Constipation

Constipation is a very common gastrointesinal disorder experienced by most people at some time during their lives. Constipation basically refers to a reduction in the frequency of bowel motions or increased difficulty passing stools. Numerous conditions can lead to constipation by disrupting the normal process of absorption, stool formation and propelling of feces within the large intestine. Fortunately most causes will not be anything serious and may be just due to a poor diet with insufficient fibre, poor fluid intake or a side effect of certain medications. However, some cases of constipation may be due to a serious problem such as colon cancer. Therefore if you experience severe or recurrent constipation it is important to see your doctor. They can advise you of appropriate lifestyle measures to reduce constipation and offer you medications (called laxatives) to help improve your bowel function if you require them.

Constipation is a symptom rather than a disease. There is no strict definition of constipation as normal bowel function varies so widely between different people. In general however it is defined as passage of stools less than 3 times per week or difficulty and pain during the passage of stools. However, it can be completely normal for breastfeeding babies to go a week without passing a bowel motion. A change in bowel function from what you perceive to be normal is therefore perhaps more important to highlight the diagnosis. During constipation it is common for stools to become small in size, hard, dry and difficult to pass out the body. Constipation is a really common symptom and can affect up to one in five people. Around 2% of the population suffers recurrent and constant constipation however most people will experience a mild form at some time during their life. Elderly people have high rates of constipation due to changes in diet, medications and decreased mobility and motility. If constipation goes unnoticed some severe side effects can occur such as haemorrhoids and damage or tearing of the anus.

Constipation occurs when the large intestine absorbs too much water from the stool to make it dry and hard or the bowel walls cannot contract adequately to pass the stool and waste products along fast enough. There are numerous causes of constipation some of which are listed below:

Poor diet- Insufficient fibre and inadequate fluid intake are some of the most common causes of constipation. Immobility Life changes- Pregnancy, aging, stress and travel can all predispose to constipation.. Irritable bowel syndrome. Metabolic disorders- Hypothyroidism, diabetes mellitus, hypercalcaemia and porphyrias can disrupt the function of the bowel. Drugs- Pain medications, blood pressure medications, anti-depressants and iron supplements have been associated with constipation. You may also experience constipation following surgery. Ignoring the urge to defecate. Gastrointestinal disorders- Obstruction of the bowel and other disease of the intestine or anus can interfere with the movement of stools. Damge to the nerve supply of the bowel secondary to spinal or pelvic injury or stroke Children often experience constipation as they hold back bowel movements or forget to go to the toilet.

The potential causes of constipation are thus extensive. In most cases constipation will be caused by factors that slow down the bowel such as inadequate fluid intake, low-fibre diet, lack of physical activity, inattention to bowel habits or medications. Rarely however it may reflect a serious underlying condition such as colorectal cancer. Therefore it is important that recurrent or severe cases of constipation are assessed by a doctor.

Passage of hard stools infrequently. Abdominal pain or bloating. Straining during passage of bowel motions. Nausea, headacheand malaise (general feeling of discomfort) may be associated with constipation.

Your doctor will ask you lots of questions about the timing of your constipation and specific features of the stool to help them decide on the likely cause. They will also get you to describe you diet and any other general medical problems. The doctor will also want to check what medications you are taking as they may be the cause of your constipation. Next they will conduct a physical exam mainly focusing on the abdomen, pelvis and rectum. A rectal examination involves the doctor gently putting a gloved finger into the back passage to feel any masses or abnormalities and identify the presence of blood. You may require further investigations such as blood tests, stool samples, sigmoidoscopy, colonoscopy or barium enema to identify the cause of your constipation. These investigations are particularly important if your over 50, have lost weight, have blood in your stools or have a family history of colon cancer as you may be at risk of more sinister conditions.

Treatment of constipation largely focuses on treating the underlying cause. You can take several measures to help treat your problem including:

Eating plenty of fibre (20-35 grams daily) which is found in cereals and fruit especially. You can talk to a dietician about the best way to increase your fibre intake. Some patients can benefit from fibre supplements such as Metamucil but these can have significant side effects such as cramping and gas.. Drinking plenty of fluid. Exercising regularly. Responding to your body when it tells you it needs to defecate. Holding on excessively damages and weakens the bowel

If you employ these lifestyle measures you may be able to prevent constipation developing in the first place! If you have severe constipation and the above measures do not help, your doctor may prescribe you some laxative medications to help get the bowel moving. Several different types are available such as bulking agents, stool softeners, osmotic agents (that drag fluid into the stool), motility stimulants and lubricants. Your doctor will decide the type suitable for you based on the likely underlying cause. Laxatives should only be used for short periods because they can cause severe damage and lead to 'lazy bowel syndrome' where your bowel becomes reliant on them to function properly.

Basson M. Constipation [online]. Omaha, NE: WebMD eMedicine; 2006 [cited 27 July 2006]. Available from: URL link Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Book]Longmore M, Wilkinson I, Rajagopalan S. Oxford Handbook of Clinical Medicine (6th edition). Oxford: Oxford University Press; 2004. [Book]Constipation [online]. Scottsdale, AZ: Mayo Clinic; 2006 [cited 27 July 2006]. Available from: URL link Constipation [online]. Bethesda, MD: Medline Plus; 2005 [cited 27 July 2006]. Available from: URL link Constipation [online]. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 2006 [cited 27 July 2006]. Available from: URL linkWald A. Constipation [online]. Waltham, MA; UpToDate; 2006 [cited 27 July 2006]. Available from: URL link

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Obesity Management

Obesity is becoming a global problem. The majority of Australians are overweight, and 20% are obese. Professor Jeffrey Hamdorf talks about the problems caused by obesity and the possible treatments for obesity.

You would probably be aware that the health problems associated with excessive weight have been increasing in the Western world, particularly over the past two decades or so. The health problems we are talking about here include an increased risk of heart disease and high blood pressure (which can in turn cause stroke); also, there is a very high risk of developing diabetes and other problems with breathing such a sleep apnoea and asthma, and some digestive disorders as well. Overweight people have problems with mobility and they are at risk of developing diabetes affecting, especially, the weight bearing joints, like the ankles and knees. Fertility is affected, especially in women; this means that women which are overweight have a smaller chance of getting pregnant.

Obesity is regarded as morbid obesity when it reaches a point where there is a significant risk to health – and we can calculate and index for people. This is called the body mass index and it takes into account your weight and height. We are talking about morbid obesity, but this relates to people who have significant illnesses related to their weight, or who are in the order of 40 kilograms overweight. Obesity is a chronic illness and it does require significant treatment.

Now the reasons for obesity are many – it’s not simply a result of over eating. Once a patient becomes morbidly obese, a change in lifestyle – such a calorie-controlled diet – and increasing exercise is really important, but these have a limited effect on morbid obesity. Patients just can’t seem to lose enough weight using a diet approach alone to correct their health problems.

The principals for those that are overweight, but perhaps not obese, include a supervised diet and exercise program and this is entirely appropriate and there are many of these programs around. Unfortunately, these are not entirely suitable for obese patients, and particularly morbidly obese patients, because in over 90% of cases the weight lost in supervised programs is resumed within a couple of years. Once a patient’s weight is classified in the obese category then diet and lifestyle changes are not enough and medications may need to be added. There are two major medications in this area; they include Reductil, or Sebutramine, and Xenical, or Orlistat. These medications have to be offered under medical supervision.

Now another method which is successful in obese patients is cognitive behavioural therapy. This is group therapy supervised by a clinical psychologist and it looks at the reasons behind the peoples’ troublesome eating habits. This is available in Australia through general practitioner initiated care plans, so a GP needs to organise it.

For those patients that have morbid obesity (those people who are more than 40 kg overweight) or that have health problems created or made worse by their weight, then surgery is the mainstay treatment. Surgical procedures are based on reducing the amount of food one is able to eat before fullness occurs, or – and these are called reductive procedures – an old fashioned gastric stapling and more recently, a laparoscopic adjustable band or lap band. With the laparoscopic banding, a silicone band is placed around the top part of the stomach creating a small upper pouch. The band can be made tighter or looser depending on the weight loss, and this operation is one that is almost always done using the keyhole technique. The band can be adjusted and can be reversed if necessary. This is a method that helps people keep a sensible calorie-controlled diet and if it is reversed, more patients will resume their weight rather quickly. Another method which is gaining some popularity is called a sleeve or tube gastrectomy where a part of the stomach is surgically removed so that one is able to eat less. None of these methods tell a patient what to eat so we need to be fairly conscious about diet and for all surgical care of weight loss, a team approach is necessary with advice for the patient coming from a physician as well as a surgeon, a dietician, and sometimes a psychiatrist or a psychologist as well. Some teams use an exercise physiologist or a specialist physiotherapist to help design supervised exercise programs according to patients' needs.

More extensive surgery includes a procedure, which is particularly popular in the United States, called a Roux-en-Y gastric bypass. In this operation, the stomach is cut at the top portion leaving a small pouch and this is then connected to the intestine lower down; only small amounts of food may be eaten and these small amounts of food may take some time before they get to the digestive part of the bowel. That means that if the patient eats the wrong sorts of foods then they would experience significant indigestion symptoms. In addition to this, they will require daily nutritional supplements such as vitamins and minerals. Surgery for weight loss is very successful in a patient who is well prepared and well motivated to succeed, and most patients can expect to lose up to 60% of their excess weight. We find that this helps to correct the diabetes very quickly, patients sleep better and are much more mobile, improving their quality of life. Surgery is an important part in weight control and it should only be considered where a multidisciplinary team is used to help supervise patient care.

For more information on measures of weight and nutrition, including GI, GL, BMI, WC and WHR, as well as some useful tools, see Measures of Nutrition and Weight.
For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss.

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Lumbar Puncture (Cerebrospinal Fluid Examination)

A lumbar puncture is a procedure that is used to examine the cerebrospinal fluid (CSF). The cerebrospinal fluid is the fluid which circulates around the brain and membranes around the brain and spinal cord (the meninges). It is mainly used in aiding diagnoses pertaining to infection, inflammatory diseases and traumatic injuries. It can also be used therapeutically and for anaesthesia, however this document is mainly concerned with the investigative use of a lumbar puncture.

To begin with the procedure is usually carefully explained to the patient, including the risks and benefits. In experienced hands, a lumbar puncture is a relatively safe procedure. Proper positioning of the patient is extremely important. The patient is asked to lie on their side, with their back toward the examiner and then curl into a ball. This involves the patient flexing their neck and lower spine, whilst drawing up their thighs toward their chest. The shoulders and pelvis should be vertically aligned without forward or backward tilt. In approximately 94% of individuals the spinal cord terminates at the level of the L1 vertebrae. In the further 6% of individuals the spinal cord can extend to the L2-L3 interspace. Therefore a lumbar puncture is generally performed at or below the L3-L4 interspace. As a general anatomical rule, the line drawn between the posterior iliac crests often corresponds closely to the level of L3-L4. The interspace is selected after palpation of the spinous processes at each lumbar level.Once the area for needle insertion has been ascertained, the examiner puts on a mask and sterile gloves - this decreases the risk of infection. The skin is then cleansed with alcohol and usually an iodine based disinfectant and the area is draped with a sterile cloth. A local anaesthetic, commonly 1% lignocaine, is injected into the subcutaneous area - this should be ideally done at least 5 minutes prior to insertion of the lumbar puncture needle.The lumbar puncture needle is typically a 20 - 22 gauge needle and it is inserted into the target area and slowly advanced. The bevel of the needle is maintained in a horizontal position (with the flat portion of the bevel pointing up) and it should be parralel to the direction of the dural fibers. In most cases the needle is advanced 4 - 5cm before the subarachnoid space is reached - this is characteristically recognized by a sudden decrease in resistance and sometimes a 'popping' sound may be heard. Once a subarachnoid space has been reached, a manometer can be attached to the needle to record the opening pressure. Fluid is then usually obtained for collection. Fifteen millilitres of CSF is usually sufficient for a sample. The fluid is then taken and may be analysed for a number of parameters (according to the clinical presentation) including: cell count with differential protein and glucose concentrations culture - bacterial, fungal, mycobacterial and viral smears - gram stains and acid-fast bacilli smear antigen tests and serology (e.g. cryptococcal antigen, latex agglutination, limulus lusate tests) PCR (polymerase chain reaction) tests to amplify DNA or RNA of micro-organisms antibody tests immunoelectrophoresis cytology or cell studiesSome normal values for CSF parametes are as follows: Glucose 2.22-3.89mmol/L Lactate 1-2mmol/L Protein 0.15-5g/L Red Blood Cells 0 IgG 0.009-0.057g/LThe minor risks and complications associated with a lumbar puncture include backache, post lumbar puncture headache, radicular pain and numbness. Major complications that rarely occur include infection, haemorrhage, damage to the spinal cord or nerve roots and herniation of cerebral tissue in patients with pre-existing increased intracranial pressure.



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CoaguChek

The CoaguChek monitor is a hand-held device that is used to measure the international normalised ratio (INR) in individuals taking warfarin. 

The INR is a laboratory measurement used to determine the effects of oral anticoagulants (warfarin) on the clotting system. Warfarin (e.g. Coumadin, Marevan) is an anticoagulant – a substance that inhibits blood clot formation – that you can take orally in tablet form. It works by reducing the ability of several clotting factors (components in the blood responsible for forming blood clots) to form a blood clot.

It is important to monitor the INR regularly to ensure a correct dose of warfarin. Frequent monitoring helps to balance the risk of excessive bleeding (when the INR is too high) against the risk of thrombosis or clotting (when the INR is too low).

The CoaguChek is a portable device which allows an individual to measure their own INR at frequent intervals.

The CoaguChek device comes packaged as a kit, including:

CoaguChek device;Four alkali-manganese AAA batteries or a power supply unit;Lancing device and lancet;Carry case;User manual.

Consumable materials used in testing are purchased separately:

CoaguCheck test strips;Code chip which corresponds to and provides specific information about each set of test strips, including calibration data and expiry dates. 

If you are using the CoaguChek for your own personal use, it is important that you do not have any limitations that would prevent you from using the device suitably.

Some limitations include:

Physical limitations (such as arthritis or amputations involving the hands) that prevent proper use of the device;Cognitive limitations that prevent proper use of the device or interpretation of the results;Problems attending training sessions; andFailing training assessments.

Suitable individuals should attend a structured educational program to receive training in areas of:

Self-testing: How to use the device, how to record and interpret or report results, and how often to self-test;Instructions to prevent complications: Information on your target INR (the range of INR values that are best suited to you to maximise benefits and minimise side effects), and what to do if you have a result outside of this range; andAffect of diet and medications: The INR can vary with changes in diet, some illnesses and many medications, it is therefore important that you inform your health professional that you are taking warfarin and perhaps monitor your INR more regularly following changes in medication and/or diet.

Calibrating the device

When the device is used for the first time, you must set the correct date and time to ensure the device provides correct measurements. If the batteries are removed or replaced, you should check that the date and time is correct when the batteries are inserted. The date and time should be reset if necessary. Instructions for setting the date and time are included in the device user manual.

Using CoaguChek to test blood samples

In general, the following steps should be followed:

Familarise yourself with the device and operating instructions.Prepareyour materials CoaguChek meter;CoaguChek test strips;Code chip: Contained within each box of test strips and unique to those test strips. The code chip holds information on the expiration date and lot number of the test strips; andCoaguChek lancing device: For finger pricking to obtain the blood sample. Ensure that a new lancet is inserted into the device for each use.Turn the device on using the on/off switch. Alternatively, insert a test strip and the device will automatically turn itself on. The device will automatically check its display properties, by displaying a range of symbols on the screen.Wash your hands in warm soapy water. The hands and fingertip should be dried thoroughly.Remove the test strip from the container and insert it into the test strip guide on the device in the direction of the arrows on the strip. Close the container immediately with the stopper. You must use the test strip within 10 minutes of removing it from the container.Confirm that the code chip number displayed on the device matches the number on the test strip container. If the numbers are identical, press the M button to confirm this. While you do this, the machine will take approximately 30 seconds to warm up, during which time an hourglass will be displayed on the screen. When the device is warmed up, a blood drop will appear on screen. You must apply a drop of blood to the test strip within 120 seconds in order for the test to work properly.Collect a blood sample from the side of your fingertip using the CoaguChek lancing device and the tips to improve blood supply below. Apply the first drop of blood which appears to the test strip.Apply the blood sample to the target area on the test strip within 15 seconds of sticking the fingertip. You should hold the blood drop to the testing strip until a beep is heard and/or the flashing blood drop symbol disappears.Await the result, which should appear in approximately one minute. When blood is applied to the test strip, it mixes with various ingredients contained within the test strip. Once the meter determines that the applied blood has clotted, the time to clot is used to calculate the INR. An hourglass will be displayed on the screen while the device is determining the result. Do not disturb the device or apply more blood to the test strip during this time.Record the result: CoaguChek automatically records up to 100 of the most recent measurements, and these measurements can be accessed at any time by pressing the M button on the device. Some people may also record the results separately in a log book.Occasionally the result will be displayed with a small C underneath it. This often indicates contamination of the blood sample (e.g. from water on hands). In these cases, you need to perform the test again. If the C appears again, contact your doctor;Pack away: Dispose of the test strip and lancing device with other household waste, turn the meter off and, if dirty, wipe clean with an approved cleaner.

Introduced in the 1990s, portable devices allow individuals to measure their INR at home with a single drop of whole blood. Individuals who self-test have the option of:

Self-monitoring: In which they test their INR at home and then phone a clinic for the appropriate dose adjustment; orSelf-managing: In which they test their INR at home and adjust their oral anticoagulant dose according to a pre-determined dose INR schedule.

Self-testing has the advantage of improved convenience, greater treatment adherence, increased monitoring frequency and a reduction in the side effects associated with oral anticoagulation.

For some people, self-testing is not applicable as they may encounter difficulties such as physical limitations, problems attending training sessions/education, failing training assessments and problems with the device. You should discuss this option and your suitability with your doctor, who can advise you further.

If you do not feel comfortable or are unsuitable for self-monitoring or management, some doctors' surgeries own a CoaguChek and have a nurse trained in the area who can determine your INR.  Otherwise, your INR can still be measured at the pathology laboratory.

In order to maintain a safe and reliable system for measuring the INR:

The meter should be operated at room temperature (15–32 oC);The meter should be operated at a relative humidity of < 85%;The meter should be operated at an altitude no higher than 4,300 metres;The meter should be kept level when testing;If storing the meter for a period of time, store it in the carry case provided; andThe meter should not be used near a strong magnetic field.

In order to maintain a safe and reliable system for measuring the INR, you should avoid:

Operating the device in conditions outside of those listed above;Removing or inserting a code chip whilst the meter is performing a measurement;Using a code chip from a box of test strips other than the one in use. To prevent this from happening, change the code chip each time you begin using a new set of test strips and discard the old chip;Using wet hands to open a container of test strips or wetting the code chip;Touching test strips with wet hands;Touching and/or removing the test strip while the device is performing a test;Delaying application of the blood onto the test strip by more than 15 seconds after the finger has been cut with the lancing device;Adding more blood once the test has begun; andTouching buttons on the device while the device is testing.

Some models such as the CoaguChek XS have advanced features, including:

Touch screen;Infrared interface;Option to change the unit of measurement (%Q, secs, INR);Option to disable/enable the beeping; andAbility to set a therapeutic range.

Results are automatically stored within the device. Up to 100 results are stored. Where more than 100 tests have been performed, the oldest result is deleted to make room for the new value. Results stored in the memory can also be downloaded to another device.

Results are stored even when there are no batteries in the device. However, if the device is without batteries for longer than one minute, the time and date settings may require resetting.

A few simple measures can be taken to increase blood flow to the finger before finger prick testing, including:

Warm the hand and fingers: This can be done by holding your hand under your armpit, using a hand warmer or washing the hands with warm water;Lower the hand below the waist; andMassage the finger from its base towards the tip. Do not squeeze or press the finger.

More detailed information can be read in the user manual of the device. The user manual provides information relating to:

Inserting and/or changing batteries;Setting the date and time;Inserting a new code chip;Testing a blood sample;Preparing for a test;Out of range values;Optional testing methods;Memory;Cleaning and disinfecting;Advanced features;The meter's display;Error messages;Product specifications;Support/services;Symbols; andWarranty.

If you have any concerns or issues, discuss them with your doctor.

CoaguChek® XS User's Manual. Castle Hill, NSW: Roche Diagnostics; 2011.Garcia-Alamino JM, Ward AM, Alonso-Coello P, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2010;(4):CD003839. [Abstract | Full text]Shephard M, Shephard A, Watkinson L, et al. Design, implementation and results of the quality control program for the Australian government's point of care testing in general practice trial. Ann Clin Biochem. 2009;46(Pt 5):413-9. [Abstract]Coaguchek® XS Plus Operator's Manual. Castle Hill, NSW: Roche Diagnostics; 2011.

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Transcutaneous Electrical Nerve Stimulation (TENS) devices

TENS or transcutaneous electrical nerve stimulation devices are used in the treatment of pain. A TENS device works by passing a small electrical current across the skin. This procedure is completely painless.

TENS machines or devices became popular in the 1970's and are commonly used by physiotherapists today. Many people will report a reduction in pain after TENS treatment or therapy. However, research evidence to support these patient reports is mixed.

TENS devices are primarily used to treat various forms of pain including chronic musculoskeletal pain (for example arthritis or back pain), pain that occurs following an operation or surgery, cancer pain, phantom limb pain (pain in an already amputated arm or leg, as if it were still there) and pain during childbirth.

TENS has also been reported to be useful in reducing nausea following chemotherapy and in the healing of ulcers or wounds.

A TENS device will typically consist of an electrical pulse generator, leads and electrodes. When switched on, the electrical pulse generator will create waves or pulses of electricity that travel along the leads to the electrode that are placed on the skin. The electrodes are placed either near to the site of the pain, or sometimes along the spinal cord. The patient or practitioner can control the electrical pulses and alter their amplitude (whether the pulses are strong or weak), frequency (how often the pulses occur) and duration (how long the pulses last for).

TENS devices can be portable, battery powered and easily operated by patients. These TENS devices tend to be small and lightweight, and can be concealed under clothing. Other TENS devices may be powered through an electrical outlet and will tend to be larger. These devices will typically require a physiotherapist or technician to operate them.  

There are two theories about how electrical pulses generated by TENS devices may relieve pain. One theory suggests that the electrical pulses may aid in the release of endorphins - the body's natural pain-killers. Another theory (the gate control theory) suggests that electricity can stimulate nerve fibres that will block pain messages to the brain.

TENS devices are usually available at physiotherapy centres and at some hospitals. Small TENS devices are also available for commercial sale to patients. 

There are no strict guidelines on how long a TENS device should be used for. An initial session will generally last for 10 to 30 minutes. The intensity of the electrical pulse will be set below a patient's pain threshold. However the patient should feel tingling, prickling or buzzing sensations called paraesthesias.

Pain relief usually occurs soon after the onset of the electrical pulses, and should persist for at least the time that the machine is switched on. Patients may use the TENS device at home as needed. Alternatively, TENS can be applied at fixed intervals, two or three times daily. Patients are often encouraged to experiment with pulse amplitude, frequency and duration to maximise their comfort.

TENS devices should not be used while driving or operating machinery, should never be used near water (e.g. in the shower) and should not be used near an open wound, or on broken or irritated skin.

TENS devices are thought to reduce the severity of pain. TENS devices can be relatively easy to use and accessible for patients. When used appropriately, there are no known side effects of these devices.

Currently, there is mixed support for the use of TENS devices in the treatment of pain. Some studies have found pain reduction following the use of TENS whereas others have found no significant reduction in pain.

If the TENS device is not used appropriately (i.e. at high voltages) there is a risk of increasing pain rather than easing it. TENS is not recommended for use on pregnant women as it may induce contractions. TENS is not recommended for individuals with cardiac pacemakers. The electrical pulses may interfere with the operation of the pacemaker. TENS is not recommended for patients with epilepsy or severe allodynia (e.g. a heightened pain response to gentle touch).It is recommended that TENS electrodes should not be placed over the throat, eyes or carotid sinus (the area on the neck just below the ear and near the jaw where the carotid artery lies).Bercovitch M, Waller A. Transcutaneous electrical nerve stimulation (TENS). In: Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford Textbook of Palliative Medicine. 3rd ed. Oxford: Oxford University Press; 2004. p. 405-410.Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: A meta-analysis of randomized controlled trials. Pain 2007; 130: 157-65.Bjordal J, Johnson M, Ljunggreen A. Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain 2003; 7: 181-8. Carroll D, Tramer M, McQuay H, Nye B, Moore A. Randomization is important in studies with pain outcomes: systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain. Br J Anaesth 1996; 77(6): 798-803.Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965; 150: 971-9.

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Happy marriage adds pounds

Findings challenge the notion that quality relationships always benefit health, indicating that satisfied spouses gain weight over time because they may be less motivated to attract an alternative mate.

On average, young newlyweds who are satisfied with their marriage gain weight in the early years after they exchange vows, putting them at increased risk for various health problems related to being overweight.

That is the finding of a new study on marital satisfaction and weight gain, according to psychologist Andrea L. Meltzer, lead researcher and an assistant professor in the Department of Psychology at Southern Methodist University in Dallas.

“On average, spouses who were more satisfied with their marriage were less likely to consider leaving their marriage, and they gained more weight over time,” Meltzer said. “In contrast, couples who were less satisfied in their relationship tended to gain less weight over time.”

The study’s researchers said the findings challenge the long-held notion that quality relationships are always beneficial to one’s health. Instead, they said, the findings suggest that spouses who are satisfied in the marriage are less motivated to attract an alternative mate. As a result, satisfied spouses relax efforts to maintain their weight.

The article is published online in the scientific journal Health Psychology.

The study was based on data from 169 first-married newlywed couples whose marital satisfaction and weight were tracked over the course of four years.

Previous psychological research has established that marriage is associated with weight gain and that divorce is associated with weight loss. But the role of marital satisfaction in those changes in weight is less clear, Meltzer said.

Previous research also has demonstrated that marital satisfaction is associated with health maintenance behaviours, she said.

“For example, studies have found that satisfied couples are more likely to take medications on time and schedule annual physicals,” Meltzer said. “Yet the role of marital satisfaction and actual health is less clear.”

Meltzer set out to examine the association between marital satisfaction and changes in weight over time.

For four years, the newlyweds reported twice a year on their marital satisfaction and steps toward divorce. They also reported their height and weight, which was used to calculate their body mass indices.

Spouses who were less happy in their marriage were more likely to consider leaving their partner, Meltzer said, and on average gained less weight over time.

“So these findings suggest that people perhaps are thinking about their weight in terms of appearance rather than health,” she said.

The study suggests young couples should be educated and encouraged to think about their weight as a factor of maintaining their health.

“We know that weight gain can be associated with a variety of negative health consequences, for example diabetes and cardiovascular disease,” Meltzer said. “By focusing more on weight in terms of health implications as opposed to appearance implications, satisfied couples may be able to avoid potentially unhealthy weight gain over time in their marriages.”

(Source: SMU: Health Psychology)

Article Date: 17/4/2013

View the original article here

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Slim women have a greater risk of developing endometriosis than obese women

Women with a lean body shape have a greater risk of developing endometriosis than womn who are morbidly obese, according to the largest prospective study to investigate the link.

The study, which is published online today (Wednesday) in Europe's leading reproductive medicine journal Human Reproduction [1], found that the risk of endometriosis was 39% lower in morbidly obese women - those with a body mass index [BMI] greater than 40kg/m2- compared with women with a current BMI in the low normal range (18.5-22.4 kg/m2).

When the researchers looked back at the women’s BMIs when they were 18, they found that women who were morbidly obese at that point in their lives had a 41% lower risk of developing endometriosis than women with low normal BMI.

The association was strongest in the group of women who were infertile – those who had been trying to become pregnant for more than a year: there was a significantly lower rate of endometriosis (62%) among the currently morbidly obese compared with those with a low normal BMI, while it was 77% lower among women who were morbidly obese at age 18 compared with those with a low normal BMI at 18.

The authors of the study stress that although their findings establish firm evidence of a link between endometriosis and BMI, it does not show that low BMI causes endometriosis. “It is important to note that despite the strength of the evidence underlying the association between body weight and endometriosis, inferences regarding causation or the pathophysiologic process underlying these relations cannot be made,” they write in their paper.

The mechanisms that might be responsible for the link between BMI and risk of endometriosis are unclear, but the researchers point to the possibility that BMI at a younger age may have an influence on health in later life, especially as it is known to have an effect on other diseases; and also that polycystic ovarian syndrome (PCOS) is more common among obese women and the effect it has on menstruation and hormones might play a role in reducing or slowing the growth of endometrial lesions.

First author of the study, Clinical Assistant Professor, Divya Shah (MD), at the University of Iowa Hospitals and Clinics (Iowa City, USA), said: “Further research is needed to understand the biological mechanisms underlying the associations that we have seen in our study. Maintaining a healthy body weight (BMI 20-24.9 kg/m2) throughout childhood, adolescence, and adulthood is associated with a myriad of known health benefits. The study does not suggest that the morbidly obese women are, in some way, healthier than the lean women and that is the reason for their lower risk of endometriosis. It is more likely that factors related to infertility, which is more common among the very obese, are linked to the reduced risk of endometriosis.

“Our finding that lean women have a higher risk is useful information for doctors when making a diagnosis. It also means that future research can focus on these women to discover the causes, so that we can design treatments that could help prevent the condition developing.”

The findings come from the Nurses’ Health Study II (NHS II), which has been following 116,430 female nurses in the USA since September 1989. Data were analysed after ten years, but now the researchers have a total of 20 years of data from 1989 to June 2011.

During the 20 years of the study, a total of 5504 women were diagnosed with endometriosis using laparoscopy [2]. Only women with a diagnosis of endometriosis that had been confirmed by laparoscopy were included in the analyses. The women were between 25-42 years of age when they were enrolled in the study in 1989. They completed a questionnaire about their medical history when they joined the study, including their weight and height at the age of 18, and then at two-year intervals thereafter. Information on current weight, height, and, from 1993, waist and hip circumference and any diagnosis of laparoscopically-confirmed endometriosis was also included.

The senior author of the study, Associate Professor, Stacey Missmer (ScD), of Harvard Medical School (Boston, USA), said: “Analysis of the first ten years of NHS II data revealed an inverse relation between endometriosis and BMI at age 18 among all women, and, in a subset of infertile women, an inverse relation between endometriosis and current BMI. Availability of an additional ten years of NHS II data yielded 2986 additional cases of endometriosis, and enabled us to trace women who were diagnosed with endometriosis after age 25 through most of their reproductive lifespan. This study confirms that women with a low BMI, both currently and at age 18, have a greater risk of developing endometriosis. The association remains stronger in infertile women, but is present in all women regardless of fertility status.

“Insomuch as any data can ever claim to be definitive, we do believe that this large prospective study provides conclusive evidence of the inverse association between endometriosis and BMI.”

Endometriosis is estimated to affect approximately one in ten women of reproductive age. As a diagnosis of endometriosis can only be confirmed by laparoscopy, it is difficult, if not impossible, to establish the precise point at which endometriosis appears. A recent study of women in 16 centres in ten countries [3], showed that the average age at which women presented with symptoms of endometriosis was 26, with most women experiencing a delay of six or seven years between the onset of symptoms and a definitive diagnosis.

Source eshre

Article Date: 17/6/2013

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Want kids to eat healthier? Dont tell them, show them

If given the choice between eating a salad loaded with veggies or a burger and fries, most kids -- and for that matter, most adults -- would likely pick the less healthful option. But instead of telling kids to eat more fruits and vegetables, Iowa State University researchers found the trick may be to convince them visually.    

Laura Smarandescu, an assistant professor of marketing, and Brian Mennecke, an associate professor of information systems, did just that using a digital display featuring a rotating image of a salad along with menu information. They found salad consumption among kids increased as much as 90 percent when a digital display showed a rotating image of the salad. The results are from a field study conducted in July at the YMCA of Greater Des Moines camp in Boone. The camp is for children with diabetes, ages 6-12.

Campers were offered a nutritionally balanced daily menu, which included foods like tacos, sloppy joes, fruits and vegetables and had the additional option of a salad bar. The kitchen staff weighed the salad bar items before and after each meal to calculate how much was consumed. The digital sign had the greatest appeal among boys at the camp, who were 50 to 70 percent more likely to serve themselves lettuce, cucumbers, tomatoes and carrots when the digital display showcased a vivid picture of a salad.

“The cool effect that we found and didn’t expect was with boys,” Smarandescu said. “It makes sense because boys like video games and interact more with technology. We noticed many boys stopping to look at the display and their behavior seemed to be more influenced by the presence of the display.”  

The results from the field study mirror what Smarandescu and Mennecke discovered in the lab. When given the choice between a still photo of a particular food or a rotating image, participants in the lab opted for the rotating menu item. Mennecke said the studies show the influence of environmental cues and images on consumer behavior.

“The more vivid the image, in terms of movement, color and accuracy of representation, the more realistic, the more it’s going to stimulate your response to it,” Mennecke said. “You respond to the image on the display like you would respond to a plate in front of you. If you’re hungry you respond by saying, ‘I’ll have what’s in that picture.’”

Taking the technology to the lunchroom

Fast food companies, like Burger King, have embraced the technology by using digital menu boards to feature new items or target key demographics. ISU researchers believe the displays could have a positive impact in school cafeterias and influence students to make better choices. The concept is similar to the “Smarter Lunchrooms Movement” developed by Brian Wansink at Cornell University, who has partnered with Smarandescu and Mennecke on their project.

By displaying nutritious foods and drinks in a way that makes them more accessible and attractive in the lunchroom, Wansink has found students greatly increase their choice for more healthful options. Iowa State researchers believe a digital display can motivate students to make better choices in the same way.

“We’re hoping that these displays – a small, low-cost intervention – could lead to large-scale behavior changes,” Smarandescu said. “Students will feel like they made the decision themselves as opposed to being told to take the healthier option.”

Ann Wolf, executive director of the diabetes Camp Hertko Hollow, who worked with researchers on the field study, is interested in adding a permanent digital display for next summer’s camp. Not only do campers relate to the technology, but Wolf said it reinforces a lesson they hope to teach campers.

“Children need to make healthy choices,” Wolf said. “We try to educate our children to eat well and manage their diabetes to live a long and healthy life.”

Using digital displays to boost sales

Targeting kids at camp or consumers at the point of purchase can have a powerful effect, Smarandescu said. If people are hungry and the digital display is right in front of them, research suggests the display will have more impact than a traditional advertisement. The more detail incorporated into the display, the better.   

“A lot of times these videos are very vivid and they look very good. Sometimes they zoom in on the food and just by having that fine detail they make the food look better,” Smarandescu said. “If you can’t see what an item looks like you have more uncertainty in a way. By seeing a picture of an item that looks good, that will likely influence choice.”

To test this, researchers plan to use a digital display to feature daily menu items at restaurants and determine the effectiveness by tracking sales. They also want to determine the importance of content. Just because a display is there for consumers to see, doesn’t mean they are tuned in.   

“People will ignore a sign that they see every day if the content doesn’t change,” Mennecke said. “That’s the challenge – getting the imagery and making it look nice and having varied content. That’s not a trivial issue; you have to worry about the content and be creative. This is the hard part of using digital signage.”

Source Iowa State University 

Article Date: 26/7/2013

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South Beach Diet A to Z - Phase 1 Acceptable...

South Beach Diet A to Z: Phase 1 Acceptable Foods

The following foods are acceptable during Phase 1 of The South Beach Diet: Certain Meats and PoultryBeans Certain vegetablesOne serving of nuts dailyLow-fat cheesesEggsFats and oilsSugar substitutesSpecific treats such as sugar-free gelatin, hard sugar-free candy, and fudge pops

You will find a more extensive list of allowable foods in our South Beach Diet 101 section. Return to
South Beach Diet A to Z

Suggested Reading:
 The South Beach Diet by Arthur Agatston, MD
 The South Beach Diet Good Fats Good Fats Guide
 The South Beach Diet Cookbook
 The South Beach Diet Quick & Easy Cookbook

Source:
The South Beach Diet : The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss, Arthur Agatston, MD, St. Martin's Griffin (April 19, 2005 edition).

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Easy Exercise Programs to Lose Weight

Many people shy away from exercise because they think that all workouts have to be difficult and uncomfortable sweat fests. But that’s not true. Especially for people who are trying to lose weight, easy workouts are essential. No matter what fitness level you’re at, regardless of your previous workout history, learn how to incorporate easy workouts into your routine to make your weight loss program more enjoyable and more effective.Peter Dazeley/Getty ImagesAre you new to exercise? Have you had bad experiences at the gym or in exercise classes? Have you gotten bored with exercise in the past? Have you started an exercise program only to quit in frustration? If the answer is yes to any of these questions, you need a new weight loss workout program. Learn why easy exercise sessions are the foundation of weight loss workout programs for beginners. Then get started with one of the exercise programs provided or design one of your own. zSB(3,3)Mike Harrington/Getty ImagesIf you are currently exercising and not seeing results, this is the article for you. Do you feel like you work out hard enough without any change? Do you feel like you can’t possibly work any harder? The key to getting results might not be working harder; it might be exercising easier. Sounds strange, right? Learn why easy workouts are essential for your workout program and why people who are trying to lose weight may benefit the most from easy workouts. Alvimann/morguefileNeed a fast path to weight loss? Dieters often add intense exercise to their crash diets only to find themselves injured or exhausted and unable to exercise. Extreme diets don't work, but a combination of healthy habits can create real change in a shorter period of time. Use one of these plans for a week to feel better, look better and see real change. Winston Davidian/morguefileIt’s important to set an intensity goal for every workout session. If your workout is designed to be an easy, low-intensity session, make sure you keep it that way by monitoring your heart rate, your rating of perceived exertion or both. Tracy Frankel/Getty ImagesThere are some exercise programs that are particularly well suited for overweight exercisers and for those who are new to exercise. Try one of these workouts and use the tips for getting started to make your experience more enjoyable. Taxi/Getty ImagesFor almost all exercisers, the best weight loss workout programs combine sessions that are difficult, moderate and easy. Learn how to set up your weekly workout schedule with easy exercise, moderate intensity exercise and high intensity workouts to gain the greatest benefits from your fitness program. if(zSbL

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15 Facts for Weight Loss Newbies!

1. Your weight affects you in many ways other than your appearance: Your overall quality of life;self-esteem;health risks;depression;and physical abilities are also influenced.

Think of all the positive changes you can experience by losing weight.

2. You will need to see your doctor for a physical if you haven't had one recently and you really should get her approval before starting a weight loss regime.

3. You should ask yourself these questions as you begin: Why do you want to lose weight?Are you truly committed? Do you have a support system set up?Can you accept mistakes without giving up altogether?

4. To lose weight effectively, you will have to permanently change four aspects of your life:
1.) what you eat
2.) how you eat
3.) your behavior and
4.) your activity level.

5. You shouldn't set your sights too high (... like losing 30 pounds in a month. Those signs advertising weight loss pills are not true!).

Small goals (e.g. 5 pounds; 10 percent of your current weight) are far more attainable and easier to stay focused on.

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Easy Workouts to Lose Weight

If you think you have to exercise to the point of exhaustion every day to lose weight, you’re wrong. In fact, easy workouts are essential if you want to burn fat and lose weight with exercise. But how you set up your easy workout plan depends on your workout history.

Beginning and advanced exercisers use easy workouts differently. For beginners, low intensity exercise lays the groundwork for building a fitness program. If you are new to exercise or if you’ve had no luck maintaining an exercise program, start with a program of easy weight loss workouts. But if you are an intermediate or advanced exerciser, use easy exercise on your active recovery days.

An active rest day, or a recovery day, is part of a complete workout program that includes high intensity, moderate intensity and low intensity exercise. During the low intensity recovery days you still exercise, but you keep your heart rate low (no higher than 70% of your maximum heart rate) and focus on activities that loosen the muscles, increase your range of motion, and allow your body and mind to recover from more intense sessions.

During a typical week, you should schedule a recovery day after each high intensity workout day. So, if you do high intensity intervals on Mondays and Thursdays, you should schedule easy workouts for Tuesday and Friday. If you do a high intensity workout on Sunday, make Monday your active rest day.

Weight Loss Benefits of Easy Workout Days

It’s tempting to flop on the couch the day after a high intensity exercise session, but if you’re trying to lose weight, you should choose to do an active recovery workout instead. The weight loss benefits add up.

Burn calories. Even low intensity exercise burns calories, especially if you compare it to sitting on the couch. You may only burn 200 calories during your easy workout, but over the course of an eight-week exercise program, that adds up to almost 3500 extra calories burned or one extra pound of weight lost if you do it twice per week Build/Maintain Consistent Workout Schedule. The hardest part of starting an exercise program is building a new routine. You’ll build the routine faster if you get into the habit of exercising every day. With active rest days, you are more likely to be able to maintain a daily exercise habit. Increased Range of Motion. Active recovery days are great opportunities to do exercises and activities that use your muscles in new and different ways. This helps to create a healthy balanced body that remains injury-free for more intense calorie-blasting workouts. Decrease Stress. Easy workouts should make you feel good. They are a great way to blow off steam and avoid emotional binge eating.

Easy Workout Ideas

There are countless options for your active recovery days. To maximize the health benefits of your fitness program, try to do easy workouts with muscles that are different than the ones you use during your hard day workouts, or that stretch the muscles that are tired and sore. For example,

if you complete a high intensity run on Monday, a good rest day workout might include a walk. Even though you are still using your legs, walking focuses on the muscles in the back of your legs (glutes and hamstrings) and walking lengthens the hip flexors that tighten when you run. if you ride your bike to lose weight, try swimming or yoga on your recovery day. Cycling primarily works the lower body. Swimming and yoga help build upper body strength and depending on how you do the workout, can help to increase range of motion in your legs.If you completed a high intensity circuit workout, use your easy exercise day to focus on flexibility and stretching. Take a dance class, do restorative yoga, or aqua jog for 20 minutes followed by 10 minutes of poolside stretching.

The Best Recovery Day Workout

The best recovery day workout is the one that you do. Remember, the purpose of this easy workout is not just to burn calories, but it is to help you to maintain a consistent daily exercise program. Rest days are also opportunities to destress and give your mind a break, so don't worry about doing the right workout or the right exercise. Just do something. If you do a workout, any workout, no matter what it is, you’ve gained a benefit.

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South Beach Diet 101 ~ Phase 2 Foods to Eat ~...

South Beach Diet 101

Foods you will be eating during Phase 2 of the South Beach Diet include low-GI fruits, whole grain bread and pasta, and low-fat dairy. You can also continue to eat all acceptable Phase 1 foods. The acceptable foods include, but are not limited to:

Low-GI fruits, including ApplesBananasCantaloupeGrapesOrangesPearsStarches, including: Whole wheat bagelsWhole wheat breadSome cerealsWhole grain crackersWhole wheat pastaA variety of additional vegetables, including: Green peasCarrotsPotatoesPumpkinYamsSemi-sweet chocolateNon-fat yogurtFat-free puddingWine (1 or 2 glasses a day)You will find both a complete list of these foods in the South Beach Diet book in the section about Phase 2.

Continue: Phase 3 of The South Beach Diet >>

(Please note: In order to correctly follow The South Beach Diet, you will need to read The South Beach Diet: The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss, which is also available on CD.

You may also find the companion food guide helpful.)

South Beach Diet 101

Related Resources:
South Beach Diet 101: Phase 1
South Beach Diet 101: Phase 2
South Beach Diet Main

Suggested Reading:
The South Beach Diet by Arthur Agatston, MD
The South Beach Diet Good Fats Good Fats Guide
The South Beach Diet Cookbook
The South Beach Diet Quick & Easy Cookbook

Source:
The South Beach Diet : The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss, Arthur Agatston, MD, St. Martin's Griffin (April 19, 2005 edition).

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10 Tips for Eating Out on a Diet

Focus on your friends, not the food, and you'll enjoy eating out on a diet even more.

© [2009] Jupiterimages Corporation Eating out on a diet doesn't have to be cause for panic. Sure, you hear about oversize restaurant portions and the plethora of fattening menu choices available all the time, but that doesn't mean dining out will doom your dieting efforts! Just use these 10 simple tips for eating out on a diet: Cram for tonight's dinner. Many eateries post their entire menu online so you can print it out for reference. If you often eat at "mom and pop" type restaurants that aren't online, call and ask for the menu to be faxed to you, or pick up a takeout menu on your next visit. Highlight the healthiest options for each menu and store them all in a central location. Then, when you are planning your next night out, take the time to decide on your dishes at home before you've been tempted by the sight of other choices. Order your main dish from the appetizer menu. Not only are appetizers more reasonably-portioned, they will save you some money as well. (This is a great way to save enough calories and cash to split dessert with someone!) Too peckish to be satisfied with just a starter? Order a side salad, too -- the fiber-rich veggies will round out your meal. Soup is super-filling, so it's an awesome appetizer add-on, too (just steer clear of cream-based ones).Beware these high-fat menu buzz words: Cream sauce, butter, oil, au gratin, breaded, Alfredo, battered or batter-dipped, "with gravy," or smothered. Unless you've spared yourself treats for several days and snacked on salad greens all day, these little "extras" aren't worth the extra calories.Modify the menu. In my neck of the woods, anything and everything can be batter-dipped and fried, so I make special requests all the time. Many restaurants will take your dietary needs into account so you'll be a happy customer and return. Don't hesitate to request anything on the menu to be prepared in a more diet-friendly and for sauces or dressings to be served on the side. It's not likely that you will be denied.The meat is on. As tempting as that bucket of fried chicken looked on the commercial before you left home, order poultry steamed, poached, roasted, broiled, boiled, grilled or baked. Ask for skinless chicken whenever possible or remove it yourself. If you do treat yourself to fried chicken, choose white meat as it has fewer calories than dark. Of course, chicken, chicken and more chicken gets old after a while, so if you're asking, "Where's the beef?" allow yourself red meat a few times a week -- just be sure to choose leaner cuts of meat like loin or flank.Keep tabs on that tubini. Endless pasta at your favorite Italian restaurant may be carb-lovers' heaven (Darn near nirvana for yours truly!), but it's a waist-widening trap for those of us who tend to overeat (How are you supposed to know when to say "when" if they keep bringing more?). As tempting as the great "value" for your money that infinitely-refilling pasta bowl seems, it's certainly not a bargain for your calorie budget. Order a portion-controlled main dish instead. "Ixnay" on the endless breadsticks, too! "Wrap it up, I'll take it!" You know you're at a nice restaurant when the server takes your plate away and wraps up your leftover food for you at the end of the meal. (And if you're in a really nice restaurant, you'll get the eating out equivalent of a balloon animal -- the tin foil swan!) To ensure you don't leave sans swan, keep temptation at bay and ask the server to wrap up half of your as soon as it is served.Take control of takeout. You don't have to swear off takeout when you're dieting -- there are many healthy options at ethnic restaurants. Portion control is key, though: Take out half of your takeout before dishing up your dinner, put the food in microwave containers and tuck it away in the fridge before you even start eating. (Instant will power and instant next-day lunch!)Banish buffets. Portion control can become a foreign concept for even the most determined dieter at an all-you-can-eat buffet. (Who can practice moderation when there are new, clean plates just beckoning to be filled?) The sheer variety of foods available at buffets is also daunting -- studies have shown that when we're given more choices, we tend to eat more without realizing it. Simply avoid buffet restaurants and you won't have to face this temptation.Mini meals are a must. It's smart to eat smaller meals during the day when you're planning to dine out. Just don't eat too sparingly, though -- you don't want to be so famished by the evening that you overeat. (It was a dark day when I ate too-mini mini meals and -- clearly ignoring my own tip number 9! -- visited a buffet in a ravenous state with a fellow waist-watcher ... the look of sheer horror on her face as I went for round number four is not something I will soon forget!) If mini meals don't tide you over, have a small, healthful snack in the afternoon to curb your appetite and you'll be much more in control come dinner time.

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Evolution Vs Revolution

Weight loss doesn't happen overnight, but the decision to change happens in an instant. It's really no different than any other decision to change. It's more than thinking about it, although that's where it often starts. It's more a decision to commit. Sometimes the decision to change starts off as nothing more than a passing thought in the back of your mind. Some thoughts disappear as quickly as they came and others grow into nagging desires.

Once the light bulb comes on and you decide, I mean really commit, to making a change about something in your life, that is a revolution. It can even feel like an epiphany. It's the a-ha moment. Maybe you're fed up with your current situation or just want something else entirely different for yourself. Whichever it is, having a revolution means wanting the change badly enough to commit to completing the steps it will take to make that change a reality.

The revolution is the kick-off to the evolution.

Again, change doesn't happen overnight. Now the hard work kicks in. To really change something, especially your weight, you need to commit to a lifestyle change. Temporary solutions offer temporary results. Why bother? We're talking about permanent, healthy change. And that is definitely an evolution. You know your body will not magically transform overnight. Don't expect your habits and thoughts to, either. And both of those components are necessary to create lasting change.

Let's look at your habits first. So many people set New Year's Resolutions to lose weight. It's become very cliche. Now that spring is here... how are you doing on that resolution? It's very difficult to wake up one morning and do everything differently than you did in the previous months and years. A healthy lifestyle includes eating the right foods in the right amounts and exercise, all on a regular basis. It takes a great deal of time and energy to make these changes. Some people are successful at it on a short-term basis. They can do enough of the right things for a week or two and maybe even see some results. However, much of the time these efforts slip and old habits return whether it be out of comfort, habit, social pressure or whatever.

By changing your habits slowly, you give yourself the opportunity to build a healthy lifestyle in a sustainable manner.

Small changes done one or a few at a time allow you to incorporate them into your daily routine and get used to them before taking on additional changes. It's not as disruptive or time consuming to learn a few things at a time versus having to work to learn all new recipes, habits, etc. at once.

Now let's look at your thoughts. Your thoughts play a large role in weight loss. What kind of mind set are you in regarding the changes you're making? Consider what you are giving yourself versus what you are taking away from yourself. Try to frame your thoughts in a positive perspective versus a negative perspective.

For example, what would you say to yourself and others if one of your changes was to not eat sweets like doughnuts for breakfast anymore? If someone brings a fresh, hot box of doughnuts into the office to help everyone beat the "Monday blues," and you know you need to politely decline, how do you word it? Do you say "No thanks, I've already eaten this morning." Or do you say "I wish I could but I'm on this stupid diet and I'm not allowed." One of these responses indicates that you gave yourself a nutritious breakfast at home or on the way to work that morning. The other indicates that you feel like you are depriving yourself of something you want.

Whatever you think about will drive your actions.

If you think about being healthy and eating the right foods, you will seek those things. If you allow yourself to be consumed by thoughts of foods that are detrimental to your health, you will crave them and eventually consume them.

If you are overweight and want to become slimmer and healthier, then you must make changes in your lifestyle. The same actions that got you where you are today will not get you where you want to go. Creating a healthier lifestyle is a journey. Change doesn't happen overnight but the decision to can. If you've made that decision and are committed to it, congratulations. You've had a revolution. Awesome! Now you're ready to start your evolution. Ask yourself "What small changes am I willing to commit to this week? Month? Year?" Make a promise to yourself and keep it.

Stacie Dickerson is the CEO of the Healthy Lifestyle Institute for Women. Access their free article archive, become a member absolutely free and get your health & fitness tools at  http://hliwconnect.com/.

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