied while the skin is still damp. These products retain skin moisture in various ways: </p> <ul> <li>Occlusives, such as petroleum jelly, prevent water from evaporating.</li> <li>Humectants, including glycerin, act by pulling water up to the surface of the skin from deep tissues. People with oily skin generally should use the humectant type.</li> <li>More powerful compounds, such as monolaurin (Glylorin), contain mixtures of fatty molecules (lipids), which may help restore the skin's natural barriers against moisture loss and damage.</li> </ul> <p>Most moisturizers contain combinations of these compounds. They usually have other ingredients as well, such as alpha hydroxy acids, sunscreens, collagen, and keratin. Collagen and keratin leave a protein film and temporarily stretch the skin. They range widely in price, and a major consumer organization found little difference in general between the more and less expensive products. </p> <p>The skin under the eyes is very thin and does not produce as much of the protective oils that keep skin soft and supple. Manufacturers market their under-eye gels as being able to reduce puffiness and dark circles. The creams typically work in one of two ways: </p> <ul> <li>By temporarily constricting blood vessels to prevent the build-up of fluids</li> <li>By firming the skin with an invisible film</li> </ul> <p>Never rub the creams under the eyes, as this may cause more wrinkles to form. Instead, apply these products with a light tapping motion to stimulate the skin. </p> <p>Cosmetics, if properly applied, can be surprisingly effective in camouflaging the signs of aging skin, including wrinkles and age spots. Moreover, they offer additional benefits by retarding water loss and providing a physical barrier to UV radiation. However, as women age, less is more. </p> <p>Here are some suggestions for older women: </p> <p><i>Moisturizers.</i> Apply moisturizers before foundation. If reddish discoloration is extensive or the skin is sallow, tinted moisturizers may be helpful and can be worn alone or under foundation. </p> <p><i>Foundations.</i> Caking on make-up will cause cracks at the wrinkle lines and only increase the appearance of aging. Try to cover large areas of the face with a moderate-coverage foundation that has a matte or semi-matte finish. Facial powder reflects light and thus minimizes wrinkles, but people with dry skin should avoid it. </p> <p><i>Correcting Color.</i> When blemishes are especially prominent, applying color correctors under the foundation can be very effective: </p> <ul> <li>Green neutralizers mask red lesions.</li> <li>Yellow will camouflage dark circles and bruises.</li> <li>Mauve (a purplish-pink color) helps neutralize sallow skin or yellowish blemishes.</li> <li>A white, pearled base helps to minimize wrinkles.</li> </ul> <p><i>Blushes.</i> Blushes and color washes can help conceal the spidery network of dilated capillaries on the nose and cheeks. Powder blushes are preferred because they blend easily on top of foundation. </p> <p><i>Eyes.</i> Powder eye shadows applied on top of a moisturizer are better than cream-based shadows. Light-colored shadow, applied along the upper eyelid crease and above the iris (the colored part of the eye) is best for offsetting the appearance of deep-set eyes. You should then apply a slightly deeper shade of the same color to the lower part of the eyelid, and draw it out to the corner. </p> <p><i>Lips</i>. A lip-setting cream or facial foundation should be applied before lipstick to help prevent it from bleeding into surrounding wrinkles. Try using a stiff bristle brush instead of a lip pencil. The brush will help keep the lipstick on and prevent bleeding. (Some women use the pencil itself for the full lip, which gives color but appears natural.) Some make-up artists recommend cream lipsticks instead of matte. </p> <p>The Food and Drug Administration (FDA) does not regulate herbal remedies and dietary supplements. In other words, the manufacturers and distributors of such products do not need FDA approval to sell their products. In addition, any substance that affects the body's chemistry can, like any drug, produce side effects that may be harmful. There have been numerous reported cases of serious and even deadly side effects from herbal products. </p> <p>Overexposure to sunlight can damage skin. The following natural remedies may cause extra sensitivity to light (photosensitivity): </p> <ul> <li>St. John's wort (<i>Hypericum perforatum</i>) is a popular herbal remedy for depression. People who are sensitive to light should not use it. A case report suggests that St. John's wort may cause skin reactions in patients who have laser treatment.</li> <li>Kava (<i>Piper methysticum</i>) is an herb used to calm nerves and reduce stress. In addition to photosensitivity, it can cause liver damage.</li> <li>Yohimbe (<i>Pausinystalia yohimbe</i>) is used to treat erectile dysfunction. Both the herb and the pharmaceutical drug (yohimbine) can cause sensitivity to light.</li> <li>Essential oils in many botanical aromatherapy products can trigger photosensitivity. Avoid citrus oils (grapefruit, lemon, lime, and orange) as well as bergamot, cumin, ginger, and angelica root oils.</li> </ul> <h3 id="adamHeading_8">Resurfacing Treatments</h3> <p>There are many choices for skin resurfacing (also called exfoliation), and the patient must consider several different factors that affect the choice. Resurfacing can achieve the following: </p> <ul> <li>Removal of abnormal tissue and rough skin</li> <li>Stimulation of new skin growth</li> <li>Stimulation of collagen and elastin production</li> </ul> <p>In addition to determining the skill of the surgeon and the safety of the procedure, the patient must discuss the desired depth of the resurfacing and the capability of each procedure to reach this depth safely. All resurfacing procedures require a healing period afterward, during which the skin is red and sensitive. The deeper the procedure, the higher the risk for complications, including delayed healing, infection, loss of pigment (skin color), and scarring. </p> <p>If you make the decision to pursue intensive treatments, consider the following factors, among others, and discuss them with your dermatologist or plastic surgeon: </p> <ul> <li>The ability of the procedure to safely reduce wrinkles</li> <li>The ease and safety record of the procedure</li> <li>The skill of the doctor</li> <li>The length of recovery</li> <li>Possible complications</li> <li>How long the benefits will last</li> </ul> <p>A person's age also helps determine the procedure: </p> <ul> <li>For people in their 30s, a simple chemical peel is sufficient.</li> <li>After age 40, people may benefit from collagen or fat implants.</li> <li>At age 50 and over, plastic surgeons recommend laser resurfacing and customized treatments for individual needs.</li> </ul> <p>In older individuals, combination procedures may be beneficial. Some examples include the following: </p> <ul> <li>Laser surgery may be used for deep lines (such as those around the mouth) and chemical peels used over the rest of the face.</li> <li>For enhancing the eye by correcting droopy eyelids, bags, and a "sinking" brow, combinations of eyelift (blepharoplasty), Botox, and laser resurfacing may be used.</li> </ul> <p>Chemical peels, also known as chemosurgery, help restore wrinkled, lightly scarred, or blemished facial skin. Much like chemical paint strippers, chemical peels strip off the top layers of skin, and new, younger-looking skin grows back. The procedure is very effective for the upper lip but cannot be performed around the eyes. Partial peels are often done in conjunction with a face-lift. Combinations of the topical antioxidants, such as tretinoin and vitamin C, along with a chemical peel, may be particularly effective. </p> <p><i>The Procedure.</i> </p> <ul> <li>A dermatologist applies chemicals to the skin. They include trichloroacetic acid, high concentrations of alpha hydroxy or beta hydroxy acids, or combinations of all three.</li> <li>In some cases, tretinoin or alpha hydroxy is applied 4 - 6 weeks before, and starting one day after, the peel. Such treatments can enhance the effects of a peel and reduce the risk of discoloration in people at risk for this complication. Tretinoin is being tested as a chemical peel.</li> <li>A crust or scab generally forms within 24 hours after surgery. You can remove this scab by gently cleansing with soap and water.</li> <li>The skin takes 6 - 7 days to heal.</li> <li>After the scab disappears, the visible skin is deep red but gradually lightens as it regenerates.</li> </ul> <p><i>Complications.</i> Complications include white heads, cold sores, infection, scarring, numbness, and permanent discoloration, particularly in people with darker skin. Refinement of chemical peel techniques are now permitting doctors to reach deeper skin, improvements which make it easier to apply peels to non-facial skin and to individuals with darker skin. </p> <p>Dermabrasion affects deeper layers of skin than chemical peels, and may be useful for removing disfiguring marks, such as deep acne scars or deep wrinkles. As with chemical peels, it is effective for wrinkles on the upper lip and chin, and cannot be used around the eyes. Some doctors prefer dermabrasion to lasers for skin surfacing of people with darker skin colors. </p> <p><i>Standard Dermabrasion.</i> Standard dermabrasion uses a rotating brush that removes the top layers of a person's skin. As with chemical peels, dermabrasion selectively strips away the upper layers of skin, leaving the underlying skin layers exposed. Similar to chemical peels, after the procedure, the treated skin oozes and forms a scab, a reaction that looks and feels uncomfortable, but only temporary. Postoperative care is similar for both procedures. </p> <p><i>Microdermabrasion.</i> A gentler variation called microdermabrasion uses very tiny crystals to polish the skin and a vacuum technique to remove them. It has largely replaced the older dermabrasion, and, in fact, was the fourth most common non-surgical cosmetic procedure performed in 2005, with over a million done. Results are similar to light chemical peels. Patients can have this procedure done on their lunch hour and return to work. Only mild redness occurs after treatment, although for best results five or six repetitive treatments are needed every 1 - 2 weeks. To date, overall patient satisfaction has been very high. </p> <p>Lasers are currently the most effective exfoliation tools for eliminating wrinkles. Their unique advantages over other resurfacing methods are their ability to tighten the skin. A successful procedure can make patients look 10 - 20 years younger, and the results can last up to 10 years. </p> <p>The procedure is most beneficial for the following areas: </p> <ul> <li>It is best around the mouth and eyes. Recent evidence suggests CO₂ lasers may be even better than dermabrasion for the upper lip.</li> <li>It is slightly less beneficial for the area around the nose.</li> </ul> <p>Used alone, current laser therapy does not eliminate crow's feet, broken blood vessels, or dark circles under the eye. The evidence of the effects of lasers on acne scars is incomplete. </p> <p>Standard laser dermabrasion is too harsh for thinner skin layers, such as on the neck. Newer and gentler laser techniques, however, stimulate collagen without removing skin layers, and may prove to be useful for necklines. </p> <p><i>The Laser Resurfacing Procedure.</i> In general the procedure works in the following way: </p> <ul> <li>Laser pulses penetrate the skin quickly, vaporizing water and surface skin without damaging the deeper layers, allowing new top skin to grow.</li> <li>In addition, the laser delivers enough heat to shorten collagen fibers, restoring some elasticity to the skin.</li> </ul> <p><i>Choice of Lasers</i>. The lasers used depend on skin type and severity of the condition. Some of the more common laser types are: </p> <ul> <li>The carbon dioxide (CO₂) laser. This is the most powerful laser treatment and is used for deep wrinkles and skin imperfections. People who have had silicone injections should not have CO₂ procedures, which can burn and scar the skin over the implanted area.</li> <li>The erbium: YAG (Er:YAG). This laser is gentler than the CO₂ laser, and is effective for mild wrinkles and for providing a smooth skin texture. It has a shorter recovery time. Some experts have even found the YAG laser as effective in removing deep wrinkles as CO₂ when used to sufficient depth. A variable pulse YAG laser can shift between pulses that destroy skin tissue to those that heat the skin. This process effectively resurfaces the skin with fewer side effects than CO₂ laser therapy.</li> <li>Pulsed dye laser. Pulsed dye laser uses yellow light, which is easily absorbed by hemoglobin, the molecule that gives blood its red color. Pulsed dye laser treatments are used to treat skin blemishes that are due to blood vessel abnormalities, such as port-wine stains.</li> </ul> <p>A gentle laser procedure called non-ablative laser resurfacing (NLite), also called photorejuvenation, is now approved for the treatment of all facial wrinkles. The procedure uses light energy to gently stimulate new collagen, and possibly elastin production, without removing the skin tissue itself. Its effects are less pronounced than those of other laser procedures. However, because it does not injure the external layers of skin, it can be used on delicate skin areas, such as the neck and around the eyes. It also causes very little irritation afterward. </p> <p>Some surgeons are using combination techniques that employ more than one laser technology in one session, to achieve different effects. For example, one combination technique uses CO₂, YAG, pulsed-dye laser, and one other laser technology to both improve wrinkles and clear under-eye dark circles and acne scarring. Pretreatment with botulinum (Botox) injections before laser resurfacing significantly improved the treatment of crow's feet in one study. </p> <p><i>Post-Procedure Recovery.</i> The procedure itself is relatively painless, but the redness and irritation that occur during the healing process can be severe. Non-ablative laser resurfacing does not have the same severe after-effects as other laser treatments. For 8 - 9 days, the face looks skinned and swollen, and requires continuous moisturizing. Some doctors suggest that people with very sensitive skin, who cannot tolerate the necessary medications and lubricants, should avoid laser resurfacing. Redness and sensitivity can persist for 1 - 4 months. The patient must stay out of the sun as much as possible during this time, and should always avoid sunbathing and damaging their skin again. Early research suggests that silicone dressings may reduce post-procedure pain and crusting. </p> <p><i>Complications.</i> Scarring and infections can occur in about 1% of procedures. The risk of complications depends on the experience of the surgeon. People with a history of herpes simplex may experience flare-ups of fever, facial pain, and flu-like symptoms for 5 or 6 days after the procedure. In addition, people with darker skin may wish to avoid the procedure, because it can cause unpredictable and dramatic lightening of the skin. </p> <p>A new skin rejuvenation technology, called Plasma Skin Resurfacing, or Portrait Plasma, was introduced in February 2005. The technology uses plasma energy (heat and light energy) to rejuvenate the skin from the deeper layers outwards. While new skin regenerates, the outer layers of the skin act as a natural bandage. When the outer layers peel off in the week after treatment, the new skin emerges. The process prevents or minimizes the raw appearance that follows laser treatments. This system uses radio waves to "excite" nitrogen gas, resulting in the release of energy. According to the manufacturer, skin regeneration using the Portrait Plasma system is rapid, and satisfaction with the procedure appears high. Long-term follow-up studies are not available yet for this new method. In 2006, the Food and Drug Administration approved this method for the treatment of wrinkles on other areas of the body, besides the face. </p> <p><i>Cold Ablation.</i> Cold ablation, called coblation for short, delivers saline (salt water) to the skin, through which a cool electric current is passed. A subsequent reaction heats and vaporizes the top shallow layer of skin. The procedure is very specific and appears to minimize any damage to other areas of the skin. </p> <p><i>Radiofrequency Resurfacing.</i> A promising technique uses low radiowave energy to resurface the skin. Preliminary research indicates that this procedure may eventually be as effective as laser surgery in reducing severe wrinkles around the eyes and mouth, with minimal pain and a shorter recovery time. In one study, one radiofrequency treatment with only a skin anesthetic resulted in tighter facial skin for 14 out of 15 patients within 12 weeks. All but one patient returned to normal activity immediately afterward. A small clinical trial published in <em>Dermatology Surgery</em> found that a noninvasive radiofrequency technique called NARF safely and effectively improved drooping lower eyelids. </p> <p><i>Intense Pulsed Light.</i> Intense pulsed light (IPL) uses filters to deliver different wavelengths of light. Doctors use it to treat a number of photoaging skin problems, and it appears to have long-term effects. Typically, four to six treatments are performed over a four-month period. Each treatment takes 15 - 20 minutes. Unlike laser light, which uses one color wavelength (such as green or red), intense pulsed light starts with a full spectrum of light. It then allows the doctor to selectively block off specific wavelengths, depending on how shallow or deep the procedure should go. IPL machines are less expensive and safer than lasers. </p> <h3 id="adamHeading_9">Implant Procedures</h3> <p>Implants, also called injectable fillers, are becoming a common means of erasing wrinkles and folds. Several materials are being used for deep wrinkles, depression under the eyes, lip enhancements, and acne scars. </p> <p>After being banned from the market in 1992, silicone is making a comeback in research settings as a potential permanent wrinkle eraser. Scientists are looking into a new microdroplet technique (the use of very small drops) combined with purified silicone as a way to eliminate any danger. The past problems with silicone occurred when it was mixed with a foreign substance, like mineral oil, or when it was injected in large doses. </p> <p>Most implants to date, however, are not completely satisfactory. Collagen implants and biologic fillers from animal, bacterial, or human sources do not provide long-lasting benefits. Synthetic fillers are permanent but may cause an allergic reaction, which can lead to chronic problems. Such reactions are rare, but they can be painful and unattractive. </p> <p>The U.S. Food and Drug Administration (FDA) approved the Juvéderm product line in June 2006. Juvéderm is an injectable treatment of moderate-to-severe facial wrinkles and folds. Juvéderm products are gels made from hyaluronic acid. They are injected into the face. Doctors report good results after a single treatment with Juvéderm, and the results last for at least 6 months. </p> <table border="1" cellpadding="3" cellspacing="0"> <tr> <td valign="top" colspan="5" /></tr> <tr> <td valign="top"><b>Name and Material Used</b></td> <td valign="top"><b>Procedure</b></td> <td valign="top"><b>Specific Areas Affected</b></td> <td valign="top"><b>Benefits</b></td> <td valign="top"><b>Drawbacks</b></td> </tr> <tr> <td valign="top"> <p>Collagen implants. Collagen is the protein that forms the structures in the body (such as skin, bones, cartilage). </p> <p>The implant procedure has typically used bovine (cow) collagen. A form of human collagen (CosmoDerm, CosmoPlast) has now been approved. </p> </td> <td valign="top"> <p>Injected into target wrinkles with needle and syringe. Several weeks after injection, cow collagen breaks down and is replaced by newly created human collagen. </p> </td> <td valign="top"> <p>Wrinkles around the eyes and mouth. It is used to give lips greater fullness. </p> </td> <td valign="top"> <p>Very simple with faster recovery than many other implant techniques. </p> </td> <td valign="top"> <p>Wrinkles form again, and require repeat treatments 3 - 12 months later. Rarely, severe allergic reactions occur. Should not be used by children, pregnant women, and people with a history of autoimmune disease. </p> </td> </tr> <tr> <td valign="top"> <p>Microlipoinjection. Fat tissue from the patient's own thigh or abdomen. </p> </td> <td valign="top"> <p>Injected into target wrinkles with needle and syringe. </p> </td> <td valign="top"> <p>Deep wrinkles around the nose and mouth, folds in the forehead, and wrinkles on the hands. </p> </td> <td valign="top"> <p>No allergic or immune reaction because substance is patient's own fat. </p> </td> <td valign="top"> <p>Body eventually absorbs the fat, resulting in a need for multiple injections. Some studies suggest that 70% of the fat may still be in place after at least a year. </p> </td> </tr> <tr> <td valign="top"> <p>Gore-Tex. Highly porous (full of tiny holes) and inert (not chemically active) synthetic material. </p> </td> <td valign="top"> <p>Requires some surgery. Tiny patches are inserted under the skin to fill out wrinkles. Skin cells and blood vessels pass through the porous material easily, reducing the risk of severe irritation. </p> </td> <td valign="top"> <p>Deep wrinkles. </p> </td> <td valign="top"> <p>Material does not break down. </p> </td> <td valign="top"> <p>Possible scarring from surgical procedure. Allergic reactions are rare but can occur even with chemically inactive materials. </p> </td> </tr> <tr> <td valign="top"> <p>Artecoll. Contains PMMA, or polymethylmethacrylate, an inert substance, enclosed in tiny droplets of natural collagen. </p> </td> <td valign="top"> <p>Material is injected. Body absorbs collagen. PMMA remains and stimulates new collagen growth. </p> </td> <td valign="top"> <p>Deep wrinkles. </p> </td> <td valign="top"> <p>Although part of the implant is a natural collagen implant, it does not degrade as quickly as a full collagen implant. </p> </td> <td valign="top"> <p>Repeat treatments may still be needed. Possible allergic reaction. </p> </td> </tr> <tr> <td valign="top"> <p>Hyaluronic acid. Natural (non-animal) substance acts like a molecular sponge to absorb water. The FDA approved Restylane in 2003, Captiva, Hylaform-Plus, and Hylaform in 2004, and Juvéderm in 2006. </p> </td> <td valign="top"> <p>Gel is injected under the skin. </p> </td> <td valign="top"> <p>Moderate-to-severe wrinkles. </p> </td> <td valign="top"> <p>Low risk for allergic reaction. May last longer than cow collagen. </p> </td> <td valign="top"> <p>Repeat treatments needed. </p> </td> </tr> <tr> <td valign="top"> <p>Poly-L-lactic acid. Synthetic polymer. Approved in US as Sculpta. Approved in other countries as New-Fill. </p> </td> <td valign="top"> <p>Material is injected under the skin. </p> </td> <td valign="top"> <p>Approved in U.S. only for patients with facial fat loss due to HIV. Approved in other countries for wrinkles. </p> </td> <td valign="top"> <p>Low risk of allergies. Treatment effects can last 18 - 24 months. </p> </td> <td valign="top"> <p>Doctors require special training. </p> </td> </tr> </table> <p>The popularity of Botox injections has skyrocketed in the United States. Between 2004 and 2005, the number of procedures performed jumped 16 percent. Botox injection was the number one non-surgical cosmetic procedure in 2005, with more than 3.2 million injections. Botulinum, the deadly toxin found in uncooked foods, is also a powerful muscle-relaxant. Tiny amounts of a purified form (Botox) are injected into wrinkles to relax the surrounding muscles. It may benefit forehead and frown lines, crow's feet, lower eyelids, lines on the side of the nose, and the area between the upper lip and the nose. It is also useful for treating involuntary muscle movements that can occur after a face-lift. </p> <p>The injections need to be repeated every few months, since the effects wear off. The treatment decreases the ability to frown or squint and may cause the corners of the mouth to turn down. When used for areas around eyes, it produces a rounder appearance afterward, which patients should be aware of before they undertake the procedure. </p> <p>The drug does not cross the blood-brain barrier, and, to date, the only side effects are temporary muscle weakness near the injection site. Although there have been some reports that Botox can reduce migraine and tension headaches, Botox also <i>causes</i> headaches in about 1% of cases. In some cases, the headaches can be very severe and long lasting (from 8 days to a month). Some researchers suggest that either a contaminated batch of Botox or a specific injection technique may be the cause, but additional investigation is needed. </p> <h3 id="adamHeading_10">Plastic Surgery</h3> <p>In 2005, there were over 2.1 million cosmetic surgeries, up 1% from the year before. Most of these surgeries were liposuction and breast surgeries. However, over 200,000 each of eyelid and nose surgeries were performed. Facial plastic surgeries range from being fairly minimal, such as a brow lift, to a full face-lift. </p> <p>Several face-lift procedures (called rhytidectomies) are available. Face-lifts can provide individuals with a more youthful look. The degree of improvement, however, depends on many factors, including age, bone structure, skin type, and personal habits, such as smoking and sunbathing. </p> <p><i>The Procedure.</i> When a face-lift is a relatively simple procedure, it can take about 2 hours under local anesthetic in a doctor's office. Complicated face-lifts are done under general anesthesia in a hospital and can take 3 - 6 hours. The face-lift procedure may be one of the following: </p> <ul> <li>Superficial musculoaponeurotic system (SMAS) is the most common face-lift procedure. The surgeon makes an incision at the hairline and separates the skin from the underlying tissue and muscles. The muscles are tightened and excess fat and tissue, such as fat under the chin and neck, are removed.</li> <li>The endoscopic subperiosteal or subgaleal face-lift is a less invasive surgical technique. The surgeon raises facial structures rather than cutting away flaps of skin. Only a few half-inch incisions are made, and scarring is minimal. Not all individuals are candidates for this procedure, however.</li> </ul> <p>Neither SMAS nor the endoscopic version is effective for the middle part of the face, particularly the deep lines (naso-labial folds) that run down from the nose beside the mouth. Some time after the SMAS face-lift, the upper face begins to age again while the lower area keeps its shape, causing the face to look imbalanced. Researchers are looking at other approaches, such as one called composite face-lift, that lift most muscles in the face. </p> <p><i>Recovery Process.</i> Recovery normally lasts from several weeks to several months. Swelling and discoloration are common. Some patients report tingling or numbing sensations after surgery. These sensations generally decrease as damaged nerves regenerate. </p> <p><i>Complications.</i> A face-lift is not without risks. A postsurgical hematoma is a collection of blood that can occur after a face-lift. In one study, major hematomas occurred in 2.2% of patients and minor hematomas in 6.65% of patients. They generally develop within 2 weeks of the surgery and require draining. Even minor hematomas need fast treatment to prevent greater complications. Such complications can include infection, changes in skin color, fluid buildup, and prolonged recovery time. </p> <p>Other less common complications may include the following: </p> <ul> <li>Infection</li> <li>Excessive bleeding</li> <li>Imbalanced facial muscles</li> <li>Delayed healing</li> <li>Scarring</li> <li>Permanent injury to the nerves that control facial movements</li> </ul> <p>These complications are rare, particularly with a skilled surgeon, but the more complex the face-lifts, the greater the risk. </p> <p><i>Blepharoplasty.</i> Blepharoplasty is the primary surgical procedure for eye lifts. Results usually last 5 -10 years. Although simple, it has potential complications, including permanent difficulty in closing the eyes or making a stern expression. Newer techniques, however, are preventing this complication. Assuming the surgeon is experienced, laser surgery is now preferred to the standard surgical scalpel approach. Laser surgery reduces bleeding and bruising, and both the operation and recovery are faster. Temporary blurred or double vision is common. More serious complications include infection, bleeding, dry eyes, difficulty in closing the eyes, and pulling down of the lower lids. Rare cases of blindness have been reported. </p> <p><i>Transconjunctival Upper Blepharoplasty.</i> An innovative procedure called transconjunctival upper blepharoplasty removes fat from the membrane that lines the eyelids (the conjunctiva) and is an effective technique for treating both the upper and lower eyelids. Unlike traditional blepharoplasty, this procedure does not cause scarring in the nasal area. In patients who have scars from previous surgeries, transconjunctival removal of fat can also make existing scars less obvious. Long-term side effects and effectiveness of this procedure have not been studied. </p> <p><i>Laser Liposculpture and Platysma Resurfacing.</i> A procedure called laser neck and jowl liposculpture and platysma resurfacing may prove to be an alternative to face-lifts. The procedure requires only a one-inch incision under the chin and removing excess fat. After the fat is removed, the surgeon tightens the platysma, the thin muscular sheet under the skin of the neck, which improves the shape of the neck. Only local anesthetic is needed, and the patient can return to normal activities in 2 days. The patient's skin should be elastic enough to be able to reform without sagging. </p> <h3 id="adamHeading_11">Resources</h3> <ul> <li><a href="http://www.aad.org/" target="_blank">www.aad.org</a> -- American Academy of Dermatology</li> <li><a href="http://www.asds.net/" target="_blank">www.asds.net</a> -- American Society for Dermatologic Surgery</li> <li><a href="http://www.plasticsurgery.org/" target="_blank">www.plasticsurgery.org</a> -- American Society of Plastic and Reconstructive Surgeons</li> <li><a href="http://www.surgery.org/" target="_blank">www.surgery.org</a> -- American Society for Aesthetic Plastic Surgery</li> <li><a href="http://www.skincarephysicians.com/agingskinnet/" target="_blank">www.skincarephysicians.com/agingskinnet</a> -- Aging Skin Net</li> </ul> <h3 id="adamHeading_12">References</h3> <p>Autier P, Gandini S. Vitamin D Supplementation and Total Mortality : A Meta-analysis of Randomized Controlled Trials. <em>Arch Intern Med</em>. 2007;167:1730-1737. </p> <p>Cho HS, Lee MH, Lee JW, et al. Anti-wrinkling effects of the mixture of vitamin C, vitamin E, pycnogenol and evening primrose oil, and molecular mechanisms on hairless mouse skin caused by chronic ultraviolet B irradiation. <em>Photodermatol Photoimmunol Photomed</em>. 2007;23(5):155-62. </p> <p>Edison BL, Green BA, Wildnauer RH, Sigler ML. A polyhydroxy acid skin care regimen provides antiaging effects comparable to an alpha-hydroxyacid regimen. <em>Cutis</em>. 2004;73(2 Suppl):14-17. </p> <p>Gordon, ML. A conservative approach to the nonsurgical rejuvenation of the face. <em>Dermatol Clin</em>. 2005 Apr;23(2):365-71. </p> <p>Helfrich YR, Yu L, Ofori A, et al. Effect of smoking on aging of photoprotected skin: evidence gathered using a new photonumeric scale. <em>Arch Dermatol</em>. 2007;143(3):397-402. </p> <p>Hercberg S, Ezzedine K, Guinot C, et al. Antioxidant supplementation increases the risk of skin cancers in women but not in men. <em>J Nutr</em>. 2007;137(9):2098-105 </p> <p>Kang S. A multicenter, randomized, double-blind trial of tazarotene 0.1% cream in the treatment of photodamage. <em>J Am Acad Dermatol</em>. 2005; 52(2): 268-274. </p> <p>Mitsuhashi Y, Kawaguchi M, Hozumi Y, Kondo S. Topical vitamin D3 is effective in treating senile warts possibly by inducing apoptosis. <em>Dermatol</em>. 2005;32(6):420-423. </p> <p>Rubino C, Farace F, Dessy LA, Sanna MP, Mazzarello V. A prospective study of anti-aging topical therapies using a quantitative method of assessment. <em>Plast Reconstr Surg</em>. 2005;115(4):1156-1162. </p> <p>Samuel M, Brooke RC, Hollis S, Griffiths CE. Interventions for photodamaged skin. <em>Cochrane Database Syst Rev</em>. 2005;(1):CD001782. </p> <p>Sudel KM, Venzke K, Mielke H, et al. Novel aspects of intrinsic and extrinsic aging of human skin: beneficial effects of soy extract. <em>Photochem Photobiol</em>. 2005;81(3):581-587. </p> <p>Thornfeldt C. Cosmeceuticals containing herbs: fact, fiction, and future. <em>Dermatol Surg</em>. 2005;31(7 Pt 2):873-880. </p> <p>Vochelle D. The use of poly-L-lactic acid in the management of soft-tissue augmentation: a five-year experience. <em>Semin Cutan Med Surg</em>. 2004;23(4):223-226. </p> <p>Yarosh D, Klein J, O'Connor A, Effect of topically applied T4 endonuclease V in liposomes on skin cancer in xeroderma pigmentosum: a randomised study. Xeroderma Pigmentosum Study Group. <em>Lancet</em>. 2001;357(9260):926-9. </p> <div id="health_topic_footer"> Review Date:<br /> 10/23/2007<br /> Reviewed By:<br /> Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.<br /> <div style="margin:10px 0px;"> <div style="float:left;margin:0px 10px 5px 0;"> </div> <div style="margin-bottom:5px;"> A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC&#39;s <a href="http://webapps.urac.org/healthwebsiteaccreditation/default.asp?id=878843645" target="_blank">accreditation program</a> is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. 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Any duplication or distribution of the information contained herein is strictly prohibited. </div> <div align="center"><a href="http://www.adam.com" target="_blank">adam.com</a></div> </div> </div> </div> </div> </div> <div class="clear"></div> http://www.fitsugar.com/2331195#comment In-Depth Report Wed, 08 Oct 2008 17:34:59 -0700 FitSugar http://www.fitsugar.com/2331195 http://www.fitsugar.com/2331164 <a href="http://www.fitsugar.com/2331164"></a><div id="health_topic"> <div id="health_topic_left"> <div class="left_nav_block"> <h3>In This Report</h3> <ul> <li class="indent"><a href="#adamHeading_2" rel="section">Highlights</a></li> <li class="indent"><a href="#adamHeading_3" rel="section">Introduction</a></li> <li class="indent"><a href="#adamHeading_4" rel="section">Biological and Medical Caus...</a></li> <li class="indent"><a href="#adamHeading_5" rel="section">Cultural and Emotional Caus...</a></li> <li class="indent"><a href="#adamHeading_6" rel="section">Risk Factors</a></li> <li class="indent"><a href="#adamHeading_7" rel="section">Complications</a></li> <li class="indent"><a href="#adamHeading_8" rel="section">Weight Loss and Maintenance...</a></li> <li class="indent"><a href="#adamHeading_9" rel="section">Weight Management</a></li> <li class="indent"><a href="#adamHeading_10" rel="section">Medications</a></li> <li class="indent"><a href="#adamHeading_11" rel="section">Other Treatments</a></li> <li class="indent"><a href="#adamHeading_12" rel="section">Resources</a></li> <li class="indent"><a href="#adamHeading_13" rel="section">References</a></li> </ul> </div> </div> <div id="health_topic_right"> <div id="health_topic_from_adam"> HEALTH GUIDE REFERENCE FROM A.D.A.M </div> <div id="health_topic_content"> <h3 id="adamHeading_2">Highlights</h3> <p><strong>Cancer and Weight Control:</strong> </p> <ul> <li>Cancer prevention guidelines from the American Cancer Society stress the importance of maintaining a healthy weight throughout life. A healthy weight is even more important than eating specific healthy foods, when it comes to cancer prevention.</li> </ul> <p><strong>Drug Warning:</strong> </p> <ul> <li>The US Food and Drug Administration (FDA) is warning consumers not to buy a product known as the "Brazilian diet pill." This product is labeled as a dietary supplement, but contains several chemicals found in powerful prescription drugs. The products are also known as Emagrece Sim and Herbathin dietary supplements.</li> </ul> <p><strong>New Over-the-Counter Medication:</strong> </p> <ul> <li>In February 2007, the FDA approved the first over-the-counter (OTC) weight-loss drug. Orlistat, previously available only by prescription as Xenical, will be available OTC at half its prescription strength. It will be sold under the name <em>alli</em>. Those eager to use the new pill should consider its cost and modest benefits compared with its side effects, most commonly oily diarrhea. This pill, which prevents fat absorption from food, also increases the risk of not absorbing important nutrients from food while using it. The FDA recommends taking a daily multivitamin supplement when using alli.</li> </ul> <p><strong>Research News:</strong> </p> <ul> <li>A small study in Norway found that a diet low in fat and high in carbohydrates ("carbs") increases symptoms of psychological distress, such as depression and anger. The study compared three different diets with varying amounts of fat and carbohydrates.</li> <li>A study released in March 2007 found that obesity in young girls results in early puberty -- as early as age 9.</li> </ul> <p><strong>Effects of Obesity on the Body:</strong> </p> <ul> <li>Obesity is associated with certain problems related to infertility, such as uterine fibroids or menstrual irregularities. In men, obesity can contribute to reduced testosterone levels.</li> <li>People who are obese are at higher risk for carpal tunnel syndrome and other problems involving nerves in their wrists and hands.</li> <li>The Pickwickian syndrome, named for an overweight character in a Dickens novel, occurs in severe obesity when lack of oxygen produces intense and chronic sleepiness and, eventually, heart failure.</li> </ul> <h3 id="adamHeading_3">Introduction</h3> <p>A stable weight depends on a good balance between the energy you get from food and the energy you use. You use energy during the day in three ways: </p> <ul> <li>As energy expended during rest (basal metabolism)</li> <li>As energy used to break down food (thermogenesis)</li> <li>As energy used during physical activity</li> </ul> <p>Basal metabolism accounts for about two-thirds of spent energy. Your body generally uses this energy to keep your body temperature steady and keep the muscles of your heart and intestine working. Thermogenesis accounts for about 10% of spent energy. </p> <p>When a person consumes more calories than the energy they use, the body stores the extra calories in fat cells. Fat cells function as energy reservoirs. They enlarge or shrink depending on how people use energy. If people do not balance energy input and output by eating right and exercising, fat can build up. This can lead to weight gain. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">When energy input is equal to energy output, there is no expansion of fat cells (lipocytes) to accommodate excess. It is only when more calories are taken in than used that the extra fat is stored in the lipocytes and the person begins to accumulate fat.</div> </div> </div> <p>Obesity is determined by measuring body fat, not just body weight. People might be over the weight limit for normal standards, but if they are very muscular with low body fat, they are not obese. Others might be normal or underweight, but still have excessive body fat. The following measurements and factors are used to determine whether or not a person is overweight to a degree that threatens their health: </p> <ul> <li>Body mass index (BMI) (a measure of body fat)</li> <li>Waist circumference (size around the waist)</li> <li>Waist-hip ratio</li> <li>Skin fold measurement (anthropometry)</li> <li>The presence or absence of other disease risk factors (e.g., smoking, high blood pressure, unhealthy cholesterol levels, diabetes, relatives with heart disease)</li> </ul> <p>A person's disease risk factors plus BMI may be the most important components in determining health risks with weight. </p> <p><i>The Body Mass Index (BMI).</i> The current standard measurement for obesity is the body mass index (BMI). In general, a BMI of 25 - 29.9 means you are overweight. Obesity is a BMI of 30 and above. Obesity is then classified into three categories: </p> <ul> <li>Class 1: BMI of 30 - 34.9</li> <li>Class II: BMI 35 - 39.9</li> <li>Class III: BMI of 40 and greater</li> </ul> <p>These guidelines are very important for people at risk for diabetes, heart disease, or certain cancers. It is also used to determine treatment approaches such as when surgery may be appropriate. The higher the BMI, the greater the risk for significant health problems. </p> <p><em>Calculating Body Mass Index (BMI).</em> One's body mass index (BMI) is calculated by multiplying a person's weight in pounds by 703, dividing by the height in inches, and then dividing that number by the height in inches. The steps are as follows: </p> <ul> <li>Multiply one's weight in pounds by 703</li> <li>Divide that answer by height in inches</li> <li>Divide that answer again by height in inches</li> </ul> <p>For example, a woman who weighs 150 pounds and is five feet eight inches (or 68 inches) tall has a BMI of 22.8. </p> <p><i>Waist Circumference and Waist-Hip Ratio.</i> The extent of abdominal fat can also be used in assessing risk of disease. Some studies suggest that: </p> <ul> <li>Women whose waistlines are over 31.5 inches and men whose waists measure over 37 inches should watch their weight.</li> <li>A waist size greater than 35 inches in women and 40 inches in men is associated with a higher risk for heart disease, diabetes, and impaired functioning.</li> </ul> <p>Evidence strongly suggests that more body fat around the abdomen and hips (the apple-shape) is a more consistent predictor of heart problems and health risks than BMI. </p> <p>The distribution of fat can be evaluated by dividing waist size by hip size. For example, a woman with a 30-inch waist and 40-inch hip circumference would have a ratio of 0.75; one with a 41-inch waist and 39-inch hips would have a ratio of 1.05. The lower the ratio the better. The risk of heart disease rises sharply for women with ratios above 0.8 and for men with ratios above 1.0. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331221" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see a depiction of the waist-to-hip ratio.</div> </div> <p><i>Anthropometry.</i> Anthropometry is the measurement of skin fold thickness in different areas, particularly around the triceps, shoulder blades, and hips. This measurement is useful in determining how much weight is due to muscle or fat. </p> <h3 id="adamHeading_4">Biological and Medical Causes</h3> <p>Obesity results when a person consumes more calories than they need for the energy they use. Several different factors may influence weight gain. </p> <p>About 90% of people who lose weight through dieting gain every pound back regardless of their weight-loss method. </p> <p>Some evidence suggests that every person has an inherited weight. This range varies by only about 10% either up or down from some set point. For instance, a man whose "genetically-determined" weight is 200 pounds would tend to swing from 180 - 220 pounds. He would be unlikely to lose or gain more than this. </p> <p>Genetic factors may play some part in 70 - 80% of obesity cases. </p> <p>Appetite is determined by processes that occur both in the brain and gastrointestinal tract. Eating patterns are controlled by areas in the hypothalamus and pituitary glands (in the brain). The body produces a number of molecules that increases or decreases appetite. In some cases, the following factors may produce imbalances in this process: </p> <ul> <li><i>Insulin.</i> Insulin is a hormone that helps change blood sugar (glucose) into energy. During digestion, carbohydrates from our diet break down into different types of sugar molecules (including glucose). Proteins from our diet break down into smaller molecules called amino acids. Immediately after eating, blood glucose levels rise. This triggers the release of insulin, which pours into the bloodstream. Insulin pushes the glucose and amino acids into cells and muscles. Insulin and other hormones determine which nutrients will be burned for energy or stored for future use. The inability to use insulin efficiently (insulin resistance) has been associated with both obesity and diabetes.</li> <li><i>Leptin</i>. Leptin is a hormone that is released by fat cells. A number of scientists think this hormone may also be released by cells in the stomach. Leptin appears to play an important role in insulin resistance and fat storage in the body, but its role in obesity is unclear. The most likely scenario is that leptin levels rise as the cells store more fat. This increase in leptin levels decreases appetite. Falling levels of leptin make you feel hungry. In people who have genetically lower levels of leptin, however, the brain may be tricked into thinking that it is always starving because there is no leptin to decrease appetite. This can lead to weight gain.</li> <li><i>Resistin.</i> Resistin is a hormone produced by fat cells. It makes the body resistant to insulin activity. Some experts believe it may help explain the role of obesity in diabetes type 2.</li> <li><i>Intestinal Chemicals.</i> Ghrelin is a chemical produced in the stomach. It appears to be important in triggering the desire to eat. Peptide YY3–36 (PYY) is a substance secreted in the intestines after a meal. The level of PYY is proportionate to the number of calories a person eats. PYY tells the brain that you feel full. Deficiencies in ghrelin and PYY may contribute to some cases of obesity. Researchers are hoping that blocking ghrelin or infusing PYY may be possible treatments for obesity.</li> <li><i>Other Chemicals.</i> Many brain chemicals are being studied for their role in appetite stimulation and weight gain. Among them are neuropeptide Y, melanocortins, agouti-related protein, and melanocyte stimulating hormone. Pain-relieving chemicals called endorphins may be critical in reducing appetite and regulating energy use. Cholecystokinin, a hormone released in the upper intestine that stimulates digestive juices, may work to control meal size.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Insulin is a hormone produced by the pancreas that is necessary for cells to be able to use blood sugar.</div> </div> </div> <p>Genetics may directly contribute to severe obesity in people with family histories of the problem. Genetic factors such as slow metabolisms may also make people more likely to be overweight. At least seven genetic mutations have been associated with specific and uncommon cases of severe obesity. Some are outlined below. </p> <ul> <li>HOB1 (human obesity 1) is a gene that is linked to a high BMI in women.</li> <li>Leptin gene variants have been linked to leptin deficiencies and obesity.</li> <li>Melanocortin-4 receptor is a gene that helps turn off the urge to eat. It may not work properly in those with a family history of obesity.</li> <li>Researchers have also identified a mutation in a gene for a protein called proopiomelanocortin, which results in a syndrome of obesity, red hair, and deficiencies in stress hormones.</li> <li>A protein called agouti-related protein increases hunger. About 5% of severely obese people have mutations that over-respond to agouti-related protein.</li> </ul> <p>Genetics also determine the number of fat cells a person has. Some people are simply born with more. It should be noted that even when genetic factors are present, a person can still control their diet. </p> <p><i>The Thrifty Gene.</i> Some experts think the existence of a so-called "thrifty" gene regulates changes in hormone levels, to accommodate seasonal changes. Theoretically, it works in the following manner: </p> <ul> <li>In certain populations, hormones are released during seasons when food supplies have traditionally been low. This leads to insulin resistance and increased fat storage.</li> <li>The process is reversed in seasons when food is readily available.</li> <li>Because modern industrialization has made high carbohydrate and fatty foods available all year long, the gene no longer serves a useful function. Fat, originally stored for famine situations, is not used.</li> </ul> <p>This theory could explain why the previously nomadic Native American tribes who now have Western dietary habits have such high rates of Type 2 diabetes and obesity. In the past, the traditional low-fat, high-fiber foods tribe members ate may have protected them from obesity and type 2 diabetes. Today, these tribes' diet consists of more Western foods, which are higher in fat. Furthermore, these foods are readily available year-round, and many members of the tribe are sedentary. The result is a very high incidence of Type 2 diabetes and obesity. Although genetic abnormalities may make it harder or easier to lose weight, the occurrence of obesity has dramatically increased over the past two decades, and genes cannot have changed within that short amount of time. Our ability to use the food that we eat evolved so that our body could conserve energy and store fat during times of famine. Most cases of obesity now occur in people with normal body function who live in industrialized nations, where there is more than enough food. </p> <p>A number of medical conditions may contribute to being overweight, but rarely are they a primary cause of obesity. </p> <ul> <li>Hypothyroidism is sometimes associated with weight gain. But, patients with an underactive thyroid generally show only a moderate weight increase of five to 10 pounds.</li> <li>Very rare genetic disorders, including Froehlich's syndrome in boys, Laurence-Moon-Biedl, and the Prader-Willi syndromes, cause obesity.</li> <li>Abnormalities or injury to the hypothalamus gland can cause hypothalamic obesity.</li> <li>Cushing's disease is a rare condition caused by high levels of steroid hormones. It results in obesity, a moon-shaped face, and muscle wasting.</li> <li>Obesity is also linked to polycystic ovarian syndrome, a hormonal disorder in women.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331124" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of polycystic ovaries.</div> </div> <p>Some prescription medications contribute to weight gain, usually by increasing appetite. Such drugs include the following: </p> <ul> <li>Corticosteroids</li> <li>Female hormone treatments, including some oral birth control pills (effect is usually temporary), and certain progestins (such as Megestrol) used to treat cancer</li> <li>Antidepressants and anti-psychotic drugs, including lithium and valproate</li> <li>Insulin and insulin-stimulating drugs used to treat diabetes often lead to weight gain, a particularly unfortunate conflict of interest for obese individuals with type 2 diabetes</li> </ul> <p>You should not stop taking any medications without your doctor's knowledge. </p> <h3 id="adamHeading_5">Cultural and Emotional Causes</h3> <p>Enough food is produced in the US to supply 3,800 calories every day to each man, woman, and child in the country, far more than the average person needs to sustain life. In a 2002 study, participants carefully recorded everything they ate and drank, and all activities and psychological factors surrounding the eating events. The people who gained weight ate more and their portions were larger than those who did not. This may be an obvious conclusion, but the public press often plays up biologic factors involved with obesity and overlooks the simple notion that Americans eat too much and exercise too little. </p> <p>Obesity is dramatically increasing not only in American children and adults, but also in every country that has adopted similar cultural habits. The World Health Organization now considers obesity to be a global epidemic and a public health problem as more nations become "Westernized." In spite of the proven health risks of obesity, the government, insurance companies, and the medical profession do not spend nearly enough money to balance the commercial and cultural pressures that are producing millions of overweight people. </p> <p>In 2007, the Robert Wood Johnson Foundation sounded a positive note with the announcement of a $500 million initiative, aimed at “reversing the childhood obesity epidemic by 2015.” The money will be used for research, education, and activities that promote healthy eating among America’s children. </p> <p>Perhaps the primary reason for the dramatic rise in obesity is the sedentary (inactive) lives led by most Americans, including children and young people. In a 2003 study comparing modern life to the past, researchers found that labor saving devices had reduced a person's energy use by 111 calories a day -- adding up to an extra 11 pounds a year. Half the difference in energy use was due to less walking. At the same time, according to the U.S. Centers for Disease Control and Prevention, between 1970 and 2000 the typical American man increased his caloric intake by 168 calories a day (good for 17 pounds a year) while the average woman added 335 calories a day. </p> <p>Regular television watching has been singled as the most hazardous pastime. According to a major 2003 study, for every 2 hours a person spends in front of the TV each day, the risk for obesity increases by 23% and for type 2 diabetes by 14%. In the study, TV watching produced the lowest metabolic rates compared to sewing, playing board games, reading, writing, and driving a car. Just the act of watching TV encourages unhealthy snacks and eating patterns. In addition, the advertising on the television complicates the problem by promoting fast foods, cereal, and snack products that are high in salt, fats, and carbohydrates. Even worse, much of these advertisements are directed at children -- the most vulnerable group. </p> <p>People are not only eating more food than they did 20 years ago, they are also replacing home cooking with packaged foods, fast food, and dining out. This behavior, according to studies, places people at higher risk for obesity. Fast foods may be more harmful than restaurant cooking. These foods tend to be served in larger portions. They generally contain more calories and unhealthy fats, and less nutritious ingredients, than homemade or restaurant meals. Snack foods and sweet beverages, including juice and soft drinks, are specific problems that add to the increasing rates of obesity. Frequent small, healthy meals (instead of two or three large daily meals) have been associated with <em>lower</em> weights. </p> <p>People react differently to stress. Some overeat and gain weight and others stop eating and lose weight. People who gain weight in response to stress often overeat foods high in sugar, fats, and salt. A 2003 study on rats suggested that stress hormones increase the pleasure of eating such so-called "comfort foods." Furthermore, the study supported previous research showing that stress-related eating was connected to the unhealthy accumulation of abdominal fat. </p> <h3 id="adamHeading_6">Risk Factors</h3> <p>Where you live plays a role in your risk for obesity. Simply living in the United States makes a person more susceptible to obesity. The prevalence of obesity in America has risen dramatically over the past few years and continues to increase. </p> <ul> <li>According to the latest figures available, 32.2% of American adults (aged 20 and older) are obese (BMI over 30) -- up from about 23% in the early 1990s.</li> <li>The number of Americans aged 20 - 74 who were overweight also increased -- from about 44.8% in 1960 to 65.2% in 2002.</li> <li>The rate of extreme obesity (BMI &gt; 40) increased from 0.8% in 1960 to 4.9% in 2002.</li> <li>Obesity has increased in every state, in both men and women, across all age groups, and in every ethnic group, although some groups may face slightly higher risks than others.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Fat tends to settle in certain regions, depending on gender. Women gain fat predominantly in the stomach, hips and thighs, while men tend to gain fat in the belly and waist.</div> </div> </div> <p><i>Risk by Age.</i> People of any age are at risk for obesity. More children and adolescents are overweight in America than ever before. Gaining some weight is inevitable with age and adding about 10 pounds to a normal base weight over time is not harmful. The current weight gain in American adults over 50, however, is significant. By age 55, the average American has added nearly 40 pounds of fat during the course of adulthood. This condition is made worse by the fact that muscle and bone mass decrease with age. </p> <p><i>Risk by Gender.</i> In men, BMI tends to increase until age 50 and then it levels off. In women, weight tends to increase until age 70 before it plateaus. A 2000 study found that there are three high-risk periods for weight gain in women. </p> <ul> <li>The first is at the onset of menstruation, particularly if it is early. In fact, a study released in March 2007 found that obesity in young girls results in early puberty -- as early as age 9. This, in turn, increases the risk for more weight gain as girls enter puberty.</li> <li>The second is after pregnancy, with higher risk for women who are already overweight.</li> <li>Finally, many women gain weight after menopause.</li> </ul> <p>These findings are significant because they may allow women to target high-risk times, and consequently prevent unnecessary weight gain. </p> <p><i>Risk by Economic Group</i>. Obesity is more prevalent in lower economic groups. One 2002 study reported that women who reported that they did not have enough food were more likely to be overweight than those who said they had sufficient food. Researchers discovered that the low-income women tended to have fewer fruits and vegetables but were actually taking in more calories a day than higher-income women. However, obesity is increasing in young adults with college education as well as in other groups. </p> <p><i>Ethnic Groups.</i> Among ethnic groups in general, African-American women are more overweight than Caucasian women but African-American men are less obese than Caucasian men. (Currently, 80% of African-American women are overweight.) Hispanic men and women tend to weigh more than Caucasians. </p> <p><i>US Regions.</i> Regionally, the prevalence of obesity is lowest in the Western states and highest in the South. </p> <p>A number of dietary habits put people at risk for becoming overweight: </p> <ul> <li><i>Night-Eating Syndrome.</i> Night-eating syndrome is defined as having no appetite in the morning, insomnia, and consuming more than half of daily food intake after 6:00 PM. It is associated with obesity and is difficult to treat. Stress reduction and relaxation techniques may be helpful.</li> <li><i>Binge Eating and Eating Disorders.</i> About 30% of people who are obese are binge eaters who typically consume 5,000 - 15,000 calories in one sitting. To be diagnosed as a binge eater, a person has to binge at least twice a week for 6 months. Many experts believe that binge-eating carbohydrates causes an increase in a natural opiate leading to dependence on carbohydrates. Therefore, this condition should be treated as an addiction. Other eating disorders are bulimia and anorexia. Bulimia is binge eating followed by purging in order to lose weight. Anorexia nervosa is a mental illness in which the person refuses to maintain weight at the normal level. The patient with anorexia has a terrible fear of getting fat, and an abnormal perception of what his or her body looks like. Both conditions pose risks for serious medical problems, and anorexia nervosa can be life-threatening. A combined approach using behavioral therapy and antidepressants may help these individuals. [See In-Depth Report #49: Eating disorders.]</li> <li><i>Restrained Eating.</i> Some people, mostly middle-aged women who have normal weight, have a pattern referred to as restrained eating. This pattern requires a high level of conscious control and usually maintains a lower weight. However, such restraint places these individuals at higher risk for loss of control and subsequent overeating.</li> <li><i>Infrequent Eating.</i> There is some evidence to suggest that eating small frequent meals uses more calories than infrequent large meals. It should be strongly noted, however, that packaged snack foods add calories and some do not produce a feeling of being full, so that people simply eat more than they should.</li> </ul> <p><i>Anyone with Sedentary Lifestyles.</i> Office workers, drivers, and anyone whose lifestyle involves sitting for long periods are at higher risk for obesity. </p> <p><i>Ex-Smokers.</i> The trend toward weight increase has followed the trend for quitting smoking. Nicotine increases the metabolic rate, and quitting, even without eating more, can cause weight gain, which may be considerable. It is important to note that weight control is not a valid reason to smoke. People in previous centuries did not smoke cigarettes, nor were they usually obese. </p> <p><i>Shift-Workers.</i> A recent study found that individuals who work late shifts (between 4 p.m. and 8 a.m.) tend to eat more and take longer naps than day workers and are more likely to gain excess weight. </p> <p><i>People with Disabilities.</i> Obesity rates are higher than average in people with physical or mental disabilities. Those with disabilities in the lower part of the body, such as the legs, are at highest risk. </p> <p>Overweight in children and adolescents is rising at an alarming rate. In 2004, 19% of young children aged 6 - 11 were overweight, an increase of 8% from 1994. Among children aged 25, 13.9% were overweight in 2004, up from 7.2% 10 years earlier. </p> <p><b>Definition of Overweight in Children</b> </p> <p>Children and adolescents are considered to be overweight if their BMI is above 95% of the children in their age and sex categories. Ethnic variations, timing of growth spurts, and higher normal fat levels around puberty can affect these measurements. </p> <p><b>Causes and Risk Factors for Overweight in Children</b> </p> <p><i>Lifestyle Factors.</i> Without educational or parental guidance, children are extremely vulnerable to the intense cultural pressures that are largely responsible for the obesity epidemic. The following are some specific problems created by the culture: </p> <ul> <li>Excessive television watching plays a critical role in obesity in children. Not only is it a sedentary activity, but television also offers innumerable temptations with its advertisements for fast foods, sugar cereals, and unhealthy snacks. In one study obesity rates were lowest in children who watched television 1 hour or less a day and highest in those who watched 4 or more hours.</li> <li>Sugar, particularly from soda, other sweetened beverages, and fruit juice, may be the major contributor to childhood obesity. One study reported that drinking soda regularly increases a child's risk for obesity by 60%. The average American adolescent consumes 15 - 20 extra teaspoons of sugar a day just from soda and sugary drinks. (Juice, while better than soda, is still filled with sugar.)</li> <li>Less physical exercise and greater sedentary activities play another significant role in obesity in children. A high level of physical activity -- not just using up energy -- is important for weight control in young people. Unfortunately, according to one study, the annual distance walked by children has fallen by nearly 30% since 1972, partially because more parents are driving their children to school out of fear of abduction, molestation, and traffic accidents. Schools are also offering fewer opportunities for daily physical activities than in the past.</li> </ul> <p>Neither the media nor the educational system has strong well-financed programs that encourage healthy alternatives, including exercise and healthy foods. </p> <p><i>Family History.</i> Parental obesity more than doubles the risk that a young child, whether thin or overweight, will become obese as an adult. In older children and teenagers, obesity in parents starts to count less as a predictor for body weight than their own weight. The risk for obesity may be due to environmental or genetic factors, or both. </p> <p><i>Ethnic and Socioeconomic Factors.</i> As in adult populations, children from lower socioeconomic groups and minority populations are at higher risk for obesity. For example, among young Mexican Americans and African-Americans, there has been an increase in overweight prevalence of about 13% to over 23%. </p> <p><i>Factors Surrounding Birth.</i> The following factors surrounding birth are associated with a child's weight: </p> <ul> <li>Low birth weight is a risk factor for later obesity and diabetes. One theory is that humans have a "thrifty gene" that produces metabolic changes in infants with low birth weight. Such changes affect insulin and fat accumulation, in order to produce a "catch-up" weight in these young children as quickly as possible. This rapid weight gain in infancy increases the risk for obesity in children and young adults.</li> <li>In a study of African-American children, having an overweight pregnant mother increased the risk for later weight gain, but low birth weight did not.</li> </ul> <p>Although some small studies have reported protection against obesity from breastfeeding, evidence is weak. In a 2003 study, for example, children who were breast fed for 3 - 5 months had a lower risk for obesity, but prolonged breastfeeding had no effect. Nevertheless, given the healthful effects of breast feeding and the possibility that it may have even a slight impact on childhood obesity, it is highly recommended. </p> <p><b>Biological Effect of Childhood Overweight on Adult Weight</b> </p> <p>Achieving a healthy weight becomes more difficult as children get older. The odds of obesity persisting into adulthood ranges from 20% in 4 year olds to 80% in teenagers. One reason for the persistence is biological. The fat cells change in number or mass depending on a person's age: </p> <ul> <li>Fat cells themselves multiply during two growth periods: early childhood and adolescence. Overeating during those times increases the <i>number</i> of fat cells. Some people are also just born with more fat cells.</li> <li>After adolescence, fat cells tend to increase in <i>mass</i> rather than quantity, so that adults who overeat and gain weight tend to have larger fat cells, not more of them. This growth in mass may be responsible for the greater risk of persistent obesity among teenagers compared to small children who are overweight. Losing weight after adolescence reduces the size of the fat cells but not their number, so weight loss becomes much more difficult.</li> </ul> <p><b>Health Consequences of Childhood Overweight</b> </p> <p>Children and adolescents who are overweight have poorer health than other children. Studies are reporting unhealthy cholesterol levels and high blood pressure in overweight children and adolescents. Of great concern is the dramatic increase in type 2 diabetes in young people, which is largely due to the increase in overweight children. Overweight in children is also linked to asthma, gallbladder problems, sleep apnea, and liver abnormalities. Overweight girls are more likely to enter puberty early, according to a new study, and subsequently be at higher risk for breast cancer. </p> <p>It is not clear yet how many of these childhood problems persist in people who achieve normal weight as adults. Staying overweight into adulthood certainly carries health risks. </p> <p><b>Managing Overweight Children</b> </p> <p>Childhood obesity is best treated by a non-drug, multidisciplinary approach including diet, behavior modification, and exercise. Evidence suggests that reducing calories by only 200 - 260 per day would prevent weight gain in most overweight children. Here some tips for children who are overweight: </p> <ul> <li>Limit (or avoid, if possible) take out, fast foods, high-sugar snacks, commercial packaged snacks, soda, and sugar-sweetened beverages (including too much juice).</li> <li>Let children snack but make sure the snacks are healthy. Eating small frequent healthy meals (instead of two or three large ones) has been associated with being thinner and having a better cholesterol profile.</li> <li>Let children choose their own food portions. One study indicated that children naturally ate 25% less when they chose their own portion size. When they were given larger portions their bite sizes were larger and they ate more.</li> <li>Do not criticize a child for being overweight. It does not help and such attitudes could put children at risk for eating disorders, which are equal or even greater dangers to their health.</li> <li>Limit television, video games, and computer use to a few hours a week. This can contribute significantly to weight control, regardless of diet and physical activity.</li> <li>For young children, try the traffic-light diet. Food is designated with stoplight colors depending on their high caloric content: Green for go (low calories); yellow for "eat with caution" (medium calories); red for "stop" (high calories).</li> <li>Try a low glycemic index diet. This may be as beneficial, and possibly more, than a standard reduced-fat diet in overweight children. Such a diet focuses on certain carbohydrates (for example, dried beans and soy), which raise blood sugar more slowly than other types of carbohydrates. This diet is sometimes used in diabetes, and as a dietary approach in overweight adults. [See <i>In-Depth Report</i> #42: <a href="/2331296" >Diabetes diet</a>.]</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331139" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image about TV watching.</div> </div> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331226" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of childhood overweight.</div> </div> <h3 id="adamHeading_7">Complications</h3> <p><i>General Adverse Effects of Obesity.</i> Obesity, defined as a BMI of 30 or over, accounts for nearly 300,000 deaths in the U.S. each year. It is associated with more chronic health problems than smoking, heavy drinking, or poverty. Furthermore, given the current increase in obesity, it will surpass smoking as the most important preventable cause of death in America. </p> <p>Some studies indicate the following health risks by body mass: </p> <ul> <li>The lowest risks for heart disease, diabetes, and some cancers are in people with BMI values of 21 - 25.</li> <li>The risks increase slightly when BMI values are between 25 - 27.</li> <li>The risks are significant in BMIs between 27 - 30.</li> <li>The same risks are dramatic at BMIs over 30.</li> </ul> <p>Anyone with chronic health problems such as heart or lung disease, stroke, or arthritis, should be concerned about extra weight. This same concern also applies to people with known risk factors for such conditions. </p> <ul> <li><em>Metabolic Changes.</em> As fat stores increase, the fat cells themselves enlarge and produce chemicals that increase the risk for several diseases. Such diseases may include diabetes, high blood pressure, gallbladder disease, and some cancers.</li> <li><em>Increased Mass.</em> The increased body weight itself causes problems that result in injury and diseases, including osteoarthritis and sleep apnea.</li> <li><i>Harmful Fat Cell Types.</i> Weight concentrated around the abdomen and in the upper part of the body (the apple shape) poses a higher health risk than fat that settles around the hips and flank (the pear shape). Fat cells in the upper part of the body appear to have different qualities from those found in the lower parts. In fact, studies suggest a higher risk for diabetes in people with the "apple shape" and lower risk in those who are "pear shaped."</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Weight gain in the area of and above the waist (apple type) is more dangerous than weight gained around the hips and flank area (pear type). Fat cells in the upper body have different qualities than those found in hips and thighs.</div> </div> </div> <p><i>General Adverse Effects of Being Overweight (Not Obese).</i> It is still not clear if being overweight (a BMI of 25 - 29.9) hurts healthy people with no risk factors for serious illnesses. </p> <p>According to one 2001 study, just being overweight increased the risk for developing diabetes, gallstones, hypertension, heart disease, stroke, and colon cancer. The risk rose according to how much the individuals were overweight. In any case, adults who are overweight in middle age face a poor quality of life as they age, with the quality declining the greater the weight. One study suggested, however, that being over 65 and overweight (but not obese) is not associated with higher mortality rates. </p> <p>Some experts argue, in fact, that in anyone who is not severely obese, it is the unhealthy diet and sedentary lifestyle that causes harm -- not weight per se. In support of this argument, a British study found that overweight fit individuals had half the death rate of unfit trim individuals. </p> <p>Being somewhat overweight may also have some benefits under specific circumstances: </p> <ul> <li>In older women, some excess fat may produce extra estrogen that helps slow down bone loss, and insulates bones from fall-related injuries. It should be strongly noted, however, that when older overweight women lose weight they report less pain, improved vitality, and improved physical function. The same positive effect of overweight does not appear to hold in older men.</li> <li>Conditioned athletes may have high BMIs because of very dense muscle tissue. Being fit in general may protect many overweight people.</li> <li>Some evidence suggests that Caucasians have the lowest mortality with BMIs of 24.3 - 24.7 while African-Americans are better off in the range of 26.8 - 27.1.</li> <li>Children may have higher normal fat levels during growth spurts and around puberty.</li> </ul> <p>Individuals with a BMI of at least 30 have a 10 - 50% increased rate of death from all causes, compared with individuals with a BMI of 20 - 25. Mortality rates from many causes are higher in obese people, but heart disease is the primary cause of death. People who are obese have almost three times the risk for heart disease as people with normal weights. Being physically unfit adds to the risk. </p> <p>Weight concentrated around the abdomen and in the upper part of the body (apple shape) is particularly associated with insulin resistance and diabetes, heart disease, high blood pressure, stroke, and unhealthy cholesterol levels. Fat that settles in a pear shape around the hips and lower body appears to have a lower association with these conditions. </p> <p>Obesity poses many dangers to the heart and circulatory system. </p> <p><i>Damage in the Blood Vessels.</i> As people age, changes in body fat (particularly increasing abdominal fat) seem to cause stiffness in the aorta, the major blood vessel leading from the heart. Studies are finding higher levels of a factor called C-reactive protein (CRP) in people with obesity and abdominal fat. CRP is now considered to be a marker for inflammation and damage in the arteries. (Losing weight reduces CRP levels.) </p> <p><i>High Blood Pressure.</i> High blood pressure is the health problem most commonly associated with obesity, and the greater the weight, the greater the risk. High blood pressure carries serious risks of stroke, heart attack, and heart failure. The link between obesity and high blood pressure is complex, and may be a combination of genetic, population, and biological factors. Many studies have reported that modest weight loss is beneficial for reducing existing high blood pressure. [See <em>In-Depth Report</em> #14: <a href="/2331469" >High blood pressure</a><em>.</em>] </p> <p><i>Heart Failure.</i> An important 2002 study reported that obesity might account for 11% of heart failure cases in men and 14% in women. This link existed independently of other risk factors, such as high blood pressure, sleep apnea, and diabetes, which are also associated with obesity. The biologic mechanisms involved in obesity that lead specifically to heart failure are not clear. [See <em>In-Depth Report</em> #13: <a href="/2331508" >Heart failure</a>.] </p> <p><i>Unhealthy Cholesterol Levels and Lipid Levels.</i> The effect of obesity on cholesterol levels is complex. Although obesity does not appear to be strongly associated with overall cholesterol levels, among obese individuals triglyceride levels (the major form of fat storage in the body) are usually high, while HDL levels (the "good" cholesterol) tend to be low. Both conditions are risk factors for heart disease. [See <em>In-Depth Report</em> #23: <a href="/2331191" >Cholesterol</a><em>.</em>] </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331105" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of coronary artery disease.</div> </div> <p><i>Stroke.</i> Obesity is also associated with a higher risk for stroke. [See <em>In-Depth Report</em> #45: <a href="/2331466" >Stroke</a>.] </p> <p><i>Type 2 Diabetes and Insulin Resistance.</i> Most people with type 2 diabetes are obese and, in fact, studies strongly suggest that weight loss may be the key in controlling the current epidemic of type 2 diabetes. The common factor appears to be <em>insulin resistance</em>. Insulin is a critical hormone in the use of sugar. In type 2 diabetes, different factors cause the body to become insulin resistant -- that is, the body can no longer respond properly to insulin. This has the effect of increasing sugar levels in the blood, the hallmark of diabetes. Both obesity and insulin resistance, at different phases, are marked by high levels of certain chemicals. It is not known yet if the higher levels are simply a product of obesity, or play some role in causing diabetes. </p> <p>Insulin resistance is also associated with high blood pressure and abnormalities in blood clotting. Some research indicates that obesity, in fact, is the one common element linking insulin resistance, diabetes type 2, and high blood pressure. [See <em>In-Depth Report</em> #60: <a href="/2331173" >Diabetes - type 2</a>.] </p> <p><i>Metabolic Syndrome.</i> Metabolic syndrome (also called syndrome X) is a pre-diabetic condition that is significantly associated with heart disease and higher mortality rates from all causes. The syndrome consists of obesity marked by abdominal fat, unhealthy cholesterol levels, high blood pressure, and insulin resistance. A 2002 study estimated that nearly a quarter of the U.S. population now has this condition. Even worse, according to a 2003 study, nearly a million American teenagers have this syndrome. A combination of weight loss and exercise is an effective treatment for this syndrome. </p> <p>The American Cancer Society released new cancer prevention guidelines in September 2006. The guidelines stress the importance of keeping a healthy weight throughout life. The Society indicates that healthy weight is even more important than eating specific healthy foods, when it comes to cancer prevention. </p> <p>Obesity has been associated with a higher risk for cancer in general and specific cancers in particular. Studies have also suggested that restricting calories reduces the risk for cancer. Some experts believe that effective weight control for children and adults could reduce cancer rates by 30 - 40%. One way obesity may increase the risk for cancer is its association with high levels of hormones called growth factors, which can trigger rapid cell production leading to cancer. </p> <p><i>Uterine Cancers.</i> The risk of uterine cancer in obese women appears to be two or three times higher than in thinner women. </p> <p><i>Prostate Cancer.</i> New studies from 2005 and 2006 report that obesity is associated with an increase in prostate cancer mortality, although not with the risk for less aggressive forms of prostate cancer. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331403" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of prostate cancer.</div> </div> <p><i>Breast Cancer.</i> Studies are mixed on the association between obesity and breast cancer. A number of studies have linked obesity to breast cancer in postmenopausal women, particularly in women who begin to gain weight after age 18. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331340" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an illustrated series detailing a breast cancer surgery (mastectomy).</div> </div> <p><i>Gallbladder Cancer.</i> Obese women are at higher risk for gallbladder cancer. </p> <p><i>Gastrointestinal Cancers.</i> A number of cancers in the gastrointestinal tract have been associated with obesity: </p> <ul> <li>Cancer of the esophagus may be due to a higher incidence of gastroesophageal reflux disorder (heartburn) in people who are overweight.</li> <li>Colon cancer has been linked to increased body mass in both men and women.</li> <li>Pancreatic cancer and obesity have been weakly linked, with one study reporting a lower risk in overweight people who are physically active.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331167" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an illustrated series detailing a colon cancer surgery.</div> </div> <h5>Muscles and Bones</h5> <p>Obesity places stress on bones and muscles. Studies report that the incidence of osteoarthritis is significantly increased in people who are overweight. People who are obese are also at higher risk for carpal tunnel syndrome and other problems involving nerves in their wrists and hands. It should be noted that some weight may be protective against osteoporosis (loss of bone thickness). </p> <p>Obesity increases the risk for the following mouth and eye disorders: </p> <ul> <li>Gum disease</li> <li>Cataracts</li> <li>Maculopathy, an eye disease related to aging</li> </ul> <p><i>Infertility.</i> Abnormal amounts of body fat, either 10 - 15% too high or too low, can contribute to infertility in women. Obesity is specially related to certain infertility problems, such as uterine fibroids or menstrual irregularities. In men, obesity can contribute to reduced testosterone levels. </p> <p><i>Effect on Pregnancy.</i> Obesity has many dangerous effects on pregnancy. These include high blood pressure, gestational diabetes (diabetes, usually temporary, that occurs during pregnancy), urinary tract infections, blood clots, prolonged labor, and higher fetal death rate in late stages of pregnancy. Obesity is also associated with increased rates of cesarean delivery. Infants of women who are obese are also at higher risk for neural tube birth defects, which affect the brain or spine. Folic acid supplements, ordinarily effective in preventing these conditions, may not be as protective in overweight women. </p> <p>Obesity is thought to be a risk factor for symptoms of adult-onset asthma. Though there is evidence that obesity causes wheezing and shortness of breath, it does not appear to be strongly associated with the disease mechanisms in the lungs that cause true asthma. </p> <p>Obesity also puts people at risk for <em>hypoxia</em>, a condition in which there is not enough oxygen to meet the body's needs. Obese people need to work harder to breathe. They tend to have breathing muscles and lungs that do not work as well as those in thinner people. </p> <p>The Pickwickian syndrome, named for an overweight character in a Dickens novel, occurs in severe obesity when lack of oxygen produces intense and chronic sleepiness and, eventually, heart failure. </p> <p><i>Nonalcoholic Fatty Liver Disease</i>. People with obesity, particularly if they also have type 2 diabetes, are at higher risk for a condition called nonalcoholic fatty liver disease, also called nonalcoholic steatohepatitis (NASH). This condition causes liver damage that is similar to liver injury seen in alcoholism. In some cases, it can be very serious and require liver transplantation. It occurs in about half of people with diabetes, and 20 - 50% of obese people, depending on how severe their obesity is. NASH can also occur in overweight children. </p> <p><i>Gallstones.</i> The incidence of gallstones is significantly higher in obese women and men. The risk for stone formation is also high if a person loses weight too quickly. In people on ultra-low calorie diets, gallstones may be prevented by taking ursodeoxycholic acid (Actigall). </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331157" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of gallstones.</div> </div> <p>People who are obese and nap tend to fall asleep faster and sleep longer during the day. At night, however, it takes them longer to fall asleep, and they sleep less than people with normal weights. In an apparent vicious circle, studies have suggested that obesity not only interferes with sleep but that sleep problems may actually contribute to obesity. </p> <p><i>Sleep Apnea.</i> Obesity, particularly the apple shape, is strongly associated with sleep apnea, which occurs when the upper throat relaxes and collapses from time to time during sleep. This collapse temporarily blocks the passage of air. Sleep apnea is increasingly being viewed as a potentially serious health problem, which may lead to complications such as heart disease and stroke. Some studies suggest that among overweight people, those who have sleep apnea have a greater risk of heart disease than those without it. In one study, the more obese a person with sleep apnea was, the higher the pressure on the airway, and therefore the greater the obstruction of the airway. Obstructive sleep apnea may also add to obesity, however, as sleepy people tend to be sedentary. Some studies indicate that treating sleep apnea may help people lose abdominal fat. </p> <p><i>Narcolepsy.</i> A small European study found a link between narcolepsy (a sleep disorder characterized by excessive daytime sleepiness with frequent daily sleep attacks) and high BMI. </p> <p><i>Depression.</i> A number of studies have reported an association between depression and obesity, particularly in obese women. There may be a number of factors to explain the link. In some cases of atypical depression, people overeat and may gain weight. Overweight people may also become depressed because of social problems and a poor self-image. In these cases, depression usually disappears when people lose weight. </p> <p>There is evidence, however, that obesity itself may impair levels of tryptophan -- a chemical needed to make serotonin, a brain chemical associated with mental well-being. In one study, even after people lost weight, tryptophan levels were lower than normal. </p> <p>There does not appear to be any association between depression and obesity in men. </p> <p><i>Social Problems.</i> One long-term study reported that overweight young women completed fewer years of school, were 20% less likely to be married, and had 10% higher rates of household poverty than their thinner peer. Obese young men were also less likely to be married, and their incomes were lower than their thinner peers. Nevertheless, studies consistently show that overweight males (both boys and men) are not as severely emotionally affected as females of any age. Women and girls tend to blame themselves for being heavy, while males tend to blame being overweight on outside factors. </p> <h3 id="adamHeading_8">Weight Loss and Maintenance</h3> <p>Even modest weight loss can reduce the risk factors for heart disease and diabetes. The simplest (but still difficult) approach to weight loss is reducing calories and exercising at least 150 minutes a week. Behavioral and mental changes in eating habits, physical activity, and attitudes about food and weight are also essential to weight management. For people who are very overweight and cannot lose weight through lifestyle changes, a number of effective weight-loss medications are available. For those with severe obesity, surgical procedures are proving to be very beneficial. </p> <p><i>Some Tips for Losing Weight.</i> The following are some general suggestions for dieters: </p> <ul> <li>Start with realistic goals. Diet failure is extremely common, and the odds of significant weight loss are low, particularly in people with the highest weights. People who are able to restrict calories, engage in an exercise program, and get help in making behavioral changes can expect to lose between 5 - 10% of their current body weight. That is generally all that is needed to achieve meaningful health changes. Certainly, the distorted image of a super-thin female shape should not be anyone's goal.</li> <li>Maintain a regular exercise program, assuming you have no health problems that will stop you. Choose a program that you enjoy. Check with your doctor about any health considerations. [See <em>In-Depth Report</em> #29: <a href="/2331315" >Exercise</a>.]</li> <li>Do not use hunger pangs as cues to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals.</li> <li>Be honest about how much you eat and start by recording all calories in writing. Studies suggest that when many people report their own calories intake they significantly underestimate their consumption of high-calorie and over-estimate the low-calorie foods. People who do not carefully note everything they eat tend to take in too many calories when they believe they are dieting.</li> <li>Observe weekend eating. People tend to eat more on the weekends. If it is difficult to monitor all meals during the week, it be may be useful to at least track eating habits during the weekends.</li> <li>Once the pounds are lost, do your best to keep the healthier weight. Make daily, even hourly, conscious decisions about eating and exercising activities. Such thinking, in many cases, can become automatic and not painful.</li> <li>Don't give up, even after repeated weight loss failures. Most studies indicate that yo-yo dieting or weight cycling have no bad psychological or physical effects. Repeated dieting also does not harm the body's ability to burn calories efficiently.</li> <li>Weight loss, in any case, should not be the only or even the primary goal for people concerned about their health. The success of weight loss efforts should be evaluated according to improvements in disease risk factors or symptoms, and by the adoption of healthy lifestyle habits, not just by the number of pounds lost.</li> </ul> <table border="1" cellpadding="3" cellspacing="0"> <tr> <td valign="top" colspan="2" /></tr> <tr> <td valign="top"> <p><b>Lifestyle</b> </p> </td> <td valign="top"> <p>Reduce rate of eating. </p> <p>Keep food records. </p> <p>Eliminate environmental triggers to eating. </p> <p>Identify high-risk situations for overeating. </p> <p>Separate eating from other activities. </p> </td> </tr> <tr> <td valign="top"> <p><b>Exercise</b> </p> </td> <td valign="top"> <p>Face up to emotional barriers to exercise. </p> <p>Understand the link between exercise and weight control. </p> <p>Establish reasonable exercise goals. </p> <p>Develop a plan for regular activity. </p> <p>Add increased activity into daily lifestyle. </p> </td> </tr> <tr> <td valign="top"> <p><b>Attitudes</b> </p> </td> <td valign="top"> <p>Develop reasonable weight-loss goals. </p> <p>Avoid "all or none" thinking. </p> <p>Focus attention away from the scale and toward behavior. </p> <p>Uncouple weight from self-esteem. </p> <p>If you "fall off the wagon," take steps to ensure the situation does not repeat (recover from lapses with constructive action). </p> </td> </tr> <tr> <td valign="top"> <p><b>Relationships</b> </p> </td> <td valign="top"> <p>Understand the key role of social support to health. </p> <p>Identify supportive others. </p> <p>Match personal style to support-seeking activities. </p> <p>Be specific in making support requests. </p> <p>Be assertive but reinforcing in drawing help from others. </p> </td> </tr> <tr> <td valign="top"> <p><b>Nutrition</b> </p> </td> <td valign="top"> <p>Resist the temptation of popular fad diets. </p> <p>Eat with your health in mind; do not concentrate on what should be "off-limits." </p> <p>Eat with moderation in mind. </p> <p>Maximize fiber. </p> <p>Develop a tailored plan. </p> </td> </tr> <tr> <td valign="top" colspan="2"> <p>From Brownell KD. The LEARN Program for Weight Control. 7th ed. Dallas, Tex: American Health Publishing Company; 1998. </p> </td> </tr> </table> <h3 id="adamHeading_9">Weight Management</h3> <p>There are many approaches to dieting and many claims for great success with various fad diets. To date, although many diets achieve effective immediate weight loss, none has emerged as an effective tool for maintaining healthy weight. The only definite recommendation that can be made about any diet plan is to be sure it includes an exercise program, assuming there are no health problems to forbid it. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">The original food pyramid, with four food groups, has been replaced with an updated food guide called "My Pyramid." This illustrates the relative proportions of different foods that make up a nutritious, well-balanced diet and includes exercise.</div> </div> </div> <p>Calorie restriction has been the cornerstone of obesity treatment. The standard dietary recommendations for losing weight are the following: </p> <ul> <li>As a rough rule of thumb, one pound of fat equals about 3,500 calories. A person could lose a pound a week by reducing daily caloric intake by about 500 calories a day. Naturally, the more severe the daily calorie restriction, the faster the weight loss. Very-low calorie diets have also been associated with better success, but extreme diets can have some serious health consequences.</li> <li>To determine your daily calories requirements, multiply the number of pounds of ideal weight by 12 - 15 calories. The number of calories per pound depends on gender, age, and activity levels. For instance, a 50-year old woman who wants to maintain a weight of 135 pounds and is mildly active might require only 12 calories per pound (1,620 calories a day). A 25-year old female athlete who wants to maintain the same weight might require 25 calories per pound 2,025 (calories a day).</li> <li>Fat intake should be no more than 30% of total calories. Most fats should be in the form of monounsaturated fats (such as olive oil). Saturated fats (found in animal products) should be avoided.</li> </ul> <p>Extreme diets of less than 1,100 calories carry health risks. They are also often followed by bingeing or overeating, and a return to the obese state. Such diets often do not have enough vitamins and minerals, which must then be taken as supplements. Most of the initial weight loss is in fluids. Later, fat is lost, but so is muscle, which can account for more than 30% of the weight loss. No one should be on severe diets for longer than 16 weeks, or fast for more than 2 or 3 days. Severe dieting has unpleasant side effects including fatigue, intolerance to cold, hair loss, gallstone formation, and menstrual irregularities. There have been rare reports of death from heart arrhythmias when liquid formulas did not have sufficient nutrients. Pregnant women who excessively diet during the first trimester put their unborn children at risk for birth defects. Of note, those whose diets include a high intake of fluids and much reduced protein and sodium are at risk for hyponatremia, which can cause fatigue, confusion, dizziness, and in extreme cases, coma and death. </p> <p>This dietary approach requires counting only grams of fat with the goal of achieving 30% or fewer calories from fat. One gram of fat contains nine calories, while one gram of carbohydrates or protein has only four calories. Fat in your diet converts more readily to fat in the body, compared with carbohydrates or proteins. Simply switching to low-fat or skimmed dairy products may be enough for some people. </p> <p>There are possible drawbacks to this approach: </p> <ul> <li>Some people who reduce their fat intake may not get enough basic nutrients, including vitamins A and E, folic acid, calcium, iron, and zinc. People on low-fat diets should eat a wide variety of foods and take a multivitamin supplement, if appropriate. Calcium deficiencies may be particularly harmful in women at risk for osteoporosis.</li> <li>Many people start eating foods with too many carbohydrates, believing that they are not adding calories. No one should use a low-fat diet as an excuse for eating too many carbohydrates, particularly starchy foods and sugar. A high-calorie diet from any source will add pounds.</li> <li>A small study in Norway found that a diet low in fat and high in carbohydrates ("carbs") increases symptoms of psychological distress, such as depression and anger. The study compared three different diets that had varying amounts of fat and carbohydrates in each. The diets contained the same amount of calories, but differed in the percentage and type of fat. People on the low-fat, high-carbohydrate diet reported more anger and depression compared with the other two diets.</li> <li>Replacing fatty foods, such as cakes, cookies, and chips, with their commercial "low-fat" counterparts does not constitute a low-fat diet. These foods generally contain more sugar and hence calories, not to mention other ingredients, which have virtually no nutritional value. In fact, a 2002 study suggested that increasing sugar may, over time, reduce levels of HDL ("good") cholesterol.</li> <li>Very low-fat diets may increase the risk for stroke from hemorrhage in the brain.</li> </ul> <p>Some fat in a diet is essential. It should come from plant oils and fish, however, and not from animal products or hardened oils, such as margarine. Trans-fatty acids, found in hardened oils, are actually more of a risk factor for obesity than saturated fats from animal products, although both should be avoided. </p> <p><i>Fiber and Complex Carbohydrates.</i> In all cases, complex carbohydrates found in whole grains and vegetables are preferred over those found in starch-heavy foods, such as pastas, white-flour products, and potatoes. Fiber is an important component of many complex carbohydrates. Fiber is almost always found only in plants, particularly vegetables, fruits, whole grains, nuts, and legumes (beans and peas). One exception is chitosan, a dietary fiber made from shellfish skeletons. Fiber cannot be digested but passes through the intestines, drawing water with it, and is eliminated as part of feces content. The following are specific advantages from high-fiber diets (up to 55 grams a day): </p> <ul> <li>Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, and fruit and vegetable peels) has been associated with weight loss. Studies also suggest that diets rich in fiber from whole grains reduce the risk for type 2 diabetes.</li> <li>Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes) has important benefits for the heart, particularly for achieving healthy cholesterol levels and possibly benefiting blood pressure as well. Simply adding breakfast cereal to a diet appears to reduce cholesterol levels. People who increase their levels of soluble fiber should also increase water and fluid intake.</li> </ul> <p>High-protein, low carbohydrate diets, such as the Atkins and South Beach diets, have been touted as effective ways to produce short-term weight loss. Because of their emphasis on fats and proteins, many experts are concerned about long-term health problems. A report in the March 2006 <i>Lancet</i> linked the Atkins diet to life-threatening complications that caused the death of one woman. The 40-year-old woman had a deadly buildup of acids called ketones in her blood, a condition called ketoacidosis. Ketoacidosis can cause coma and death. Ketones are a known by-product of high protein, low carbohydrate diets. At low levels they can cause nausea, lightheadedness, and bad breath. </p> <p>The long-term effects of these diets are still unknown. For example, the Atkins diet restricts some vegetables and most fruits, which are known to protect against serious diseases such as heart problems and cancer. The diet may also cause too much calcium to build up in the urine. This can increase the risk for kidney stones and osteoporosis. In addition, high-protein intake, particularly from meat, can be harmful in people with kidney problems. Individuals at risk for kidney stones, or those who have other kidney problems, should not go on high-protein diets without talking to their doctor first. Unfortunately, many people with diabetes are at risk of kidney problems, which could reverse any possible benefits a high-protein diet may bring them. Eating a lot of meat has also been associated with certain common cancers, notably prostate and colon cancers. A 2002 study suggested that such diets during pregnancy may increase the risk for high blood pressure in the child. </p> <p>Still, significant studies say that such diets improve cholesterol and blood sugar levels. Studies in 2002 and 2003 have indicated that these diets lower blood glucose levels, which can be important in people who are diabetic. The diets also reduce triglyceride levels (unhealthy fat molecules) and increases HDL (" good") cholesterol levels. High triglyceride and low HDL levels are important risk factors for heart disease, and are common in people with type 2 diabetes. Studies are mixed on whether this type of diet reduces overall cholesterol or LDL ("bad") cholesterol levels. </p> <p>Experts that promote the low carbohydrate approach argue that heart problems from obesity are due to insulin disturbances from sugar imbalances. Therefore, they believe that restricting carbohydrates is the best approach for obesity -- especially for overweight people with diabetes. More research is needed, however, to determine the long-term impact of such diets on health. </p> <p>High-protein, low-carbohydrate diets include Atkins, Protein Power, Sugar Busters, and Dr. Stillman. The Atkins diet is one of the most popular and has a four-phase program: </p> <ul> <li>Induction. For the first 2 weeks, individuals consume no more than 20 grams of carbohydrates a day. The diet consists of pure protein and fats. There is no fruit, bread, grains, starchy vegetables, or dairy products other than cheese, cream, or butter. This phase is not suitable for children, pregnant women, or anyone with kidney disease.</li> <li>On-going Weight Loss. After the first phase, individuals continue to lose weight while they increase carbohydrate levels by five grams each day.</li> <li>Premaintenance. When individuals get close to their weight goal, they add another 10 grams of carbohydrates per day as long as they do not begin to gain weight. Weight loss is very slow at this time, but the individual is now getting used to maintenance.</li> <li>Maintenance. Lifetime maintenance is usually between 40 and 100 grams of carbohydrates a day, depending on steady weight level.</li> </ul> <p>Anyone who chooses this diet should prefer fish or soy products to meat as protein sources. Fish may reduce leptin, a hormone associated with fat storage and heart diseases, and would be the best protein source. People on this diet should also choose monounsaturated fats (as in olive oil) over saturated fats or trans-fatty acids fat. Patients often need supplements, at least a multivitamin and possibly calcium, chromium, omega-3 fatty acids (found in fish oil), and other supplements. </p> <p>The South Beach and Zone diets encourage healthy fats. They also allow certain carbohydrates. For example the Zone uses healthy carbohydrates (vegetables and dried beans) and unsaturated fats. The South Beach diet uses carbohydrates that have a lower impact on blood sugar levels. This is called a low-glycemic index. Low-glycemic foods include barley, dried bean and peas, milk, strawberries, and apples. High-glycemic foods include refined grains, white bread, white potatoes, and bananas and other tropical fruits. The glycemic index was developed for use in diabetes -- not for weight loss. Nevertheless, there is some evidence that foods with low glycemic indexes may produce a feeling of fullness and so discourage further eating. As with any high-protein diets, people at risk for kidney stones, or those who have other kidney problems, should avoid these plans. </p> <p>Replacing fats and sugars with substitutes may help many people who have trouble maintaining weight. In fact, in one 2003 study, people with type 2 diabetes used the artificial sweetener sucralose and a beta-glucan fat substitute (derived from oats) as part of a low-calorie diet. At the end of the 4 weeks, they achieved better weight, glucose control, and HDL levels than those on a standard diabetic diet. </p> <p><i>Fat Substitutes.</i> Fat substitutes added to commercial foods or used in baking deliver some of the desirable qualities of fat, but do not add as many calories. It should be stressed that eliminating <i>all</i> fats from a diet can be harmful to general health. </p> <p>Fat substitutes include the following: </p> <ul> <li>Stanols. Stanols are plant compounds used in margarines (Benecol, Take Control). Benecol is derived from pine bark and Take Control from soybeans. Two servings a day of either brand, as part of a low-fat, diet can lower LDL and total cholesterol by impairing its absorption in the intestinal tract. Some studies have reported that the use of stanols can allow lower doses of statins (cholesterol lowering medications). Stanols do not appear to block absorption of fat-soluble nutrients or vitamins, as olestra does.</li> <li>Olestra (Olean) passes through the body without leaving behind any calories from fat. Studies suggest that it improves cholesterol levels and helps people lose weight when it is used to replace a third of normal dietary fats. (Note that simply adding snacks containing olestra does not appear to have any effect on cholesterol or weight loss.) Early reports of cramps and diarrhea after eating food containing olestra have not proven to be significant. Of greater concern is the fact that even small amounts of olestra deplete the body of certain vitamins and nutrients that may help protect against serious diseases, including cancer. The FDA requires that the missing vitamins be added back to olestra products, but not other nutrients. The side health effects, if any, are unknown.</li> <li>Beta-glucan is a soluble fiber found in oats and barley. Products using this substance (e.g., Nu-Trim) may reduce cholesterol and have additional health benefits.</li> </ul> <p>A number of other fat-substitutes are also available. Although studies to date are not showing any significant side effects, these products' effect on weight control is uncertain, since many of the products containing them may be high in sugar. </p> <p><i>Artificial Sweeteners.</i> Many artificial or low-calories sweeteners are available. A 2002 study confirmed that people who consumed artificial sweeteners and reduced their sugar intake weighed less over time than those who took in similar types and amounts of drinks and food containing sugar. It should be noted that using these artificial sweeteners should not give dieters a license to increase their fat intake. Studies indicate that consuming some sugar is not a significant contributor to weight gain, as long as the total amount of calories in the diet is under control. There is some public concern about chemicals used to produce many of these sweeteners, and the side effects seen in studies using rats. Natural low-calories sweeteners are available that may be more acceptable to many people. </p> <ul> <li>Saccharin (Sugar Twin, Sweet n' Low, Sucaryl, and Featherweight). Saccharin has been used for years. Some studies found that large amounts of saccharin cause bladder cancer in rats. However, the rats were fed huge amounts that do not apply to human diets. Currently there is no evidence that saccharin causes cancer in humans.</li> <li>Aspartame (Nutra-Sweet, Equal, NutraTase). Aspartame has come under scrutiny because of rare reports of nervous system disorders, including headaches or dizziness, associated with its use. People with phenylketonuria (PKU), a genetic condition, should not use it. Studies have not reported any serious health dangers, but some people may be sensitive to it.</li> <li>Sucralose (Splenda). Sucralose has no bitter aftertaste and works well in baking, unlike other artificial sweeteners. It is made from real sugar by replacing part of the sugar with chlorine. Some people are concerned because chlorinated molecules used in major industrial chemicals have been associated with cancer and birth defects. Over 100 studies have been conducted on sucralose over a 20-year period, with no reports of such risks.</li> <li>Acesulfame-potassium (Sweet One, SwissSweet, Sunette). It has been used in the U.S. since 1988 with no reported side effects.</li> <li>Neotame (Neotame). Neotame is a synthetic variation of aspartame, but was developed to avoid its side effects. The association with aspartame has raised some concerns. Studies to date have reported no effects that would cause alarm, and it appears to be safe for general consumption.</li> <li>D-tagatose (Tagatose). This reduced-calorie sweetener is made from lactose, which is the sugar found in dairy products and other foods. It may be especially beneficial for people with type 2 diabetes. It may also have additional benefits that help the intestinal tract.</li> <li>Alitame (Aclame) is formed from amino acids, the building blocks of proteins. It has the potential to be used in all products that contain sugar, including baked goods.</li> <li>Stevioside (Stevia). This is a natural sweetener derived from a South American plant. It is available in health food stores. People with diabetes should avoid alcohol-based forms. It has not been carefully tested.</li> </ul> <p>Other sugar substitutes being investigated include glycyrrhizin (derived from licorice) and dihycrochalcone (derived from citrus fruits). </p> <p>Some studies have reported good success with meal replacement beverages (Slim-Fast, Sweet Success). They contain major nutrients needed for daily requirements. Each serving typically contains between 200 - 250 calories and replaces one meal. (Note: Using them for all meals reduces calories to a severe extent and can be harmful.) </p> <p>One study reported that most subjects who had undergone a 12-week weight loss program and then used Ultra Slim Fast supplements as directed for maintenance kept off more than half their weight loss after more than 3 years. A quarter of the subjects were still losing weight. </p> <p>Medical evidence suggests that a diet rich in magnesium could reduce a person's risk of metabolic syndrome, a cluster of problems including obesity, high blood pressure, and high cholesterol. Metabolic syndrome can lead to diabetes and heart disease. A long-term study of thousands of Americans found that the risk for metabolic syndrome decreased in those who consumed the most magnesium from meals. The findings were published in the journal <em>Circulation</em>. </p> <p><i>Commercial and Non-Profit Support Programs for Weight Loss.</i> There are many different types of weight-loss program. (This report cannot address all of the many commercial and nonprofit weight-loss programs currently available, nor can it assess their claims.) </p> <p>Taking off Pounds Sensibly (TOPS), a nonprofit support organization with many local chapters, is one of the least expensive programs, costing $20 a year. </p> <p>Most of the commercial programs such as Weight Watchers, Jenny Craig, and NutriSystem offer individual or group support, lifestyle changes and packaged meals. These programs tend to be expensive. There are few well-conducted studies on these programs. One 2003 study reported modest weight loss over 2 years with Weight Watchers compared to a self-help program. There were no differences in heart risk factors. </p> <p><i>Cognitive Behavioral Approaches.</i> Most support programs use some form of cognitive-behavioral methods to change the daily patterns associated with eating. They are very useful for preventing relapse after initial weight loss. The following is a typical approach: </p> <ul> <li>The patient first records in a diary all activity related to eating patterns, including the times of day, length of meal, emotional states, companions, and, of course, the kind and amounts of food eaten. Most people -- even professional dieticians, according to one study -- tend to underreport their daily calorie intake. However, writing it down is still a good method for increasing a person's awareness of eating patterns. (One patient said that recording circumstances surrounding relapses was a particularly valuable guide for understanding the stresses leading to her own eating behaviors.)</li> <li>The patient reviews the diary with a therapist or group to set realistic goals and identify patterns that the patient can change. For instance, if food is normally eaten while watching television, then the patient may be advised to eat in another room instead.</li> <li>Good eating habits are reinforced by rewards. These rewards are other pleasures that substitute the high calorie consumption and sedentary activities.</li> </ul> <p>Behavioral modification has been shown to be helpful particularly for people who have an overly strong response to the taste, smell, and appearance of food. It also may be useful for binge eaters. </p> <p><i>Stress-Reduction Techniques.</i> Stress reduction and relaxation techniques may be helpful for some people with obesity, such as those whose weight is related to night-eating syndrome. [See <em>In-Depth Report</em> #31: <i><a href="/2331667" >Stress</a></i>.] </p> <p><i>Changing Sedentary Habits.</i> Making even small changes in physical activity can expend energy. For example, simply getting up to turn the TV on and off instead of using the remote, and standing (instead of sitting) while talking on the phone may help a person lose up to five pounds a year. Other suggestions include cooking one's own food (instead of eating take-out or fast food), walking to as many places as possible, using stairs instead of escalators or elevators, and gardening. Even fidgeting may be helpful in keeping pounds off, and, in one study, chewing gum increased energy expenditure. </p> <p>No one should rely on such mild activities, however, for serious weight loss. Only high levels of physical activity -- not just using up energy -- help prevent obesity. </p> <p><i>Approach to Exercise.</i> Exercise, which replaces fat with muscle, is the critical companion for any weight control program. In a one-year study, women who regularly averaged 3.5 days (176 minutes) of exercise each week lost significantly more weight than women who did not exercise regularly. Women who exercised more than 195 minutes a week lost nearly 7% of their abdominal fat. </p> <p>People who exercise are more apt to stay on a diet plan. Exercise improves psychological well-being and replaces sedentary habits that usually lead to snacking. Exercise may even act as a mild appetite suppressant. Moreover, exercise improves overall health even with modest weight loss. In support of this, a British study found that overweight fit individuals had half the death rate of unfit trim individuals. </p> <p>Be aware, however, that the pounds won't melt off magically. Losing significant weight requires both intensive exercise and calorie restriction. In addition, if a person exercises but doesn't diet, any actual pounds lost may be minimal, because denser and heavier muscle mass replaces fat. Nonetheless, regardless of weight loss, a fit body will look more toned and be healthier. In addition, exercise benefits the heart even with modest weight loss. </p> <p>The following are some suggestions and observations on exercise and weight loss: </p> <ul> <li>The more strenuous the exercise, the better the chances for short-term and long-term success. With intense exercise, the metabolism continues to burn calories before returning to its resting level. This state of elevated metabolism can last for as little as a few minutes after light exercise to as long as several hours after prolonged or heavy exercise.</li> <li>Of the standard aerobic machines, the treadmill burns the most calories. It may be particularly effective when used in short multiple bouts during the day. In fact, frequent exercise sessions as short as 10 minutes in duration (about four times a day) may be the most successful exercise program for obese people.</li> <li>Resistance, or strength, training is excellent for replacing fat with muscles. It should be performed two or three times a week.</li> <li>As people slim down, their initial level of physical activity becomes easier and they burn fewer calories per mile of walking or jogging. The rate of weight loss slows down, sometimes discouragingly so, after an initial dramatic head start using diet and exercise combinations. People should be aware of this phenomenon and keep adding to their daily exercise program.</li> <li>As people age, they also need to exercise more to keep off the same amount of weight.</li> <li>Changes in fat and muscle distribution may differ between men and women as they exercise. Men tend to lose abdominal fat (which lowers their risk for heart disease faster than reducing general body fat). Exercise, however, does not appear to have the same effect on weight distribution in women. In one interesting study, women in aerobic and strength training programs lost fat in their arms and trunk, but did not gain muscle tissue in these regions.</li> </ul> <p><i>Warning Note.</i> Because obesity is one of the risk factors for heart disease and diabetes, anyone who is overweight must discuss their exercise program with a doctor before starting. Sudden demanding exercise, in such cases, can be very dangerous. [See <em>In-Depth Report</em> #29: <a href="/2331315" >Exercise</a>.] </p> <h3 id="adamHeading_10">Medications</h3> <p>There are several different drugs used for weight loss. Unless specifically instructed by a doctor, people should use non-drug methods for losing weight. Except under rare circumstances, pregnant or nursing women should never take diet medications of any sort, including herbal and over-the-counter remedies. </p> <p>A 2001 study reported that 7% of American adults use nonprescription weight-loss products. People must be cautious when using any weight-loss medications, including over-the counter diet pills and herbal or so-called natural remedies. Buying unverified products over the Internet can be particularly dangerous. </p> <p><em>Green tea</em>. Perhaps the best alternative advice for people who are overweight is to drink tea. Studies have indicated that regular tea drinking is associated with lower weight, particularly in people who drink it for years. Green tea specifically has been associated with increased energy expenditure. One study reported that people who took a green tea extract (Exolise) lost weight and reduced their waist size. Better evidence is needed to confirm the results on this supplement. </p> <p><em>Thermogenic Approach to Weight Loss.</em> An approach to weight loss called thermogenic (also hepatothermic) therapy is based on the idea that certain natural compounds have properties that enable the liver to increase energy in the cells and stimulate the metabolism. Theoretically, the result would be fat loss. Among the natural substances used in such products are EPA-rich fish oil, sesamin, hydroxycitrate, pantethine, L-carnitine, pyruvate, aloe vera, aspartate, chromium, coenzyme Q10, green tea polyphenols, aloe vera, DHEA derivatives, cilostazol, diazoxide, and fibrate drugs. </p> <p>Nearly all the current over-the-counter dietary aids contain some combination of these ingredients. There is no evidence that any of these ingredients can produce weight loss, and some may even have harmful effects. </p> <p>Chromium is a common ingredient in many diet supplements (e.g., Xenadrine, Dexatrim, Acutrim Natural, Twinlab Diet Fuel). It is claimed to specifically promote fat loss, rather than lean muscle loss. Some evidence suggests that niacin-bound chromium may improve insulin sensitivity. On the negative side, animal studies have suggested that chromium may have damaging effects on genetic materials in cells. This could cause sterility. </p> <p><em>Ephedra, Ephedrine, and Ma Huang.</em> The FDA does not allow the sale of drugs that contain ephedrine. In May 2004, the FDA banned the sale of dietary supplements that contain ephedra (also called Ma Huang). Ephedra has been linked to serious side effects, including strokes and heart attacks. </p> <p><em>Brazilian Diet Pill.</em> The US Food and Drug Administration (FDA) is warning consumers not to buy a product known as the "Brazilian diet pill." This product is labeled as a dietary supplement, but contains several chemicals found in powerful prescription drugs. The products are also known as Emagrece Sim and Herbathin dietary supplements. </p> <p><em>Conjugated Linoleic Acid (CLA).</em> Conjugated linoleic acid is found in many dietary products (e.g., Biosculpt Liquid, Body Success, GNC Optibolic Body Answers Dietary Formula). There is no evidence that it produces weight loss. Furthermore, there is some concern that CLA might increase insulin resistance and a dangerous inflammatory response in people with obesity. </p> <p><em>Tiratricol.</em> Over-the-counter products containing tiratricol, a thyroid hormone, have been sold for weight loss. Such products may increase the risk for thyroid disorders, heart attack, and stroke. </p> <p><em>Laxative Actions in Natural Substances.</em> Many dietary herbal teas contain laxatives, which can cause gastrointestinal distress, and, if overused, may lead to chronic pain, constipation, and dependency. In rare cases, dehydration and death have occurred. Some laxative substances found in teas include senna, aloe, buckthorn, rhubarb root, cascara, and castor oil. </p> <p><em>Guar Gum.</em> Some fiber supplements containing guar gum have also caused obstruction of the gastrointestinal tract. </p> <p><em>Chitosan</em>. Chitosan, a dietary fiber from shellfish, prevents a small amount of fat from being absorbed in the intestine. Well-conducted studies, however, have not found it to be effective. Products containing it include Cheat &amp; Lean Fat Blocker, Natrol, Chroma Slim, and Enforma. People who are allergic to shellfish should not take these supplements. </p> <p><em>Plantain.</em> Dietary remedies that list the ingredient plantain may contain digitalis, a powerful chemical that affects the heart. NOTE: This substance should not be confused with the harmless banana-like plant also called plantain. </p> <p>Orlistat (Xenical) can help about one-third of obese patients with modest weight loss, and can assist in long-term maintenance of weight loss. It works by slowing the absorption of fat (by about 30%) in the intestine. Studies indicate that between 50 - 80% of patients can achieve weight loss of 5% or greater, depending on other lifestyle changes. However, many people regain a significant portion of this weight back within 2 years. It does not work for all patients, however. In one survey of patients who took it, 10% <em>gained</em> weight or did not lose any, and 43% lost less than 5%. Nevertheless, orlistat may delay or even prevent the onset or progression of diabetes and improve cholesterol levels, regardless of weight loss. </p> <p>The drug can cause gastrointestinal problems and may interfere with absorption of the fat-soluble vitamins A, D, and E and other important nutrients. The most unpleasant side effect is oily leakage of feces from the anus. Restricting fats can reduce this effect. People with bowel disease should probably avoid it. In spite of these side effects, most patients are able to tolerate this agent. </p> <p>In February 2007, the FDA approved an over-the-counter (OTC) version of orlistat. It will be sold under the name alli, and will be available at half the prescription strength of Xenical. Those eager to use the new pill should consider its cost and modest benefits compared with its side effects, most commonly oily diarrhea. This pill, which prevents fat absorption from food, also increases the risk of not absorbing important nutrients from food while using it. The FDA recommends taking a daily multivitamin supplement when using alli. </p> <p>Sibutramine (Meridia) helps balance the brain chemicals serotonin and norepinephrine. This helps increase metabolism, causes a feeling of fullness, and increases energy levels. It may be particularly useful for binge-eaters. Studies indicate that sibutramine is effective in achieving weight loss, although the weight loss slows considerably after the first 3 months. The drug also appears to improve cholesterol and lipid (fat) levels, and may have other effects that benefit the heart. </p> <p>Side effects of sibutramine are common. They include dry mouth, constipation, and insomnia. In one study, almost half the patients dropped out as a result of these side effects. There have been reports of increases in heart rate and blood pressure while taking this medication, although a 2001 study indicates that blood pressure stabilizes over time. </p> <p>At this time, people who have a history of high blood pressure, stroke, heart disease, or arrhythmias should not take this drug. People taking decongestants, bronchodilators (such as for asthma), monoamine oxidase inhibitors, or serotonin reuptake inhibitors should also avoid sibutramine. </p> <p><i>Phentermine and Other Sympathomimetics.</i> Sympathomimetics are drugs that act like the stress hormone (and chemical messenger) norepinephrine. These medications act as stimulants in the brain. Some are approved for treating obesity, but only for short-term use. They include: </p> <ul> <li>Phentermine (Ionamin, Adipex-P, Fastin)</li> <li>Benzphetamine (Didrex)</li> <li>Phendimetrazine (Adipost, Bontril, Melfiat, Plegine, Prelu-2, Statobex)</li> </ul> <p>Phentermine is the most commonly prescribed appetite suppressant, and is less expensive than orlistat or sibutramine. Its effects are not long lasting, however. It can also raise blood pressure. In addition, phentermine is associated with depression, which is already a problem in many cases of obesity. A combination (Phen-Pro) containing phentermine and the antidepressant fluoxetine (Prozac) is being investigated to help reduce this problem. Note: Neither phentermine nor such combinations are associated with the heart problems linked to the previous phentermine combination known as Fen-Phen (phentermine and fenfluramine). </p> <p><i>Amphetamines.</i> The amphetamines dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and phenmetrazine (Pleudin) are powerful stimulants. They were used most often in the past but are no longer prescribed for weight loss. These drugs improve mood and produce some modest weight loss over the short term, but carry serious risks of addiction, agitation, and insomnia. </p> <p><em>Rimonabant.</em> Rimonabant (Accompli) belongs to a new class of drugs called selective CB1 blockers. The drug is designed to block receptors in the brain associated with the regulation of eating. Rimonabant also targets receptors in fat tissue. The Rimonabant in Obesity-Lipids (RIO-Lipids) study looked at how rimonabant affected metabolic risk factors in high-risk overweight or obese patients with blood fat disorders. The study involved more than 1,000 participants. The findings, published in the November 2005 <em>New England Journal of Medicine</em>, said that people who took the drug significantly reduced their body weight and size of their waist. </p> <p>Earlier studies involving the drug reported that obese patients treated with 20 mg of rimonabant lost significantly more weight and inches from their waist than patients who received placebo. The drug also appeared to have beneficial effects on raising HDL ("good") cholesterol levels. </p> <p><strong>Note:</strong> Fake rimonabant has been found for sale on several web sites. Patients should be aware that this drug is still experimental, and rimonabant is not available for sale. Buying and taking counterfeit drugs can have serious health consequences. In addition, an FDA advisory panel in April 2007 rejected the drug, citing fears it may cause psychiatric problems and seizures in some patients. </p> <p><em>Axokine.</em> Axokine is a type of drug called a <em>ciliary neurotrophic factor</em>. It signals the brain to suppress one's appetite. It is proving to be effective in achieving weight loss, and also improves cholesterol, lipid, and glucose levels regardless of food intake. It could be particularly helpful for people with type 2 diabetes. Early study results found that severely obese patient who took the drug lost more weight than those who took a dummy pill (placebo). Nearly half (46%) of patients who took the drug lost at least 10 pounds, compared to 5% of those who received the placebo. Study participants tolerated the drug well. There were no reports of serious side effects. </p> <p><em>Zonisamide</em>. Zonisamide (Zonegran) is an anti-seizure medication that is also being investigated for weight loss. In one study, patients who took it lost more weight than those on placebo. Zonisamide increases the risk for kidney stones, which can be reduced with increased fluid intake and citrate. It has also been associated with reduced sweating and a sudden rise in body temperature, especially in hot weather. Other side effects include dizziness, forgetfulness, headache, and nausea. </p> <p><em>Topiramate</em>. Topiramate (Topamax) is another anti-seizure medication being investigated for weight reduction. Three clinical trials have reported that patients given topiramate lost more weight than those receiving placebo. Weight loss was sustained for up to 1 year. The drug is also being studied for binge-eating disorders associated with obesity. </p> <h3 id="adamHeading_11">Other Treatments</h3> <p>Surgical procedures for obesity may be appropriate for some dangerously obese people, and may reduce heart problems and many of the risks associated with obesity. These risks include high blood pressure, sleep apnea, and diabetes. In fact, some evidence suggests that surgery may provide much greater control of weight and diabetes than nonsurgical weight-loss methods. Studies are reporting significant reductions in diabetes, and the need for diabetic medications, after surgery. Other medical conditions that often improve after surgery include heartburn, arthritis, and other joint and circulation problems. </p> <p>Bariatric surgeries produce weight loss through one of two approaches: </p> <ul> <li>Restrictive Banding Procedures. These procedures restrict the amount of food by closing off parts of the stomach with bands.</li> <li>Malabsorptive Bypass Procedures. This approach restricts the amount of food and also reduces absorption by using a bypass of parts of the intestine.</li> </ul> <p>The malabsorptive procedures are more successful in achieving weight loss than the banding approach, but they carry a greater risk for nutritional deficiencies. </p> <p>Most people who have bariatric surgery lose about two-thirds of excess weight within 2 years. In addition, diseases associated with obesity (such as diabetes, high blood pressure, sleep apnea, joint pain, and incontinence) often improve. </p> <p>Researchers at the Mayo Clinic looked at records from patients who had the surgery between 1990 and 2003. They found that those who had bariatric surgery reduced their risk of cardiovascular events such as a heart attack much more than those who lost weight without surgery. The findings were published in the September 2005 <em>Mayo Clinic Proceedings</em>. </p> <p>Other studies have shown that even though most patients maintain significant weight loss, the majority regain about to 10% of their weight. Patients must still develop a healthy life style and be calorie conscious after the operation. Follow-up must be life-long. </p> <p>Any surgical candidate must have failed consistently in losing weight through less invasive methods. Experts recommend bariatric surgery only for the following: </p> <ul> <li>Those whose BMI is above 40 (about 100 pounds overweight)</li> <li>Those with BMIs of over 35 who have type 2 diabetes or serious obesity-related medical problems</li> <li>Those with severe obesity that interfered with employment, normal physical activity (e.g., walking), and important relationship</li> </ul> <p>About a third of people who undergo these procedures achieve normal weight, and 80% experience some weigh loss. They are less successful than the bypass procedures, but carry a lower risk of nutritional deficiencies. </p> <p><i>Vertical Banded Gastroplasty.</i> Vertical banded gastroplasty (VBG) was the most common restrictive procedure. It involves creating a hole through both stomach walls and sealing the edges with a staple. This narrows the stomach, similar to a funnel, and allows only small amounts of food to pass through. </p> <p><i>Laparoscopic Gastric Banding.</i> Laparoscopic gastric banding (the Lap-Band) usually does not require a major incision and avoids some of the major complications of gastric bypass: </p> <ul> <li>It employs an adjustable silicone band that is placed around the upper part of the stomach.</li> <li>A small balloon-like reservoir attached to the band under the abdominal skin contains saline, which can be added or removed to tighten or loosen the band.</li> <li>The procedure restricts the amount of food a person can eat and gives the feeling of fullness.</li> </ul> <p>The band is removable, if necessary. Studies to date indicate that the intestinal tract returns to normal afterward. Studies, including those done in the elderly, have reported significant weight loss and improved quality of life with the procedure. </p> <p>Malabsorptive procedures produce greater weight loss than restrictive procedures. Patients generally achieve about two-thirds of their weight loss within 2 years. Furthermore, in a 2003 study, after standard bypass surgery, 83% of patients with type 2 diabetes experienced normal blood glucose levels and the rest had significant reductions. </p> <p><i>Roux-en-Y Gastric Bypass Procedure.</i> This is the most common and successful malabsorptive surgery in the United States. It involves creating a small stomach pouch that serves as a reservoir and restricts food intake. The pouch eventually holds up to 3 ounces of food and has a small outlet that delays emptying and causes a feeling of fullness. Then the surgeon creates a Y-shaped section in the small intestine that attaches to the pouch. This section allows food to bypass the lower stomach and upper part of the intestine. One 2003 study reported that this procedure was associated with significant weight loss, and 80% of patients with type 2 diabetes were able to reduce their medications. A more recent study, published in the March 14, 2006, issue of <em>Archives of Surgery</em>, found that gastric bypass surgery also helps lower the blood pressure of very obese patients. </p> <p>The procedure produces greater and more sustained weight loss than banding procedures, but it is also more complicated, and carries a higher risk of nutritional deficiencies. Laparoscopy techniques, which are less invasive, are now preferred over open surgery. They achieve equally good results with fewer complications. </p> <p><i>Biliopancreatic Diversion.</i> This procedure is more complicated and removes portions of the stomach. The pouch that is created attaches directly to the lower part of the small intestine. It poses a higher risk for nutritional deficiencies than other procedures and is not used as often. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331147" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of gastric bypass surgery.</div> </div> <p><i>General Side Effects and Complications.</i> Side effects and complications of bariatric procedures are common, and up to 25% of patients require corrective or repeat procedures. After any of these procedures people must chew all their food carefully, and they cannot eat large amounts of food at one time. If patients do not follow these guidelines, they will experience nausea, abdominal distress, or both. </p> <p>Complications from any bariatric procedure includes the following: </p> <ul> <li>Vomiting: This is the most common complication, and it is most common with banding procedures.</li> <li>Nutritional deficiencies: There is a strong risk of nutritional deficiencies, particularly with malabsorptive operations. This complication can lead to anemia and increase the risk of bone loss and osteoporosis. Taking enough mineral and vitamin supplements is important after bariatric surgery.</li> <li>Deep-vein thrombosis: There is a significant risk for deep-vein thrombosis (blood clots in the veins).</li> <li>Abdominal hernia: This is another common complication. Newer, laparoscopic techniques do not carry this risk, but not all individuals are candidates for this less-invasive approach.</li> <li>Rapid weight loss after surgery: This complication puts people at high risk for gallstones.</li> <li>Women who wish to be pregnant should wait until their weight has stabilized. Rapid weight loss and nutritional deficiencies can harm the fetus.</li> </ul> <p>People at highest risk for complications are those with heart or lung problems, severe obesity, and a history of abdominal surgeries. The mortality rate from bariatric surgeries is 0.2%, which is lower than the morality rates from severe obesity itself. Other surgical variations and less invasive techniques using laparoscopy have been developed. </p> <p><i>Specific Complications of Restrictive Banding Procedures.</i> Nausea, vomiting, or both occurs in half the patients, and severe heartburn occurs in a third. Device-related complications include band slippage, pouch dilation (widening), or both in nearly a quarter of patients, and obstruction in 12% of patients. Very serious complications are rare, but include blood clots, bleeding, infection, pneumonia, and perforation (tearing) of the stomach. </p> <p><i>Specific Complications of Malabsorptive Bypass Procedures.</i> Vomiting often occurs. Nutritional deficiencies occur more often in these procedures. The so-called dumping syndrome is a common unpleasant side effect, which occurs when food waste moves too quickly through the intestine. Symptoms include nausea, weakness, sweating, and faintness (particularly after eating sweets). </p> <p><i>Spot Exercising.</i> Anyone seeking to lose weight must expect that the results may not be as cosmetically satisfying as one would wish. Spot exercising (training particular areas of the body) is ineffective in reducing fat in specific locations because exercise draws on fat stores throughout the body. Gimmicky devices such as bust developers, vacuum pants, and exercise belts do absolutely nothing to reduce fat or add bulk in specific locations. Electrical pads wrapped around the waist, arms, or thighs were reported to cause burns and fires. </p> <p><i>Cellulite-Removal Creams.</i> Many women try to reduce fat in their thighs (cellulite) with creams that contain aminophylline (Skinny Dip, Thermojetics Body Toning Cream, Smooth Contours). Studies provide no evidence that these creams are effective. Their apparent effect on fat may simply be from narrowing blood vessels and forcing water from the skin, which could be dangerous for people with blood flow problems. </p> <p><i>Endermologie.</i> Endermologie uses motorized rollers and regulated suction to smooth out cellulite. In one study, about 28.6% of patients reported improved appearance after using it. </p> <p><i>Liposuction.</i> Liposuction eliminates fat in specific areas, such as the abdomen, thighs, buttocks, or knees. Special instruments are inserted through the skin into the pockets and suction is used to move the fat, break it up, and remove it. Small tubes may be used to drain blood and fluid during the first few days. The pain after the operation can be severe and often the skin does not contract, resulting in a flabby look. Complications can include burns from the vibrators, bruising, blood clots, and bleeding. Weight gain generally tends to develop in other locations after the operation. Some doctors are using this procedure in overweight people with diabetes to remove abdominal fat. Although there is no proof that it has an effect on diabetes, some experts believe the procedure deserves attention. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Liposuction is not recommended for major weight loss.</div> </div> </div> <h3 id="adamHeading_12">Resources</h3> <ul> <li><a href="http://www.healthierus.gov/dietaryguidelines" target="_blank">www.healthierus.gov/dietaryguidelines</a> -- Dietary Guidelines for Americans 2005</li> <li><a href="http://www.naaso.org/" target="_blank">www.naaso.org</a> -- North American Association for the Study of Obesity</li> <li><a href="http://www.eatright.org/" target="_blank">www.eatright.org</a> -- American Dietetic Association</li> <li><a href="http://www.nutrition.gov/" target="_blank">www.nutrition.gov</a>. -- Nutrition.gov</li> <li><a href="http://www.asbs.org/" target="_blank">www.asbs.org</a> -- American Society for Bariatric Surgery</li> <li><a href="http://www.cnpp.usda.gov/" target="_blank">www.cnpp.usda.gov</a> -- Center for Nutrition Policy and Promotion</li> <li><a href="http://fnic.nal.usda.gov/nal_display/index.php?tax_level=1&amp;info_center=4" target="_blank">http://fnic.nal.usda.gov</a> -- Food and Nutrition Information Center</li> <li><a href="http://www.americanheart.org/" target="_blank">www.americanheart.org</a> -- American Heart Association</li> <li><a href="http://www.nationaleatingdisorders.org/" target="_blank">www.nationaleatingdisorders.org</a> -- National Eating Disorders Organization</li> <li><a href="http://www.aabt.org/" target="_blank">www.aabt.org</a> -- Association for Advancement of Behavior Therapy</li> <li><a href="http://www.fda.gov/" target="_blank">www.fda.gov</a> -- Food and Drug Administration</li> <li><a href="http://win.niddk.nih.gov/" target="_blank">http://win.niddk.nih.gov</a> -- Weight-Control Information Network</li> </ul> <h3 id="adamHeading_13">References</h3> <p>US Food and Drug Administration FDA Approves Orlistat for Over-the-Counter Use. Rockville, MD: National Press Office; February 7, 2007. </p> <p>Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. <em>Journal of the American Medical Association.</em> 2006; 295:1549-1555. </p> <p>National Center for Health Statistics. Chartbook on Trends in the Health of Americans. Health, United States, 2005. Hyattsville, MD: Public Health Service. 2005 </p> <p>National Institute of Diabetes and Digestive and Kidney Diseases - Weight-control Information Network. Statistics Related to Overweight and Obesity. Available online. </p> <p>National Center for Health Statistics. Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004. </p> <p>Morino M, Toppino M, Bonnet G, Rosa R, et al. Laparoscopic vertical banded gastroplasty for morbid obesity. Assessment of efficacy. <em>Surg Endosc.</em> 2002 Nov;16(11):1566-72. </p> <p>Brethauer SA, Schauer PR, Chand B. Risks and benefits of bariatric surgery: Current evidence. <em>Cleveland Clinic Journal Of Medicine</em>. 2006 Nov; 73(11): 993-1007. </p> <p>Rosenthal RJ, Szomstein S, Kennedy CI, et al. Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. <em>Obes Surg.</em> 2006 Feb;16(2):119-24. </p> <p>He K, Liu K, Daviglus ML, et al. Magnesium Intake and Incidence of Metabolic Syndrome Among Young Adults. <em>Circulation.</em> 2006: Published online before print. March 27, 2006. </p> <p>Chen TY, Smith W, Rosenstock JL, Lessnau KD. A life-threatening complication of Atkins diet. <em>Lancet</em>. 2006 Mar 18;367(9514):958. </p> <p>Lopez-Jimenez F, Bhatia S, Collazo-Clavell ML, Sarr MG, Somers VK. Safety and efficacy of bariatric surgery in patients with coronary artery disease. <em>Mayo Clin Proc</em>. 2005 Sep;80(9):1157-62. </p> <p>Sidhaye A, Cheskin LJ. Pharmacologic treatment of obesity. <em>Adv Psychosom Med</em>. 2006;27:42-52. </p> <p>Fernstrom JD, Courcoulas AP, Houck PR, Fernstrom MH. Long-term changes in blood pressure in extremely obese patients who have undergone bariatric surgery. <em>Arch Surg</em>. 2006 Mar;141(3):276-83. </p> <p>Despres JP, Golay A, Sjostrom L; Rimonabant in Obesity-Lipids Study Group. Effects of rimonabant on metabolic risk factors in overweight patients with dyslipidemia. <em>N Engl J Med</em>. 2005 Nov 17;353(20):2121-34. </p> <p>Lanningham-Foster L, Nysse LJ, Levine JA. Labor saved, calories lost: the energetic impact of domestic labor-saving devices. <em>Obes Res</em>. 2003 Oct;11(10):1178-81. </p> <div id="health_topic_footer"> Review Date:<br /> 6/14/2007<br /> Reviewed By:<br /> A.D.A.M. Editorial Team: Greg Juhn, M.T.P.W., David R. Eltz, Kelli A. Stacy. Previously reviewed by Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital (4/30/2007).<br /> <div style="margin:10px 0px;"> <div style="float:left;margin:0px 10px 5px 0;"> </div> <div style="margin-bottom:5px;"> A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC&#39;s <a href="http://webapps.urac.org/healthwebsiteaccreditation/default.asp?id=878843645" target="_blank">accreditation program</a> is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.&#39;s <a href="http://www.adam.com/EditorialPolicy.html" target="_blank">editorial policy</a>, <a href="http://www.adam.com/About_ADAM/Editorial/process.html" target="_blank">editorial process</a> and <a href="http://www.adam.com/PrivacyStatement.html" target="_blank">privacy policy</a>. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch). </div> <div style="font-weight:bold">A.D.A.M. Copyright</div> <div style="float:left;margin-bottom:5px;"> The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. &#169; 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited. </div> <div align="center"><a href="http://www.adam.com" target="_blank">adam.com</a></div> </div> </div> </div> </div> </div> <div class="clear"></div> http://www.fitsugar.com/2331164#comment In-Depth Report Wed, 08 Oct 2008 17:34:58 -0700 FitSugar http://www.fitsugar.com/2331164 http://www.fitsugar.com/2331791 <a href="http://www.fitsugar.com/2331791"></a><div id="health_topic"> <div id="health_topic_left"> <div class="left_nav_block"> <h3>In This Report</h3> <ul> <li class="indent"><a href="#adamHeading_2" rel="section">Highlights</a></li> <li class="indent"><a href="#adamHeading_3" rel="section">Introduction</a></li> <li class="indent"><a href="#adamHeading_4" rel="section">Causes</a></li> <li class="indent"><a href="#adamHeading_5" rel="section">Symptoms</a></li> <li class="indent"><a href="#adamHeading_6" rel="section">Complications</a></li> <li class="indent"><a href="#adamHeading_7" rel="section">Risk Factors</a></li> <li class="indent"><a href="#adamHeading_8" rel="section">Diagnosis</a></li> <li class="indent"><a href="#adamHeading_9" rel="section">Treatment</a></li> <li class="indent"><a href="#adamHeading_10" rel="section">Treatment for NSAID-Induced...</a></li> <li class="indent"><a href="#adamHeading_11" rel="section">Medications</a></li> <li class="indent"><a href="#adamHeading_12" rel="section">Treatment for Bleeding Ulce...</a></li> <li class="indent"><a href="#adamHeading_13" rel="section">Lifestyle Changes</a></li> <li class="indent"><a href="#adamHeading_14" rel="section">Resources</a></li> <li class="indent"><a href="#adamHeading_15" rel="section">References</a></li> </ul> </div> </div> <div id="health_topic_right"> <div id="health_topic_from_adam"> HEALTH GUIDE REFERENCE FROM A.D.A.M </div> <div id="health_topic_content"> <h3 id="adamHeading_2">Highlights</h3> <p><strong>Risk with cardiovascular medications</strong> </p> <p>While nonsteroidal anti-inflammatory drugs are the major medications responsible for causing peptic ulcers, drugs taken for cardiovascular disease and its risk factors may also cause ulcers. Recent studies have found an association between increased risk of ulcer and the following drugs: </p> <ul> <li>Spironolactone, a common diuretic used in heart failure</li> <li>Niacin, a drug used to lower "bad" cholesterol and raise "good" cholesterol</li> <li>Vitamin K antagonists, commonly prescribed anticoagulants</li> <li>Dipyridamole, a drug for secondary stroke prevention</li> <li>Low-dose aspirin, prescribed for both heart attack and stroke prevention</li> </ul> <p>Risk of peptic ulcer increases dramatically when these drugs are used in combination. Considering the millions of people who take these medications to prevent a life-threatening cardiovascular event, their impact on peptic ulcer development could be monumental. </p> <p><strong>Atypical symptoms of GERD</strong> </p> <p>The burning pain of gastroesophageal reflux disease (GERD) can be confused with that of an ulcer. However, GERD pain typically develops after meals and is relieved by antacids. Elderly patients may have different symptoms that can include loss of appetite, weight loss, anemia, vomiting, or difficulty swallowing. A careful examination may be necessary to diagnose the underlying cause, since GERD and peptic ulcer may coexist. </p> <p><strong>Adjustments in triple therapy</strong> </p> <p>Peptic ulcers are commonly treated with the triple combination of two antibiotics (amoxicillin and clarithromycin) and a proton-pump inhibitor. Therapy usually lasts for 2 weeks. Recent studies indicate that 1 week may be just as effective. In addition, taking the antibiotics in sequence, rather than at the same time, may work better to eliminate <em>H. pylori</em>, the bacteria responsible for most ulcers. </p> <p><strong>Healing foods</strong> </p> <p>Milk may not be the ideal food for people with peptic ulcers because it encourages the production of stomach acid. However, certain qualities found in fermented milks and yogurts may actually offer protection against gastric ulcers. Likewise, the phenolic compounds found in virgin olive oil appear to kill many strains of <em>H. pylori</em>, including some that have become resistant to antibiotics. Vegetables contain dietary nitrate, which increases nitric oxide in the gut, causing the mucus layer to thicken. This increases protection against <em>H. pylori</em> invasion. </p> <p><strong>Protection when taking NSAIDs</strong> </p> <p>People who take NSAIDs for pain control have an immediate increased risk of ulcers. Chronic use increases risk dramatically. Taking a proton-pump inhibitor (PPI) or H2 blocker is necessary to reduce this risk. A review of clinical trials found three PPIs [omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid)] to be more effective than the H2 blocker ranitidine (Zantac). When NSAIDs were discontinued, however, healing rates with ranitidine reached nearly 100%. </p> <h3 id="adamHeading_3">Introduction</h3> <p>A peptic ulcer is an open sore or raw area that tends to develop in one of two places: </p> <ul> <li>The lining of the stomach ( <i>gastric ulcer</i>), or</li> <li>The upper part of the small intestine -- the duodenum ( <i>duodenal ulcers</i>). In the U.S., duodenal ulcers are 3 times more common than gastric ulcers.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">A peptic ulcer is an open sore or raw area in the lining of the stomach (gastric) or the upper part of the small intestine (duodenal).</div> </div> </div> <p>Ulcers average between one-quarter and one-half inch in diameter. They develop when digestive juices produced in the stomach, intestines, and digestive glands damage the lining of the stomach or duodenum. </p> <p>The two important digestive juices are <i>hydrochloric acid</i> and the enzyme <i>pepsin</i>. Both substances are critical in the breakdown and digestion of starches, fats, and proteins in food. They play different roles in ulcers: </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331407" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an image of the stomach.</div> </div> <ul> <li><i>Hydrochloric acid.</i> A common misbelief is that excess hydrochloric acid, which is secreted in the stomach, is solely responsible for producing ulcers. Patients with duodenal ulcers do tend to have higher-than-normal levels of hydrochloric acid, but most patients with gastric ulcers have normal or lower-than-normal acid levels. Some stomach acid is important for protecting against <i>H. pylori,</i> the bacteria that causes most peptic ulcers. [Note: An exception is ulcers that occur in Zollinger-Ellison syndrome. This is a rare genetic condition in which very high levels of gastrin, a potent acid, are secreted by tumors in the pancreas or duodenum.]</li> <li><i>Pepsin.</i> Pepsin is an enzyme that breaks down proteins in food. Since the stomach and duodenum are also composed of protein, they are also susceptible to the actions of pepsin. Pepsin is, then, also important in the formation of ulcers.</li> </ul> <p>Fortunately, the body has a defense system to protect the stomach and intestine against these powerful substances: </p> <ul> <li>The <i>mucous layer,</i> which coats the stomach and duodenum, forms the first line of defense.</li> <li><i>Bicarbonate</i>, which the mucous layer secretes, neutralizes the digestive acids.</li> <li>Hormone-like substances called <i>prostaglandins</i> help dilate the blood vessels in the stomach to ensure good blood flow and protect against injury. Prostaglandins are also believed to stimulate bicarbonate and mucus production.</li> </ul> <p>Disrupting any of these defense mechanisms makes the stomach and intestine lining susceptible to the actions of acid and pepsin, increasing the risk for ulcers. </p> <h3 id="adamHeading_4">Causes</h3> <p>Before the discovery of the bacterium <i>Helicobacter (H.) pylori</i>, the stomach was believed to be a sterile environment. However, in 1982 two Australian scientists identified <i>H. pylori</i> as the main cause of stomach ulcers. They showed that inflammation of the stomach and stomach ulcers result from an infection of the stomach caused by the <em>H. pylori</em> bacteria. This discovery was so important that the researchers were awarded the Nobel Price in Medicine in 2005. The bacteria appear to trigger ulcers in the following way: </p> <ul> <li><i>H. pylori's</i> corkscrew shape enables it to penetrate the mucous layer of the stomach or duodenum so it can attach itself to the lining.</li> <li>It survives in the highly acidic environment by producing urease, an enzyme that generates ammonia to neutralize the acid.</li> <li><i>H. pylori</i> then produces a number of toxins and factors that can cause inflammation and damage to the lining, leading to ulcers in certain individuals.</li> <li>It also alters certain immune factors that allow it to evade detection and cause persistent inflammation for a life -- even without invading the mucous membrane.</li> </ul> <p>Even if ulcers do not develop, the bacterium is now considered to be a major cause of active chronic inflammation in the stomach (<i>gastritis</i>) and in the upper part of the small intestine (<i>duodenitis</i>). </p> <p>It is also strongly linked to stomach (gastric) cancer and possibly other non-intestinal problems. </p> <p><i>Factors that Trigger Ulcers in H. pylori Carriers.</i><i>H. pylori</i> is found in about 25% of people who do <i>not</i> have peptic ulcers. The magnitude of <i>H. pylori</i> infection, particularly in older people, may not always predict the presence or absence of peptic ulcers. Other variables must to be present to actually trigger ulcers. These may include: </p> <ul> <li>Genetic Factors. Some people harbor genetic strains of <i>H. pylori</i> that may make the bacteria more dangerous and increase the risk for ulcers. The most intensively investigated genetic factor is cytotoxin-associated gene A (CagA), which has been associated with both gastric and duodenal ulcers, as well as with stomach cancer. Other genetic types that may also increase bacterial severity are called vacuolating cytotoxin (vacA) and antigen-binding adhesin (BabA) genotypes. Some of these genetic factors may be more or less important for development of ulcers, depending on ethnicity.</li> <li>Immune Abnormalities. Some experts suggest that certain individuals have abnormalities in the immune response of the intestine, which allow the bacteria to injure the lining.</li> <li>Lifestyle Factors. Although lifestyle factors such as chronic stress, drinking coffee, and smoking were long believed to be primary causes of ulcers, it is now thought they only increase susceptibility to ulcers in some <i>H. pylori</i> carriers.</li> <li>Shift Work and Other Causes of Interrupted Sleep. People who work the night shift have a significantly higher incidence of ulcers than day workers. Researchers suspect that frequent interruptions of sleep may weaken the ability of the immune system to protect against endotoxins.</li> </ul> <p>When <i>H. pylori</i> was first identified as the major cause of peptic ulcers, it was found in 90% of people with duodenal ulcers and in about 80% of people with gastric ulcers. As more people are being tested and treated for the bacteria, however, the rate of <i>H. pylori-</i> associated ulcers has declined. For example, a 2001 study suggested that about half of ulcers are <i>not</i> caused by <i>H. pylori</i>. Instead, they tend to be caused by regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and other common pain relievers. Genetic factors or, rarely, Crohn's disease or Zollinger-Ellison syndrome, also cause ulcers. </p> <p>Some researchers now believe that duodenal ulcers are not caused by <em>H. pylori</em>, but that the presence of the bacteria simply delays healing. This fact, they say, may explain why up to half of cases of acute duodenal perforation show no evidence of <em>H. pylori</em>, and why duodenal ulcers can recur even after <em>H. pylori</em> has been eradicated. </p> <p>A 2006 study published in the <em>Journal of Biological Chemistry</em> indicates that a protein called decay-accelerating factor (DAF) acts as receptor for <em>H. pylori</em>. Animal studies show that blocking this interaction renders <em>H. pylori</em> harmless to the stomach. Researchers hope the discovery leads to new drugs that can reduce the risk of peptic ulcer. </p> <p>Long-term use of NSAIDs is the second most common cause of ulcers, and the rate of NSAID-caused ulcers is increasing. About 20 million people take prescription NSAIDs regularly, and more than 25 billion tablets of over-the-counter brands are sold each year in the U.S. alone. The most common NSAIDs are aspirin, ibuprofen (Advil), and naproxen (Aleve, Naprosyn), although many others are available. Patients with NSAID-caused ulcers should stop taking these drugs. </p> <p>There is no doubt NSAIDs increase the risk of ulcers and gastrointestinal (GI) bleeding. The risk of bleeding is continuous for as long as a patient takes these drugs and may persist for about one year after stopping. Short courses of NSAIDs for temporary pain relief should not cause major problems, because the stomach has time to recover and repair any damage that has occurred. </p> <p>Specific NSAIDs pose greater or lesser risks for ulcers and bleeding. No NSAIDs, however, even over-the-counter brands, should be used long-term except under a doctor's direction. </p> <table border="1" cellpadding="3" cellspacing="0"> <tr> <td valign="top" colspan="3" /></tr> <tr> <td valign="top"> <p><b>Lowest Risk</b> </p> </td> <td valign="top"> <p><b>Medium Risk</b> </p> </td> <td valign="top"> <p><b>Highest Risk</b> </p> </td> </tr> <tr> <td valign="top"> <p>Nabumetone (Relafen) </p> <p>Etodolac (Lodine) </p> <p>Salsalate </p> <p>Sulindac (Clinoril) </p> </td> <td valign="top"> <p>Aspirin. Even low-dose ("baby") aspirin (81 mg) may pose some risk </p> <p>Ibuprofen (Motrin, Advil, Nuprin, Rufen) </p> <p>Naproxen (Aleve, Naprosyn, Naprelan, Anaprox) </p> <p>Diclofenac (Voltaren), Tolmetin (Tolectin) </p> <p>NOTE: Drugs in the medium risk group vary in risk. For example, studies show that naproxen is twice as likely as ibuprofen to be associated with hospitalization from GI bleeding. </p> </td> <td valign="top"> <p>Flurbiprofen (Ansaid), Piroxicam (Feldene), Fenoprofen Indomethacin (Indocin), Meclofenamate (Meclomen) </p> <p>Ketoprofen (Actron, Orudis KT). Note: Ketoprofen is often considered a medium-risk drug, but one study reported that taking the drug in low doses for as little as 1 week causes significant GI injury. </p> </td> </tr> </table> <p>Certain drugs other than NSAIDs may cause or aggravate ulcers, particularly those taken for cardiovascular disease and its risk factors. A review of more than 306,000 primary care patients found that spironolactone, a common diuretic prescribed in heart failure, was associated with a 2.7% increased risk of ulcer or upper GI bleeding. Exacerbation of peptic ulcers is a rare but noted side effect of niacin, a drug that can reduce LDL cholesterol and raise HDL cholesterol. Low-dose aspirin, dipyridamole, and vitamin K antagonists such as Coumadin nearly double the risk of upper GI bleeding. When these drugs are used in combination, the risk soars. </p> <p>Risk of GI perforation was seen in phase 3 clinical trials of bevacizumab, the first vascular endothelial growth factor agent (VEGF) approved by the FDA. This drug has been shown to increase survival and stop the progression of metastatic colorectal cancer when used in combination with chemotherapy. While the benefits of bevacizumab outweigh the risks, GI perforation is very serious. If it occurs, the drug must be discontinued. </p> <p>The least common major cause of peptic ulcer disease is Zollinger-Ellison syndrome (ZES). </p> <p>Rarely, certain conditions may cause ulceration in the stomach or intestine, including: </p> <ul> <li>Radiation treatments</li> <li>Bacterial or viral infections</li> <li>Alcohol abuse</li> <li>Physical injury</li> <li>Burns</li> </ul> <p><em>What is ZES?</em> Zollinger-Ellison syndrome (ZES) is the least common major cause of peptic ulcer disease. In this condition, tumors in the pancreas and duodenum (gastrinomas) produce excessive amounts of gastrin, a hormone that stimulates gastric acid formation. These tumors are usually malignant, so proper and prompt management of the disease is essential. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Another cause of peptic ulcer, although far less common than H. pylori or NSAIDs, is Zollinger-Ellison syndrome. A large amount of excess acid is produced in response to the overproduction of the hormone gastrin, which in turn is caused by tumors on the pancreas or duodenum. These tumors are usually malignant, must be removed and acid production suppressed to relieve the recurrence of the ulcers.</div> </div> </div> <p><em>Who Gets ZES?</em> The incidence of ZES in the United States is estimated at 1 case per million people per year, and at 0.1 - 1% among patients with peptic ulcers. The mean age at onset is 45 - 50, and men are affected more often than women. </p> <p><em>How Is ZES Diagnosed?</em> ZES should be suspected in patients with ulcers who are not infected with <i>H. pylori</i> and have no history of NSAID use. Diarrhea may precede ulcer symptoms. Ulcers occurring in the second, third, or fourth portions of the duodenum or the jejunum (the middle section of the small intestine) are signs of ZES. GERD is more prevalent and often more severe in patients with ZES, and can be complicated by ulcerations and strictures of the esophagus. </p> <p><em>How Is ZES Treated?</em> Peptic ulcers associated with ZES are typically persistent and difficult to treat. Treatment consists of removing the tumors and suppressing acid with an intravenous proton-pump inhibitor (Protonix). Previously, removing the stomach was the only option. </p> <h3 id="adamHeading_5">Symptoms</h3> <p><i>Dyspepsia.</i> The most common symptoms of peptic ulcer are known collectively as <i>dyspepsia</i>. Peptic ulcers can occur without dyspepsia or any other gastrointestinal symptom, especially when caused by NSAIDs. Dyspepsia may be persistent or recurrent and can encompass a variety of symptoms in the upper abdomen, including: </p> <ul> <li>Pain or discomfort</li> <li>Bloating</li> <li>A feeling of fullness. People with severe dyspepsia are unable to drink as much fluid as people with mild or no dyspepsia.</li> <li>Hunger and an empty feeling in the stomach, often 1 - 3 hours after a meal</li> <li>Mild nausea (Vomiting, in fact, may relieve symptoms.)</li> <li>Regurgitation (sensation of acid backing up into the throat.)</li> <li>Belching</li> </ul> <p><i>Ulcer Pain.</i> The pain of ulcers can be either localized in one place or diffuse. The pain is described as a burning, gnawing, or aching in the upper abdomen, or as a stabbing pain penetrating through the gut. The symptoms may vary depending on the location of the ulcer: </p> <ul> <li>Duodenal ulcers often cause a gnawing pain in the upper stomach area several hours after a meal, and the pain is often relieved by eating a meal.</li> <li>Gastric ulcers may cause a dull, aching pain, often right after a meal; eating does not relieve the pain and may even worsen it. Pain may also occur at night.</li> </ul> <p>Ulcer pain may be particularly confusing or disconcerting when it radiates to the back or to the chest behind the breastbone. In such cases it can be confused with other conditions such as heart attack. </p> <p>Because ulcers can cause hidden bleeding, patients may experience the symptoms of anemia, including fatigue and shortness of breath. </p> <p>A sudden onset of severe symptoms may indicate intestinal obstruction, perforation, or hemorrhage, all of which are emergencies. Symptoms may include: </p> <ul> <li>Tarry, black, or bloody stools</li> <li>Severe vomiting, which may include blood or a substance with the appearance of coffee grounds (a sign of a serious hemorrhage) or entire stomach contents (sign of intestinal obstruction)</li> <li>Severe abdominal pain with or without vomiting or evidence of blood</li> </ul> <p>Anyone who experiences any of these symptoms should go to the emergency room immediately. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Peptic ulcers may lead to emergency situations. Severe abdominal pain with or without evidence of bleeding may indicate a perforation of the ulcer through the stomach or duodenum. Vomiting of a substance that resembles coffee grounds or the presence of black tarry stools may indicate serious bleeding.</div> </div> </div> <h3 id="adamHeading_6">Complications</h3> <p>Most people with severe ulcers experience significant pain and sleeplessness, which can have a dramatic and adverse impact on their quality of life. </p> <p>Peptic ulcers caused by <i>H. pylori</i> or NSAIDs can be very serious if they hemorrhage or perforate the stomach or duodenum. Up to 15% of people with ulcers experience some degree of bleeding, which can be life-threatening. Ulcers that form where the small intestine joins the stomach can swell and scar, resulting in a narrowing or closing of the intestinal opening. In such cases, the patient will vomit the entire contents of the stomach, and emergency treatment is necessary. </p> <p>Complications of peptic ulcers cause an estimated 6,500 deaths each year. These figures, however, do not reflect the high number of deaths associated with NSAID use. Ulcers caused by NSAIDs are more likely to bleed than those caused by <i>H. pylori.</i> NSAID-related bleeding and stomach problems may be responsible for as many as 107,000 hospital admissions and 16,500 deaths each year. </p> <p>Because there are usually no GI symptoms from NSAID ulcers until bleeding begins, doctors cannot predict which patients taking these drugs will develop bleeding. The risk for a poor outcome is highest in people who have had long-term bleeding from NSAIDs, blood clotting disorders, low systolic blood pressure, mental instability, or the presence of another serious, unstable medical condition. Populations at greatest risk are the elderly and those with other serious conditions, such as heart problems. </p> <p><i>H. pylori</i> is strongly associated with certain cancers. Some studies have also linked it to a number of non-gastrointestinal illnesses as well, although the evidence is inconsistent. </p> <p><i>Stomach Cancers.</i> Stomach cancer, also called <i>gastric</i> cancer, is the second most common cause of cancer worldwide. In developing countries where the rate of <i>H. pylori</i> is very high, the risk of stomach cancer is 6 times higher than in the U.S. An important 2001 study strongly supported previous work that found a causal link between <i>H. pylori</i> infection and stomach cancer. In this study, uninfected people did not develop stomach cancer. However, the stomach cancer rates for <i>H. pylori-</i>associated conditions were 4.7% for nonulcer dyspepsia, 3.4% for gastric ulcers, and 2.2% of stomach polyps. Experts now suggest that <i>H. pylor</i>i may be as carcinogenic to the stomach as cigarette smoke is to the lungs. </p> <p>Eradication of <em>H. pylori</em> may reduce the risk of stomach cancer, but not eliminate it. A Japanese study found that continued risk is associated with degree of mucosal atrophy before <em>H. pylori</em> eradication therapy is started. This is something than can be measured during an endoscopy. </p> <p>The process most likely starts in childhood. Infection with <i>H. pylori</i> promotes a precancerous condition called <i>atrophic gastritis</i>. This may lead to cancer through the following steps: </p> <ul> <li>The stomach becomes chronically inflamed and loses patches of glands that secrete protein and acid.</li> <li>Acid protects against carcinogens, substances that cause cancerous changes in cells.</li> <li>New cells replace destroyed cells, but the new cells do not produce enough acid to protect against carcinogens.</li> <li>Over time, cancer cells may develop and proliferate in the stomach.</li> </ul> <p>Onset of <i>H. pylori</i> infection in adulthood poses a lower risk, since the development of atrophic gastritis takes years, and an adult is likely to die of other causes first. Other factors, such as specific genetic strains and diets, might also influence a higher risk for stomach cancer. For example, a diet high in salt and low in fresh fruits and vegetables has been associated with a greater risk. Some evidence suggests that the virulent <i>H. pylori</i> strain called cytotoxin-associated gene A (CagA) may also be a particular risk factor for precancerous changes. </p> <p>Interestingly, people with duodenal ulcers caused by <i>H. pylori</i> appear to have a <i>lower</i> risk of stomach cancer, although scientists do not know why. It may be that different <i>H. pylori</i> strains affect the duodenum and the stomach. Or, the high levels of acid found in the duodenum may help prevent the spread of the bacteria to critical areas of the stomach. </p> <p><i>Pancreatic Cancer. H. pylori</i> has recently been linked to pancreatic cancer. The excess risk is high in patients with unoperated gastric ulcers -- 20% after 15 years and 50% after the first hospitalization. Surgery decreased the risk dramatically. Unoperated duodenal ulcers, on the other hand, were not associated with increased risk of pancreatic cancer. </p> <p><i>Heart Disease.</i> Some research has reported a very high rate of <i>H. pylori</i> infection in men with coronary artery disease, but more recent work has found no relationship between the bacteria and heart disease. A 2001 study suggested that the only relationship between <em>H. pylori</em> and heart disease may be that people with both tend to be in lower socioeconomic groups. Further studies are needed. </p> <p><i>Other Diseases. H. pylori</i> has also been weakly associated with other nonintestinal disorders, including migraine, Raynaud's disease (marked by cold extremities), and some skin disorders, such as chronic hives. </p> <h3 id="adamHeading_7">Risk Factors</h3> <p>About 25 million people in the U.S. are expected to develop peptic ulcers at some point in their lives. Peptic ulcer disease affects all age groups, but is rare in children. Men have twice the risk of ulcers as women. The risk of duodenal ulcers tends to rise beginning around age 25 and continues until age 75; gastric ulcers peak at age 55 - 65. </p> <p>Peptic ulcers are less common than they once were. Research suggests that ulcer rates have even declined in areas with widespread <em>H. pylori</em> infection. The increased use of proton-pump inhibitor drugs may be responsible for this trend. </p> <p><i>H. pylori</i> grows and colonizes only in the intestinal tracts of primates. The bacteria are most likely transmitted directly from person to person. Still, little is yet known about its transmission. </p> <p><i>Who Is Infected with H. pylori?</i> About half the world's adults are infected with <i>H. pylori.</i> The bacteria are nearly always acquired during childhood and persist throughout life, if not treated. The prevalence in children ranges from less than 10% to more than 80%, with the highest infection rates (3 - 10%) in developing countries and the lowest (0.5%) in industrialized nations, where rates continue to decline. Even in industrialized countries, however, infection rates in regions with crowded, unsanitary conditions are equal to those in developing countries. </p> <p><i>How Does the Bacteria Pass from Person to Person?</i> It is not entirely clear how the bacteria are transmitted. One study did not find that infected students posed any risk for their classmates. Transmission within families may be the most important route for <i>H. pylori</i>. A 2002 study reported that spouses of people with peptic ulcers are at significantly higher risk for ulcers, suggesting that the bacteria may be transmitted during intimate contact. Some evidence suggests that bacteria may spread during GI tract illness, particularly when vomiting occurs. The bacteria also may be passed in stools. Since <i>H. pylori</i> can live in water, but not apparently in food, the bacteria may also be transmitting through sewage-contaminated water. </p> <p><i>Who Is at Risk for Ulcers from H. pylori?</i> Although <i>H. pylori</i> infection is common, ulcers in children are very rare, and only a minority of infected adults develops ulcers. Some known risk factors include smoking, alcohol use, having a relative with peptic ulcers, being male, and the presence of the cytotoxin-associated gene A (CagA). Experts are unable to determine, however, any single factor or group of factors that can determine which infected patients are most likely to develop ulcers. </p> <p>Between 15 - 25% of patients who have taken NSAIDs regularly will have evidence of one or more ulcers, but in most cases these ulcers are very small. Given the widespread use of NSAIDs, however, the potential total number of people who can develop serious problems may be very large. Long-term NSAID use can damage the stomach and, possibly, the small intestine. </p> <p>In April 2005, the FDA asked manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes the increased risk for cardiovascular events and GI bleeding in people taking these drugs. (Pharmaceutical companies are trying to develop new COX-2 inhibitors without these dangerous side effects. Early safety studies of the novel COX-2 inhibitor known as CS-706 showed its effect on gastric mucosa to be the same as placebo.) </p> <p>The FDA also requested manufacturers of over-the-counter NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and GI risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions. </p> <p><i>Frequent Users of NSAIDs.</i> Anyone who uses NSAIDs regularly is at risk for gastrointestinal problems. Even low-dose aspirin (81 mg) may pose some risk, although the risk is lower than with standard doses. In one 4-year study, 4.5% of regular NSAID users were hospitalized for GI bleeding. The highest risk, however, was found in people who require long-term use of very high-dose NSAIDs, notably patients with rheumatoid arthritis. Other people who take high doses of NSAIDs include those with chronic low back pain, fibromyalgia, and chronic stress. </p> <p><em>Contributing Factors</em>. Certain factors add to the risk for ulcers in NSAID-users: </p> <ul> <li>Age 65 and older</li> <li>History of peptic ulcers or upper gastrointestinal bleeding</li> <li>Other serious ailments, such as congestive heart failure</li> <li>Use of other medications, such as the anticoagulant warfarin (Coumadin), corticosteroids, or the osteoporosis drug alendronate (Fosamax)</li> <li>Alcohol abuse</li> <li>Those infected with <i>H. pylori</i>. A 2002 study reported that the combination of NSAID use and <em>H. pylori</em> posed a 3.5-fold greater risk of ulcers than either factor alone. However, not all studies have reported the higher risk in infected patients.</li> </ul> <p><i>Stress and Psychological Factors.</i> Although stress is no longer considered a cause of ulcers, studies still suggest that stress may predispose a person to ulcers or prevent existing ulcers from healing. Some experts estimate that social and psychological factors play a contributory role in 30 - 60% of peptic ulcer cases, whether they are caused by <i>H. pylori</i> or NSAIDs. Some experts even believe that the anecdotal relationship between stress and ulcers is so strong that treatment of psychological factors is warranted. </p> <p><i>Smoking.</i> Smoking increases acid secretion, reduces prostaglandin and bicarbonate production, and decreases mucosal blood flow. Results of studies on the actual effect of smoking on ulcers, however, are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One study reported that after ulcers healed, about half of nonsmokers experienced a relapse of their ulcer disease after 1 year, but that all heavy smokers relapsed after 3 months. Other studies have found no increased risk for ulcers in smokers. In any case, any impact of smoking on ulcers does not seem to be affected by the presence of <i>H. pylori</i>. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">Tobacco use and exposure may cause an acceleration of coronary artery disease and peptic ulcer disease. It is also linked to reproductive disturbances, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing.</div> </div> </div> <h3 id="adamHeading_8">Diagnosis</h3> <p>Peptic ulcers are always suspected in patients with persistent dyspepsia (bloating, belching, and abdominal pain). Dyspepsia, however, occurs in 20 - 40% of people who live in industrialized nations, and only about 15 - 25% of these people actually have ulcers. A number of steps are needed to make an accurate diagnosis of ulcers. </p> <p>The doctor will ask for a thorough report of a patient's dyspepsia and other important symptoms, such as weight loss or fatigue, present and past medication use (especially chronic use of NSAIDs), family members with ulcers, and drinking and smoking habits. </p> <p>In addition to peptic ulcers, a number of conditions, notably gastroesophageal reflux disease (GERD) and irritable bowel syndrome, cause dyspepsia. Often, however, no cause can be determined. In such cases, the symptoms are referred to collectively as functional dyspepsia. </p> <p>Peptic ulcer symptoms, particularly abdominal pain and chest pain, may resemble those of other conditions, such as gallstones or heart attack. Certain features may help to distinguish these different conditions. However, symptoms often overlap, and it is impossible to make a diagnosis based on symptoms alone. A number of tests are needed. </p> <p>The following disorders may be confused with peptic ulcers: </p> <ul> <li><i>GERD.</i> About half of patients with GERD also have dyspepsia. With GERD or other problems in the esophagus, the main symptom is usually heartburn, a burning pain that radiates up to the throat. It typically develops after meals and is relieved by antacids. The patient may have difficulty swallowing and may experience regurgitation or acid reflux. Elderly patients with GERD are less likely to have these symptoms, but instead may experience loss of appetite, weight loss, anemia, vomiting, or dysphagia (difficulty or painful swallowing). [See <em>In-Depth Report</em> #85: <a href="/2331708" >Gastroesophageal Reflux Disease</a><em>.</em>]</li> <li><i>Heart Events.</i> Cardiac pain, such as angina or a heart attack, is more likely to occur with exercise and may radiate to the neck, jaw, or arms. In addition, patients typically have distinct risk factors for heart disease, such as a family history, smoking, high blood pressure, obesity, or high cholesterol. [See <em>In-Depth Report</em> #12: <a href="/2331144" >Heart Attack</a><em>.</em>]</li> <li><i>Gallstones.</i> The primary symptom in gallstones is typically a steady gripping or gnawing pain on the right side under the rib cage, which can be quite severe and can radiate to the upper back. Some patients experience pain behind the breastbone. The pain is often precipitated by a fatty or heavy meal, but gallstones almost never cause dyspepsia. [See <em>In-Depth Report</em> #10: <a href="/2331795" >Gallstones and Gallbladder Disease</a><em>.</em>]</li> <li><i>Irritable Bowel Syndrome.</i> Irritable bowel syndrome can cause dyspepsia, nausea and vomiting, bloating, and abdominal pain. It occurs more often in women than in men.</li> </ul> <p>Dyspepsia may also occur with gastritis, stomach cancer, or as a side effect of certain drugs, including NSAIDs, antibiotics, iron, corticosteroids, theophylline, and calcium blockers. </p> <p>When ulcers are suspected, the doctor will prescribe tests to detect bleeding. These may include a rectal exam, a complete blood count, and a fecal occult blood test (FOBT). The FOBT tests for hidden (occult) blood in stools. Typically, the patient is asked to supply up to 6 stool specimens in a specially prepared package. A small quantity of feces is smeared on treated paper, which reacts to hydrogen peroxide. If blood is present, the paper turns blue. </p> <p>Traditional radiology tests have not yet proven valuable for diagnosing ulcers. However, radiologists in France who performed multidetector computed tomography (MDCT) scans on preoperative patients with proven GI perforations found the technology to be highly accurate in pinpointing the location of the perforations. </p> <p>Simple blood, breath, and stool tests can now detect <i>H. pylori</i> with a fairly high degree of accuracy. It is not entirely clear, however, which individuals should be screened for <i>H. pylori.</i> </p> <p><i>Candidates for Screening.</i> Some doctors currently test for <i>H. pylori</i> only in individuals with dyspepsia who also have high-risk conditions, such as: </p> <ul> <li>Strong indication for ulcers, such as weight loss, anemia, or indications of bleeding</li> <li>History of active ulcers</li> <li>Risk factors for stomach cancer or other complications from ulcers</li> </ul> <p>Smokers and those who experience regular and persistent pain on an empty stomach may also be good candidates for screening tests. Some doctors argue that testing for <i>H. pylori</i> may be beneficial for patients with dyspepsia who are regular NSAID users. In fact, given the possible risk for stomach cancer in <i>H. pylori-</i> infected people with dyspepsia, some experts now recommend that <i>any</i> patient with dyspepsia lasting longer than 4 weeks should have a blood test for <i>H. pylori</i>. This is a subject of considerable debate, however. </p> <p><i>Specific Screening Tests for H. pylori.</i> The following screening tests used or under investigation for <i>H. pylori:</i> </p> <ul> <li>Breath Test. A simple test called the carbon isotope-urea breath test (UBT) can identify up to 99% of people who harbor <i>H. pylori</i>. Up to 2 weeks before the test, the patient must discontinue taking any antibiotics, bismuth-containing agents such as Pepto-Bismol, and proton-pump inhibitors (PPIs). As part of the test, the patient swallows a special substance containing <i>urea</i> (a compound in mammals metabolized from nitrogen) that has been treated with carbon atoms. If <em>H. pylori</em> is present, the bacteria convert the urea into carbon dioxide, which is detected and recorded in the patient's exhaled breath after 10 minutes.</li> <li>Blood Tests. Blood tests are used to measure antibodies to <i>H. pylori</i>, with results available in minutes. Diagnostic accuracy is reported at 80 - 90%. One such important test is called enzyme-linked immunosorbent assay (ELISA). An ELISA test of the urine is also showing promise in children.</li> <li>Stool Test. A test to detect genetic fingerprints of <i>H. pylori</i> in the feces appears to be as accurate as the breath test for initial detection of the bacteria and for detecting recurrences after antibiotic therapy.</li> </ul> <p>It should be noted that such tests are not as accurate as endoscopy, an invasive procedure, which is needed to confirm a diagnosis of <i>H. pylori</i>. The breath and stool tests, however, can be particularly useful after treatment to determine if a patient has been cured. </p> <p><i>Test and Tre</i>at<i>.</i> Depending on the results of the screening tests, some doctors take the following steps: </p> <ul> <li>Approach for Noninfected Individuals. People who do not have evidence of <i>H. pylori</i> on a blood or breath test are typically given a 4-week course of acid-suppressing medication, usually a PPI such as omeprazole (Prilosec).</li> <li>Approach for <i>H. pylori-</i>Infected Individuals. Patients with evidence of bacterial infection are given antibiotics. If this does not relieve symptoms, they are given a 6-week course of the PPI omeprazole (Prilosec). (Whether to give antibiotics to infected patients with non-ulcer dyspepsia is controversial and is discussed in the section, What Are the Guidelines for Treating Peptic Ulcers Caused by <i>H. pylori</i>?)</li> </ul> <p>If symptoms persist, endoscopy is usually performed. Endoscopy is an invasive procedure, but is the only procedure in which a biopsy of stomach tissue can be taken, making it the most accurate test. </p> <p>Experts debate whether endoscopy should be performed on all patients who do not respond to initial medication, since it does not appear to add any useful information on treatment choices, unless there is evidence or suspicion of bleeding or serious complications. </p> <p>While endoscopy is the gold standard for diagnosing upper GI disorders, because it allows doctors to biopsy the stomach, 3-dimensional CT imaging may also be valuable. Researchers in China compared the results of endoscopy to the results of noninvasive CT imaging performed to diagnose GI disease. They found that the CT imaging correctly diagnosed 50 of 52 cases, including 5 cases of peptic ulcer disease. Three-dimensional CT imaging clearly showed the GI tract lesions. It is currently considered a valuable complement to endoscopy. </p> <p>Endoscopy is a procedure used to evaluate the esophagus, stomach, and duodenum using a long, thin tube tipped with a tiny video camera (endoscope). When combined with biopsy, endoscopy is the most accurate procedure for detecting the presence of peptic ulcers, bleeding, and stomach cancer, or for confirming the presence of <i>H. pylori</i>. </p> <p><i>Appropriate Candidates for Endoscopy.</i> Because endoscopy is invasive and expensive, it is unsuitable for screening everyone with dyspepsia. Most individuals with these symptoms are managed effectively without endoscopy. Endoscopy is usually reserved for patients with dyspepsia who also have risk factors for ulcers, stomach cancer, or both. Such factors include the following: </p> <ul> <li>Having so-called "alarm" symptoms (unexplained weight loss, gastrointestinal bleeding, vomiting, difficulty swallowing, or anemia).</li> <li>Being over 45 (when the risk for stomach cancer increases).</li> </ul> <p>There is some debate whether patients under 45 with persistent dyspepsia and no alarm symptoms should have endoscopy. </p> <p><i>The Procedure.</i> Endoscopy may be performed in a hospital, doctor's office, or outpatient surgery center, and typically involves the following: </p> <ul> <li>The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and relax the patient.</li> <li>The doctor then places the thin, flexible plastic tube into the patient's mouth and down the esophagus into the stomach.</li> <li>A tiny camera in the endoscope allows the doctor to see the surface of the esophagus, stomach, and duodenum, and to search for abnormalities.</li> <li>The doctor will remove about 10 small tissue samples (biopsies), which will be tested for <i>H. pylori</i>.</li> </ul> <div class="ADAMInlineGraphic"> <div class="ADAMInlineFull"><br /> <div class="ADAMTextBox">In endoscopy, the doctor places a long, thin, flexible tube (called an endoscope) down the patient's throat and into the stomach and duodenum. A camera and light on the tip of the endoscope enables the doctor to check for abnormalities. Tiny samples may be taken to check for H. pylori bacteria, a cause of many peptic ulcers. If a bleeding ulcer is found, it may be sealed with a burning tool (cauterized) during the procedure.</div> </div> </div> <p>Note: Some evidence suggests that patients who take PPIs should stop taking the medication 2 weeks before an endoscopy, since it may mask ulcers. </p> <p><i>Capsule Endoscopy.</i>Capsule endoscopy involves swallowing a capsule the size of a large vitamin, which contains tiny camera, light source, and radio transmitter. The device takes pictures as it passes through the intestinal tract. At this point, its benefits are limited to the small intestine, so it is unlikely to play a role in the diagnosis of peptic or gastric ulcers. However, capsule endoscopy has the potential to be an important tool for the diagnosis of obscure upper GI bleeding. Patients who have used it have usually found it painless and preferable to conventional endoscopy. </p> <p>An upper GI (gastrointestinal) series was the standard diagnostic method for peptic ulcers until the introduction of adequate tests for detecting <i>H. pylori</i>. In an upper GI series, the patient drinks a solution containing barium. X-rays are then taken, which may reveal inflammation, active ulcer craters, or deformities and scarring due to previous ulcers. Endoscopy is more accurate, although it is more invasive and expensive. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331807" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an illustrated series detailing treatment of GI bleeding.</div> </div> <p>Stool tests may show traces of blood that are not visible to the naked eye, and blood tests may reveal anemia in those who have bleeding ulcers. If Zollinger-Ellison syndrome is suspected, blood levels of gastrin should be measured. </p> <h3 id="adamHeading_9">Treatment</h3> <p>Antibiotic regimens that eradicate <i>H. pylori</i> can cure peptic ulcers and are now the standard medications used for ulcers in infected individuals who are not taking NSAIDs. Eliminating <i>H. pylori</i> can also cure the rare MALT lymphomas caused by this bacterium. Other drugs, such as proton-pump inhibitors or H2 blockers, are useful for relieving ulcer symptoms. </p> <p><i>Patients with Clear Evidence of Ulcers.</i> Antibiotics are clearly indicated for patients who have both ulcers and <i>H. pylori</i> infection. Despite such clear indications, however, European and American studies continue to suggest that many doctors only treat symptoms and not the ulcers themselves. Studies also suggest that most doctors do not counsel patients on the potential dangers of NSAIDs and other drugs that can cause ulcers. </p> <p>There is considerable debate about whether to test for <i>H. pylori</i> and treat infected patients who have dyspepsia, but no evidence of ulcers. </p> <p>The best approach for treating dyspepsia is highly controversial. Options include the following: </p> <ul> <li>Test and Treat. This approach involves testing for <i>H. pylori</i> and eradicating the bacteria in infected patients.</li> <li>Prescribing potent acid-suppressing agents. This approach generally employs a trial of potent acid-suppressing drugs called proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) or esomeprazole (Nexium).</li> </ul> <p>In either case, endoscopy is usually performed if symptoms persist after 4 weeks. Some evidence suggests that PPIs may mask ulcers, so patients taking these drugs may need to discontinue them for 2 weeks before endoscopy. </p> <p><i>Arguments for Testing and Treating Patients with Dyspepsia.</i> The argument supporting testing and treating patients with nonulcer dyspepsia is as follows: </p> <ul> <li>Protection against ulcers. Some evidence suggests that antibiotic treatments for infected patients with dyspepsia may prevent ulcers from developing. A 2002 study found that antibiotic regimens to eradicate <i>H. pylori</i> greatly decreased the likelihood of ulcers in infected patients with nonulcer dyspepsia who were chronic NSAID users.</li> <li>Protection against gastric cancer. Some evidence suggests that eradicating <i>H. pylori</i> may prevent or delay the onset of stomach cancer in people with long-term dyspepsia who are infected with the bacteria. A large 2001 study conducted in Japan, where gastric cancer is especially common, found that such cancers developed in about 3% of infected patients with nonulcer dyspepsia. However, none occurred in dyspeptic patients who were treated with antibiotics for <i>H. pylori</i>.</li> </ul> <p><i>Arguments against Testing and Treating Patients with Dyspepsia.</i> The arguments against testing and treating are as follows: </p> <ul> <li>Lack of significant effect on symptoms. Studies are mixed on whether antibiotics have much effect on dyspepsia symptoms. In a 2003 study, overall symptom scores after 1 year were not significantly different between dyspeptic patients who were treated for <i>H. pylori</i> and patients who were maintained on PPIs.</li> <li>Lower rates of <i>H. pylori</i> in the U.S. The number of people with <i>H. pylori</i> infection is declining in the U.S., possibly making the test-and-treat approach too expensive for the number of people it helps.</li> <li>Increased risk for gastroesophageal reflux disease (GERD). A number of studies suggest that <i>H. pylori</i> in the intestinal tract protects against GERD, which in severe cases can be a risk factor for cancer of the esophagus. Eliminating <i>H. pylori</i> may also have other adverse effects.</li> <li>Overuse of antibiotics. Concern that such treatments without clear evidence of ulcers will lead to unnecessary antibiotic prescriptions, increasing the risk for side effects. Overuse may also contribute to a growing public health problem -- the emergence of bacteria that are resistant to antibiotics.</li> </ul> <p>The standard treatment regimen for <em>H. pylori</em> uses 2 antibiotics and a PPI. Cure rates after antibiotic treatment range from 70 - 90%. A typical regimen contains three drugs: </p> <ul> <li>A PPI. These drugs include omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and rabeprazole (Aciphex). PPIs are important for all types of peptic ulcers, and are a critical partner in antibiotic regimens. They reduce acidity in the intestinal tract, and increase the ability of antibiotics to destroy <em>H. pylori</em>.</li> <li>Two antibiotics. The standard antibiotics are clarithromycin (Biaxin) and amoxicillin. Some doctors substitute the antibiotic metronidazole (Flagyl) for either clarithromycin or amoxicillin.</li> </ul> <p>This combination treatment is typically taken for at least 14 days. Many studies, however, suggest that a 7-day treatment may work just as well. A report published in 2006 evaluated a shorter course of treatment using the PPI rabeprazole and 2 antibiotics. They found that a 4-day treatment eliminated <em>H. pylori</em> and was associated with fewer side effects. A study published in 2007 comparing 1- and 2-week treatments with amoxicillin, clarithromycin, and omeprazole for <em>H. pylori</em> eradication found both regimens to be similar in efficacy, safety, and compliance. </p> <p>Interestingly, an Italian study indicated that giving antibiotics sequentially instead of at the same time may be even more effective. The researchers found that patients who took amoxicillin for 5 days, followed by clarithromycin for 5 days, had higher H. pylori eradication rates (89%) than those who took both antibiotics for 10 days (77%). </p> <p>A 2007 study showed that eradication rates with this 3-drug regimen could be improved, and side effects reduced, by adding probiotics ("good" bacteria) and the milk protein bovine lactoferrin. These products are often found in yogurts and other forms of fermented milk. </p> <p><i>Follow-Up.</i> Follow-up testing for the bacteria should be done no sooner than 4 weeks after therapy is completed. Test results before that time may not be accurate. </p> <p>In most cases, drug treatment relieves ulcer symptoms. However, symptom relief does not always indicate success, nor does persistence of dyspepsia necessarily mean that treatment has failed. Heartburn and other symptoms from GERD, for example, can worsen and require acid-suppressing medication. </p> <p><i>Failure.</i> Treatment fails in about 15% of patients, mostly when they fail to adhere to the regimen. Compliance with standard antibiotic regimens may be poor for the following reasons: </p> <ul> <li>The triple-drug regimens are complicated and require many pills. Helicide or two-drug combinations may help offset this problem.</li> <li>About 30% of patients suffer side effects from the <i>H. pylori</i> regimen. Gastrointestinal problems are very common, and severe diarrhea can occur.</li> </ul> <p>Treatment may also fail if the patients harbor strains of <i>H. pylori</i> that are resistant to the antibiotics. When this happens, different drugs are tried. </p> <p><i>Reinfection after Successful Treatment</i>. Studies in developed countries indicate that once the bacteria are eliminated, recurrence rates are below 1% per year. Reinfection with the bacteria is possible, however, in areas where the incidence of <i>H. pylori</i> is very high and sanitary conditions are poor. In such regions, reinfection rates are 6 - 15%. </p> <p><i>Weight Gain.</i> Some patients may gain weight. </p> <p><i>Gastroesophageal Reflux Disease.</i> Of ongoing interest are reports of a lower incidence of <i>H. pylori</i> in patients with GERD. There are some important unanswered questions associated with this issue: </p> <ul> <li>Is the lower incidence of <i>H. pylori </i> in GERD patients significant, and does the bacteria actually protect against GERD? Studies have not conclusively found any significant risk for GERD in people who are <i>not</i> infected with <i>H. pylori,</i> except possibly in certain regions. In a 2003 study, the absence of <i>H. pylori</i> infection in people with GERD was more pronounced in Asian patients than in those from Europe and North America. That being said, guidelines for eradication of <em>H. pylori</em> infection published in 2007 by the European Helicobacter Study Group state that "Eradication of <em>H. pylori</em> infection does not cause gastroesophageal reflux disease (GERD) or exacerbate GERD, and may prevent peptic ulcer in patients who are naive users of NSAIDs."</li> <li>Does eliminating the bacteria with antibiotic therapy actually produce GERD in some people? One study observed that patients cured of <i>H. pylori</i> infection were twice as likely to develop GERD as those who remained infected. However, a 2003 analysis of 8 studies reported no higher risk for GERD after antibiotic treatments. In addition, GERD patients did not experience worsening of symptoms. Longer follow-up studies are needed however to determine the long-term consequences, if any.</li> <li>What is the proper management of people who have GERD and <i>H. pylori</i> infection? Patients with severe GERD usually require on-going therapy with PPIs, which are powerful acid-suppressors. Some evidence suggests that in such patients, the combination of <i>H. pylori</i> and chronic acid suppression may lead to atrophic gastritis, a precancerous condition in the stomach. Guidelines then advocate eliminating the bacteria with antibiotics. There is some concern that once the bacteria are eliminated, however, GERD may worsen, which can pose a risk for Barrett's esophagus, which is also a precancerous condition. On the encouraging side, however, evidence to date does not suggest any higher risk for more serious GERD complications after <i>H. pylori</i> is eliminated.</li> </ul> <p><i>Effects on Other Gastrointestinal Infections.</i> In children, there is some evidence that <i>H. pylori</i> protects against <em>E. coli</em> and other GI infections, particularly those that cause diarrhea. If this is true, treating infected children for <em>H. pylori</em> should be done only if the bacteria are causing harm. </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331781" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an animation on ulcer treatment.</div> </div> <h3 id="adamHeading_10">Treatment for NSAID-Induced Ulcers</h3> <p><i>Preventing Ulcers or Rebleeding Caused by NSAIDs.</i> If NSAID-caused ulcers or bleeding are identified, patients should: </p> <ul> <li>Get tested for <em>H. pylori</em> and, if they are infected, take antibiotics.</li> <li>Possibly use a PPI. Studies suggest these medications lower the risk for NSAID-caused ulcers, although they do not completely prevent them.</li> </ul> <p>People who still need to take NSAIDs should: </p> <ul> <li>Use the lowest NSAID dose possible.</li> <li>Try the prescription drugs misoprostol (Cytotec) or Arthrotec. Misoprostol works as well as a PPI, however, it has many side effects. Arthrotec is a combination of misoprostol and the NSAID diclofenac.</li> </ul> <p>A warning to women: misoprostol can induce labor at any stage of pregnancy. Pregnant women should not use the drug. </p> <p><i>Healing Existing Ulcers</i>. A number of drugs are used to treat NSAID-caused ulcers. PPIs -- omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium) -- are used most often. Other drugs that may be useful include H2 blockers, such as famotidine (Pepcid AC), cimetidine (Tagamet), and ranitidine (Zantac). Sucralfate is another drug used to heal ulcers and reduce the stomach upset caused by NSAIDs. </p> <p><i>COX-2 Inhibitors (Coxibs).</i> Coxibs block an inflammation-promoting enzyme called COX-2. This drug class was initially thought to work as well as NSAIDs, while causing less gastrointestinal distress. However, following numerous reports of cardiovascular events, the FDA banned rofecoxib (Vioxx) and valdecoxib (Bextra) from use in the U.S. Celecoxib (Celebrex) is still available, but patients should discuss with their doctor whether this drug is appropriate and safe for them. </p> <p><i>Arthrote</i>c<i>.</i> Arthrotec is a combination of misoprostol and the NSAID diclofenac. It may reduce the risk for gastrointestinal bleeding. One study found that patients taking Arthrotec had 65 - 80% fewer ulcers than those who took NSAIDs alone. </p> <p><em>Acetaminophen.</em> Acetaminophen (Tylenol, Anacin-3) is the most common alternative to NSAIDs. Acetaminophen is inexpensive and generally safe. It poses far less of a risk of gastrointestinal problems than NSAIDs. It does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg); some studies suggest that ulcer risk is increased even in doses exceeding 2 grams (2,000 mg) a day, if the drug is used on a long-term basis. Patients who take high doses of acetaminophen for long periods are also at risk for liver damage, particularly if they drink alcohol. It may pose a small risk for serious kidney complications in people with preexisting kidney disease, although acetaminophen remains the drug of choice for patients with impaired kidney function. </p> <p><i>Tramadol.</i> Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties, but is not as addictive. However, dependence and abuse have been reported. It can cause nausea, but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) provides more rapid pain relief than tramadol alone and more durable relief than acetaminophen alone. Side effects are the same as for each of these agents. </p> <h3 id="adamHeading_11">Medications</h3> <p>The following drugs are sometimes used in the treatments of peptic ulcers caused by either NSAIDs or <i>H. pylori</i>. They are described in alphabetical order. </p> <p>Many antacids are available without prescription and are the first drugs recommended to relieve heartburn and mild dyspepsia. They play no major role in either the prevention or healing of ulcers, but help in the following ways: </p> <ul> <li>All rely on various combinations of three basic compounds -- magnesium, calcium, or aluminum -- to neutralize stomach acid.</li> <li>They may defend the stomach by increasing acid-buffering bicarbonate and mucus secretion.</li> </ul> <p>It is generally believed that liquid antacids work faster and are more potent than tablets, although some evidence suggests that both forms work equally well. </p> <p><i>Basic Salts Used in Antacids.</i> There are three basic salts used in antacids: </p> <ul> <li>Magnesium. Magnesium compounds are available in the form of magnesium carbonate, magnesium trisilicate, and, most commonly, magnesium hydroxide (Milk of Magnesia). The major side effect of these magnesium compounds is diarrhea.</li> <li>Calcium. Calcium carbonate (Tums, Titralac, and Alka-2) is a potent and rapid-acting antacid, but it can cause constipation. There have been rare cases of hypercalcemia (elevated levels of calcium in the blood) in people taking calcium carbonate for long periods of time. Hypercalcemia can lead to kidney failure.</li> <li>Aluminum. The most common side effect of antacids containing aluminum compounds (Amphogel, Alternagel) is constipation. Maalox and Mylanta are combinations of aluminum and magnesium, which balance the side effects of diarrhea and constipation. People who take large amounts of antacids containing aluminum may be at risk for calcium loss and osteoporosis. Long-term use also increases the risk of kidney stones. People who have recently experienced GI bleeding should not use aluminum compounds.</li> </ul> <p><i>Interactions with Other Drugs.</i> Antacids can reduce the absorption of a number of drugs. Conversely, some antacids increase the potency of certain drugs. The interactions can be avoided by taking these other drugs 1 hour before or 3 hours after taking the antacid. </p> <table border="1" cellpadding="3" cellspacing="0"> <tr> <td valign="top" colspan="2" /></tr> <tr> <td valign="top"> <p><b>Drugs that are absorbed less well if taken with antacids</b> </p> </td> <td valign="top"> <p><b>Drugs that are made more potent by antacids</b> </p> </td> </tr> <tr> <td valign="top"> <p>Tetracycline </p> <p>Ciprofloxacin (Cipro) </p> <p>Propranolol (Inderal) </p> <p>Captopril (Capoten) </p> <p>Ranitidine (Zantac) </p> <p>Famotidine (Pepcid AC) </p> </td> <td valign="top"> <p>Valproic acid </p> <p>Sulfonylureas </p> <p>Quinidine </p> <p>Levodopa </p> </td> </tr> </table> <p><i>H. pylori</i> is usually highly sensitive to certain antibiotics, particularly amoxicillin, and to antibiotics in the macrolide class, such as clarithromycin. Either type of agent serves effectively as a second antibiotic in a three-drug regimen. Other antibiotics that are sometimes used include tetracycline, metronidazole, and ciprofloxacin. </p> <ul> <li>Amoxicillin is the most common form of penicillin. It is inexpensive, but many people are allergic to it.</li> <li>Clarithromycin (Biaxin) is a macrolide and is the most expensive antibiotic used against <i>H. pylori</i>. It is very effective, but there is growing bacterial resistance to this drug. Resistance rates tend to be higher in women and increase with age. Researchers fear that resistance will increase as more people use the drug.</li> <li>Tetracycline is effective, but this medicine has unique side effects, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration. Pregnant women cannot take tetracycline.</li> <li>Ciprofloxacin (Cipro), a fluoroquinolone, is also sometimes used in ulcer regimens.</li> <li>Metronidazole (Flagyl) was the mainstay in initial combination regimens for <i>H. pylori.</i> As with clarithromycin, however, there continues to be growing bacterial resistance to the drug. Today, about 25 - 35% of <i>H. pylori</i> bacteria are metronidazole-resistant.</li> </ul> <p><i>Side Effects of Antibiotics.</i> </p> <ul> <li>The most common side effects of nearly all antibiotics are gastrointestinal problems such as cramps, nausea, vomiting, and diarrhea.</li> <li>Allergic reactions can also occur with all antibiotics, but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare, but severe -- even life-threatening -- anaphylactic shock.</li> <li>Some drugs, including certain over-the-counter medications, interact with antibiotics; patients should report to all medications they are taking to their doctor.</li> <li>Antibiotics double the risk of vaginal infections in women.</li> </ul> <p>Compounds that contain bismuth are often used in the three-drug antibiotic regimens. They destroy the cell walls of <i>H. pylori</i> bacteria. The only bismuth compound available in the U.S. has been bismuth subsalicylate (Pepto-Bismol), although a drug combination of the H2 blocker ranitidine and bismuth citrate (Tritec) has been released. High doses can cause vomiting and depression of the central nervous system, but the doses given for ulcer patients rarely cause side effects. </p> <p>H2 blockers interfere with acid production by blocking histamine, a substance produced by the body that encourages acid secretion in the stomach. H2 blockers were the standard treatment for peptic ulcers until antibiotic regimens against <em>H. pylori</em> were developed. These drugs cannot cure ulcers, but they are useful in certain cases. They are effective only for duodenal ulcers, however. </p> <p>Four H2 blockers are currently available over-the-counter in the U.S.: famotidine (Pepcid AC), cimetidine (Tagamet), ranitidine (Zantac), and nizatidine (Axid). All have good safety profiles and few side effects. There are some differences between these drugs: </p> <ul> <li><i>Famotidine (Pepcid AC).</i> Famotidine is the most potent H2 blocker. The most common side effect is headache, which occurs in 4. 7% of people who take it. Famotidine is virtually free of drug interactions, but it may have significant adverse effects in patients with kidney problems.</li> <li><i>Cimetidine (Tagamet).</i> Cimetidine has few side effects; about 1% of people taking cimetidine experience mild temporary diarrhea, dizziness, rash, or headache. Cimetidine interacts with a number of commonly used medications, including phenytoin, theophylline, and warfarin. Long-term use of excessive doses (more than 3 grams a day) may cause impotence or breast enlargement in men. These problems resolve after the drug is discontinued.</li> <li><i>Ranitidine (Zantac).</i> Ranitidine interacts with very few drugs. In one study, ranitidine provided more pain relief and healed ulcers more quickly than cimetidine in people younger than age 60, but there was no difference in older patients. A common side effect of ranitidine is headache, which occurs in about 3% of people who take it.</li> </ul> <p>That being said, a literature review of clinical trials showed that the PPIs are more effective than the H2 blockers in healing ulcers in people who take NSAIDs. After 8 weeks of treatment, healing rates of both gastric and duodenal ulcers were: </p> <ul> <li>92% and 88% with esomeprazole 40 mg and 20 mg (vs 74% with ranitidine).</li> <li>87% and 84% with omeprazole 40 mg and 20 mg (vs 64% with ranitidine).</li> <li>And 73 - 74% and 66 - 69% with lansoprazole 30 mg and 15 mg (vs 50 - 53% with ranitidine).</li> <li>However, healing rates with ranitidine reached nearly 100% when NSAIDs were discontinued.</li> </ul> <p><i>Nizatidine (Axid).</i> Nizatidine is nearly free of side effects and drug interactions. </p> <p><i>Long-Term Concerns.</i> In most cases, these H2 blockers have good safety profiles and few side effects. Because H2 blockers can interact with other drugs, be sure to tell your doctor about any other drugs you are taking. There are also some concerns about possible long-term effects -- for example, that long-term acid suppression with these drugs may cause cancerous changes in the stomach in patients who also have untreated <i>H. pylori</i> infection. More research is needed. However, the following concerns are real: </p> <ul> <li>Liver damage. This is more likely with ranitidine than other H2 blockers, but is rare in any event.</li> <li>Kidney-related complications. With famotidine, adverse effects on the central nervous system in patients with even moderate kidney insufficiency have been reported, resulting in anxiety, depression, and mental disturbances.</li> <li>Increased risk for pneumonia in hospitalized patients.</li> <li>Ulcer perforation and bleeding. Some experts are concerned that the use of acid-blocking drugs may actually increase the risk for serious complications by masking the ulcer's symptoms.</li> </ul> <p>Misoprostol (Cytotec) increases prostaglandin levels in the stomach lining, which protects against the major intestinal toxicity of NSAIDs. </p> <p><i>Actions against Ulcers.</i> Misoprostol can reduce formation of ulcers in the upper small intestine by two-thirds and in the stomach by three-fourths. It does not neutralize or reduce acid, so although the drug is helpful for preventing NSAID-induced ulcers, it is not useful in healing existing ulcers. </p> <p><i>Side Effects.</i> </p> <ul> <li>Diarrhea and other gastrointestinal problems are severe enough to cause 20% of patients to stop taking the drug. Taking misoprostol after meals should minimize these effects. One study indicated that taking the drug 2 - 3 times a day, instead of the standard regimen of 4 times, may prove to be just as effective and cause fewer side effects.</li> <li>Misoprostol can induce abortion or cause birth defects and should not be taken by pregnant women. If pregnancy occurs during treatment, the drug should be discontinued at once and the doctor contacted immediately.</li> </ul> <p><i>Actions against Ulcers.</i> PPIs are the drugs of choice for managing patients with peptic ulcers from any cause. They suppress the production of stomach acid by blocking the gastric acid pump -- the molecule in the stomach glands that is responsible for acid secretion. </p> <p>PPIs can be used either as part of a multidrug regimen for <em>H. pylori</em> or alone for preventing and healing NSAID-caused ulcers. One retrospective study found that adding a PPI to diclofenac therapy reduced hospitalization for ulcers by 60%. They are also useful in treating ulcers caused by Zollinger-Ellison syndrome. Some people carry a gene that reduces the effectiveness of PPIs. This gene is present in 18 - 20% of people of Asian descent. </p> <p><i>Standard Brands.</i> Most PPIs are available by prescription as oral drugs. There is no evidence that one brand of PPI works better than another. Brands approved for ulcer prevention and treatment include: </p> <ul> <li>Omeprazole (generic, Prilosec OTC)</li> <li>Esomeprazole (Nexium)</li> <li>Lansoprazole (Prevacid)</li> <li>Rabeprazole (Aciphex)</li> </ul> <p><i>Possible Adverse Effects.</i> </p> <ul> <li>Side effects are uncommon, but may include headache, diarrhea, constipation, nausea, and itching.</li> <li>Pregnant women and nursing mothers should avoid taking PPIs, although recent studies suggest that these drugs do not increase the risk of birth defects.</li> <li>PPIs may interact with certain drugs, such as antiseizure agents (such as phenytoin), antianxiety drugs (such as diazepam), and blood thinners (such as warfarin).</li> <li>Long-term use of high-dose PPIs may produce vitamin B12 deficiency, but studies are needed to confirm this risk.</li> <li>In theory, long-term use of PPIs by people with <i>H. pylori</i> may reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach), a risk factor for stomach cancer. Long-term use of PPIs may also mask symptoms of stomach cancer and delay diagnosis. At this time, however, there have been no reports of an increase in stomach cancer with long-term use of these drugs.</li> </ul> <p>Sucralfate (Carafate) seems to work by adhering to the ulcer crater and protecting it from further damage by stomach acid and pepsin. It also promotes the defensive processes of the stomach. Sucralfate has an ulcer-healing rate similar to that of H2 blockers. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate does interact with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline. </p> <h3 id="adamHeading_12">Treatment for Bleeding Ulcers</h3> <p>When a patient comes to the hospital with bleeding ulcers, endoscopy is usually performed. This procedure is critical for the diagnosis, determination of treatment options, and treatment of bleeding ulcers. </p> <p>In high-risk patients or those with evidence of bleeding, options include watchful waiting with medical treatments or surgery. The first critical steps for massive bleeding are to stabilize the patient and support vital functions with fluid replacement and possibly blood transfusions. People on NSAIDs should discontinue them, if possible. </p> <p>Depending on the intensity of the bleeding, patients can be released from the hospital within a day or kept up to 3 days after endoscopy. Bleeding stops spontaneously in about 70 - 80% of patients, but about 30% of patients who come to the hospital for bleeding ulcers need surgery. Endoscopy is the surgical procedure most often used for treating bleeding ulcers and patients at high-risk for rebleeding. It is usually combined with medications, such as epinephrine and intravenous proton-pump inhibitors. </p> <p>Between 10 - 20% of patients require more invasive procedures for bleeding, usually major abdominal surgery. </p> <p>Endoscopy is important for both diagnosing and treating bleeding ulcers. The doctor first places a thin, flexible plastic tube called an endoscope into the patient's mouth and down the esophagus into the stomach. </p> <p><i>Endoscopy for Diagnosing Bleeding Ulcers and Determining Risk of Rebleeding.</i> With endoscopy, doctors are able to detect the signs of bleeding, such as active spurting or oozing of blood from arteries. Endoscopy can also detect specific features in the ulcers referred to as <i>stigmata</i>, which indicate a higher or lower risk of rebleeding. </p> <p>Such features include the following: </p> <ul> <li>Low risk (5 -15%) for bleeding: flat dot; a clean or white base.</li> <li>High risk (30 - 50%) for bleeding: swollen but nonbleeding blood vessels; blood clots that adhere to ulcers.</li> <li>According to one study, if patients with these high-risk features are untreated, their risk for rebleeding after endoscopy ranges from about 10% on the first day after endoscopy to about 3% by the third day. Identifying and treating patients with stigmata can reduce these risks. Other factors that increase the risk for rebleeding include bleeding disorders, very low blood pressure, other serious medical conditions, and bleeding that started after hospitalization.</li> <li>After endoscopy, high-dose PPI therapy has been shown to significantly reduce the rate of rebleeding, need for surgery, and death from hemorrhage. The medication may be given intravenously, but studies show that oral PPI therapy is probably just as effective.</li> </ul> <p><i>Endoscopy as Treatment.</i> Endoscopy is usually used to treat bleeding from visible vessels that are less than 2 mm in diameter. This approach also appears to be very effective in preventing rebleeding in patients whose ulcers are not bleeding, but who have high-risk features (swollen blood vessels or clots adhering to ulcers). </p> <p>The following is a typical endoscopy procedure: </p> <ul> <li>The surgeon passes a probe through an endoscopic tube and applies electricity, heat, or small clips to coagulate the blood and stop the bleeding. This procedure also causes fluid buildup, which helps to compress the blood vessels.</li> <li>In high-risk cases, the doctor may inject epinephrine (commonly known as adrenaline) directly into the ulcer to enhance the effects of the heating process. Epinephrine activates the process leading to blood coagulation, narrows the arteries, and enhances blood clotting.</li> <li>Intravenous (IV) administration of a PPI (usually omeprazole or pantoprazole) significantly prevents rebleeding and appears to be cost-effective. In one study, the use of IV PPIs reduced the risk of bleeding from 23% to 7%. (Oral PPIs are also effective, but studies are needed to compare their effectiveness versus IV PPIs.) A PPI may also be useful for initial bleeding episodes when endoscopy is unsuccessful, inappropriate, or unavailable.</li> </ul> <p>Intravenous H2 blockers are often used, but a major analysis reported no benefit in bleeding duodenal ulcers, although they may be effective in gastric ulcers. </p> <p>Endoscopy is effective in controlling bleeding in more than 85% of appropriate candidates. If rebleeding occurs, a repeat endoscopy is effective in about 75% of patients. Those who fail to respond require major abdominal surgery. The most serious complication from endoscopy is perforation of the stomach or intestinal wall, which occurred in about 1.4% of patients in a large 2002 study. </p> <p>While endoscopy and clipping are routine treatment for bleeding ulcers in the U.S., a Korean study found little difference in outcomes between clipping (plus H2 therapy) and oral PPI therapy alone. In a randomized test of 129 patients, hemostasis (end of bleeding) was achieved in 93.5% of patients after clipping and 92.5% of patients on oral PPIs at 24 hours. The rate of rebleeding was 6.9% with clipping and 7.5% with PPIs. </p> <p><i>Other Medical Considerations.</i> Certain agents may be warranted after endoscopy: </p> <ul> <li>Patients who harbor the <i>H. pylori</i> bacteria, even when the bleeding has been caused by NSAID use, should be treated with antibiotic therapy to eliminate the bacteria. Triple therapy, including antibiotics, to eliminate <i>H. pylori</i> immediately after endoscopy is warranted in most patients infected with the bacteria.</li> <li>Somatostatin (a hormone used to prevent bleeding in cirrhosis) is also useful for reducing persistent peptic ulcer bleeding or the risk of recurrence. Researchers are investigating adding other therapies, such as fibrin glue, a blood clotting factor. To date, no therapy has proven to be more effective than current treatments.</li> </ul> <p>Major abdominal surgery for bleeding ulcers is now generally performed only when endoscopy fails or is not appropriate. Certain emergencies may require surgical repair, such as when an ulcer perforates the wall of the stomach or intestine, causing sudden intense pain and life-threatening infection. </p> <p><i>Surgical Approaches.</i> The standard major surgical approach uses a wide abdominal incision and standard surgical instruments (called open surgery). Laparoscopic techniques employ small abdominal incisions and the insertion of tubes that contain miniature cameras and instruments. Laparoscopic techniques are increasingly being used for perforated ulcers. Surgery is not effective for upper GI ulceration caused by chronic NSAID use. </p> <p><i>Major Surgical Procedures.</i> There are a number of surgical procedures aimed at long-term relief of ulcer complications. These include: </p> <div class="ADAMInlineGraphic"> <div class="ADAMInlineTnail" style="float: left;"><a href="/2331788" ></a></div> <div class="ADAMTextBox" style="float: left; width: 330px;"></p> <p>Click the icon to see an illustrated series detailing a gastrectomy procedure.</div> </div> <ul> <li>Vagotomy, in which the vagus nerve is cut to interrupt messages from the brain that stimulate acid secretion in the stomach. This surgery may impair stomach emptying. A recent variation that cuts only parts of the nerve may reduce this complication.</li> <li>Antrectomy, in which the lower part of the stomach is removed. This part manufactures the hormone responsible for stimulation of digestive juices.</li> <li>Pyloroplasty, which enlarges the opening into the small intestine so that stomach contents can pass into it more easily.</li> </ul> <p>Antrectomy and pyloroplasty are usually performed with vagotomy. </p> <h3 id="adamHeading_13">Lifestyle Changes</h3> <p>In the past, it was common practice to tell people suffering from peptic ulcers to consume small, frequent amounts of bland foods. Exhaustive research conducted since that time has shown that a bland diet is not effective in reducing the incidence or recurrence of ulcers, and that eating numerous small meals throughout the day is no more effective than eating three meals a day. Large amounts of food should still be avoided, because stretching the stomach can result in painful symptoms. </p> <p><i>Fruits and Vegetables.</i> The good news is that a diet rich in fiber may cut the risk of developing ulcers in half and speed healing of existing ulcers. Fiber found in fruits and vegetables is particularly protective; vitamin A contained in many of these foods may increase the benefit. Some studies on associations between specific food chemicals and ulcers are as follows: </p> <ul> <li>In one study, apples and yams appeared to be especially helpful.</li> <li>Apples, celery, cranberries, onions, red wine, and green and black tea are also high in natural chemicals known as flavonoids, which appear to inhibit <i>H. pylori</i> growth and have many other health benefits. Cranberry juice specifically may have properties that help prevent <i>H. pylori</i> from infecting the intestinal lining.</li> <li>Grapefruit has antioxidant properties that may help heal ulcers.</li> <li>Studies on rats have found that dietary nitrate increases nitric oxide in the gut and causes the mucus layer to thicken. Pretreatment with nitrate provided dramatic protection against diclofenac-induced ulcers. High levels of dietary nitrate are found in many vegetables.</li> <li>Laboratory experiments suggest that sulforaphone, a compound found in broccoli and broccoli sprouts, may be lethal to even drug-resistant strains of <i>H. pylori.</i></li> <li>Tea has chemicals that may help protect against cancers in the stomach and esophagus.</li> </ul> <p><i>Milk.</i> Milk actually encourages the production of acid in the stomach, although moderate amounts (2 - 3 cups a day) appear to do no harm. Animal studies show that a milk protein called bovine alpha-lactalbumin protects against gastric ulcers caused by stress. Certain probiotics, which are "good" bacteria added to yogurt and other fermented milk drinks, may also have gastric protective qualities. </p> <p><i>Coffee and Carbonated Beverages.</i> Coffee (both caffeinated and decaffeinated), soft drinks, and fruit juices with citric acid increase stomach acid production. Although no studies have proven that any of these drinks contribute to ulcers, consuming more than 3 cups of coffee per day may increase susceptibility to <i>H. pylori</i> infection. </p> <p><i>Spices and Peppers.</i> Studies conducted on spices and peppers have yielded conflicting results. The rule of thumb is to use these substances moderately, and to avoid them if they irritate the stomach. </p> <p><i>Garlic.</i> Some studies suggest that high amounts of garlic may have some protective properties against stomach cancer, although a recent study concluded that it offered no benefits against <i>H. pylori</i> and, in high amounts, can cause considerable GI distress. </p> <p><em>Olive Oil.</em> Studies from Spain have shown that phenolic compounds in virgin olive oil may have strong bactericidal activity against 8 strains of H. pylori, 3 of which are resistant to antibiotics. </p> <p><i>Vitamins.</i> Although no vitamins have been shown to protect against ulcers, <i>H. pylori</i> appears to impair absorption of vitamin C, which may play a role in the higher risk of stomach cancer. </p> <p>Some evidence exists that exercise may help reduce the risk for ulcers in some people. In one study, exercise was associated with a lower risk for duodenal, but not gastric, ulcers in men. In this study, exercise appeared to have no effect on ulcer development in women. </p> <p>Stress relief programs have not been shown to promote ulcer healing, but they may have other health benefits. </p> <p>Melatonin is a hormone found in the brain that is normally associated with sleep. Researchers have observed that the GI tract is rich in melatonin, and that the hormone may have properties that help prevent ulcers, reduce acid secretion, and improve blood flow. It is not known whether this would benefit people with peptic ulcers, but it appears to warrant some research. In the U.S., melatonin is classified as a dietary supplement and not a drug, so its quality and effectiveness are uncontrolled. The U.S. is the only developed nation that does not regulate this agent. </p> <h3 id="adamHeading_14">Resources</h3> <ul> <li><a href="http://digestive.niddk.nih.gov/" target="_blank">http://digestive.niddk.nih.gov</a> -- National Digestive Diseases Information Clearinghouse</li> <li><a href="http://www.gastro.org/" target="_blank">www.gastro.org</a> -- American Gastroenterological Association</li> <li><a href="http://www.acg.gi.org/" target="_blank">www.acg.gi.org</a> -- American College of Gastroenterology</li> </ul> <h3 id="adamHeading_15">References</h3> <p>deBortoli M, Leonardi G, Ciancia E, et al. Helicobacter pylori eradication: a randomized prospective study of triple therapy versus triple therapy plus lactoferrin and probiotics. <em>Am J. Gastroenterol</em>. 2007;102(5):951-956. </p> <p>Guyton JR, Bays HE. Safety considerations with niacin therapy. <em>Am J Cardiol</em>. 2007;99(6A):22C-31C. </p> <p>Hainaux B, Agneessens E, Bertinotti R, et al. Accuracy of MDCT in predicting site of gastrointestinal tract perforation. <em>Am J Roentgenol</em>. 2006;187(5):1179-1183. </p> <p>Hallas J, Dall M, Andries A, et al. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. <em>BMS</em>. 2006;333(7571):726. Epub 2006 Sept 19. </p> <p>Hobsley M, Tovey F, Horton J. Precise role of H. pylori in duodenal ulceration. <em>World J Gastroenterol</em>. 2006;12(40):6413-6419. </p> <p>Goer A, Gothe H, Schiffhorst G, Sterzel A, Grass U, Haussler B. Comparison of the effects of diclofenac or other non-steroidal anti-inflammatory drugs (NSAIDs) and dicolfenac or other NSAIDs in combination with proton pump inhibitors (PPI) on hospitalization due to peptic ulcer disease. <em>Pharmacoepidemiol Drug Saf</em>. 2007 Feb 26 [Epub ahead of print]. </p> <p>Jansson EA, Petersson J, Reinders C, et al. Protection from nonsteroidal anti-inflammatory (NSAID)-induced gastric ulcers by dietary nitrate. <em>Free Radic Biol Med</em>. 2007;41(4):510-518. </p> <p>Keefer L, Stepanski EJ, Ranjbaran Z, Benson LM, Keshavarzian A. An initial report of sleep disturbance in inactive inflammatory bowel disease. <em>J Clin Sleep Med</em>. 2006;2(4):409-416. </p> <p>Kim JI, Cheung DY, Cho SH, et al. Oral proton pump inhibitors are as effective as endoscopic treatment for bleeding peptic ulcer: a prospective, randomized, controlled trial. <em>Dig Dis Sci</em>. 2007 May 19 [Epub ahead of print]. </p> <p>Luo J, Nordenvall C, Nyren O, Adami HO, Permert J, Ye W. The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease. <em>Int J Cancer</em>. 2007;120(2):368-372. </p> <p>Malfertheiner P, Megraud F, O'Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the Maastrict III Consensus Report. <em>Gut</em>. 2007;56(6):772-781. </p> <p>Miki K, Urita Y, Ishikawa F, et al. Effect of Bifidobacterium bifidum fermented milk on Helicobacter pylori and serum pepsinogen levels in humans. <em>J Dairy Sci</em>. 2007;90(6):2630-2640. </p> <p>Moberly JB, Harris SI, Diff DS, et al. A randomized, double-blind, one-week study comparing the effects of a novel COX-2 inhibitor and naproxen on the gastric mucosa. <em>Dig Dis Sci</em>. 2007;52(2):442-450. </p> <p>Moore ML. Misoprostol-is more research needed? <em>J Perinat Educ</em>. 2002;11(3):43-47. </p> <p>Murthy S, Keyvani L, Leeson S, Targownik LE. Intravenous versus high-dose oral proton pump inhibitor therapy after endoscopic hemostasis of high-risk lesions in patients with acute nonvariceal upper gastrointestinal bleeding. <em>Dig Dis Sci</em>. 2007;63(11):773-775. </p> <p>Pietroiusti A, Forlini A, Magrini A, et al. Shift work increases the frequency of duodenal ulcer in H. pylori infected workers. <em>Occup Environ Med</em>. 2006;63(11):773-775. </p> <p>Pilotto A, Franceschi M, Leandro G, et al. Clinical features of reflux esophagitis in older people: a study of 840 consecutive patients. <em>J Am Geriatr Soc</em>. 2006;54(10):1537-1542. </p> <p>Romero C, Medina E, Vargas J, Brenes M, De Castro A. In vitro activity of olive oil polyphenols against Helicobacter pylori. <em>J Agric Food Chem</em>. 2007;55(3):680-688. </p> <p>Saif MW, Elfiky A, Salem RR. Gastrointestinal perforation due to bevacizumab in colorectal cancer. <em>Ann Surg Oncol</em>. 2007;14(6):1860-1869. </p> <p>Simon-Rudler M, Massard J, Bernard-Chabert B, et al. Continuous infusion of high-dose omeprazole is more effective than standard-dose omeprazole in patients with high-risk peptic ulcer bleeding: a retrospective study. <em>Aliment Pharmacol Ther</em>. 2007;25(:949-954. </p> <p>Take S, Mizuno M, Ishiki K, et al. Baseline gastric mucosal atrophy is a risk factor associated with the development of gastric cancer after Helicobacter pylori eradication therapy in patients with peptic ulcer disease. <em>J Gastroenterol</em>. 2007;42(suppl 17):21-27. </p> <p>Ushida Y, Shimokawa Y, Toida T, Matsui H, Takase M. Bovine alpha-lacalbumin stimulates mucus metabolism in gastric mucosa. <em>J Dairy Sci</em>. 2007;90(2):541-546. </p> <p>Vaira D, Zullo A, Vakil N, et al. Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial. <em>Ann Intern Med</em>. 2007;146(:556-563. </p> <p>Verhamme K, Mosis G, Dieleman J, Stricker B, Sturkenboom M. Spironolactone and risk of upper gastrointestinal events: population-based case-control study. <em>BMJ</em>. 2006;333(7563):330. Epub 2006 Jul 13. </p> <p>Yeomans ND, Svedberg LD, Naesdal J. Is ranitidine therapy sufficient for healing peptic ulcers associated with non-steroidal anti-inflammatory drug use? <em>Int J Clin Pract</em>. 2006;60(11):1401-407. </p> <p>Zagari RM, Bianchi-Porro G, Fiocca R, Gasbarrini G, Roda E, Bazzoli F. Comparison of 1 and 2 weeks of omeprazole, amoxicillin and clarithromycin treatment for Helicobacter pylori eradication: the HYPER study. <em>Gut.</em> 2007;56(4):475-479. </p> <div id="health_topic_footer"> Review Date:<br /> 6/22/2007<br /> Reviewed By:<br /> Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.<br /> <div style="margin:10px 0px;"> <div style="float:left;margin:0px 10px 5px 0;"> </div> <div style="margin-bottom:5px;"> A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). 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