Diaphragm

The diaphragm, which was developed in the 19th century, is one of the oldest methods of preventing pregnancy. It is a latex dome which is inserted into a woman's vagina prior to sexual intercourse. Silicon diaphragms are also available for women who are allergic to latex.

The dome is placed so that it covers the woman's cervix, and thus creates a barrier which prevents sperm from entering the uterus. A flexible spring, found in the rim of the diaphragm, prevents the dome from moving out of place during intercourse.

The device must be fitted by a health professional, to ensure the correct size diaphragm is selected, however once a diaphragm has been fitted, a woman can easily insert and remove the diaphragm before and after sexual intercourse. Diaphragms are typically used in conjunction with spermicides to increase their effectiveness.

The diaphragm prevents pregnancy by blocking the cervical opening (the entrance to the uterus). It therefore prevents sperm from entering the uterus. If a woman is fertile, (if she has a viable egg in her uterus) sperm must enter the uterus to fertilise the egg. The egg cannot be fertilised once it has been expelled into the vagina. Thus, by preventing sperm from entering the uterus, the diaphragm also prevents sperm coming into contact with and fertilising an egg.

Most women can safely use a diaphragm. However, some women may need to delay diaphragm use, and use a different method until they can safely use a diaphragm. These women include:

Those who have experienced a second trimester miscarriage or abortion should wait for at least six weeks before having a diaphragm fitted;Those who have recently given birth should wait until at least six weeks after childbirth to have a diaphragm fitted;Those with uterine abnormalities, including uterine prolapse. These women should discuss other contraceptive methods which might be more suitable with their healthcare provider so that they can choose another method;Those with latex allergies should not use a latex diaphragm. A silicon diaphragm may be appropriate, or the woman's healthcare provider will be able to give advice about other contraceptive methods.

In addition, a diaphragm should not be used by the following women

Women with a history of toxic shock syndrome - as diaphragms increase the risk of this condition. Women who have previously experienced toxic shock syndrome should discuss other, more appropriate contraceptive methods with their healthcare provider. They should also not use a cervical cap);Women who have a high risk of HIV - as a diaphragm is typically and most effectively used in conjunction with spermicide, and commonly available spermicides increase the risk of HIV infection, diaphragm use may increase a woman's HIV risk. Women who are at risk of HIV infection, for example those who have sex with partners whose HIV status is unknown, should use condoms if possible, as these reduce the risk of HIV infection and other sexually transmitted infections. (For some women find it is difficult to use condoms, for example if their partners refuse, there are pregnancy prevention methods which they can use without their partner's knowledge including hormonal contraceptive injections or implants, or a diaphragm. However, these methods do not protect against STIs.)

The Sex in Australia survey, a national study of sexual experiences and behaviours of Australians, reported that 0.9% of Australian women used a diaphragm.

When used correctly and in conjunction with spermicide during every act of sexual intercourse, the diaphragm prevents pregnancy in 94% of cases. However, most women do not use the diaphragm correctly every time they have sex, and as typically used, its effectiveness is much lower, around 84%.

It is very important for a diaphragm user to know how to use the device correctly. The health practitioner who fits the diaphragm will explain to the woman how a diaphragm is used, when they do the fitting.

Your health practitioner may recommend that new users begin by using their diaphragm in conjunction with another method. This is not because diaphragms do not work when they are first fitted, but rather to allow the woman to get used to inserting and removing the device correctly.

Diaphragm users should also be aware that:

For effective use, a diaphragm must be used prior to every act of intercourse;When a diaphragm is correctly inserted, the woman should not be able to feel it, even during intercourse;That diaphragms are most effective when used in conjunction with spermicides;That diaphragms have some side effects, the most common of which are urinary tract infections and vaginal discharges (see below).

Diaphragms must be fitted by a health professional. To select a diaphragm of the correct size, the health provider will conduct a pelvic examination. The health provider will first assess the woman's uterine cavity for any conditions which may make the diaphragm an unsuitable contraceptive method for the woman. The practitioner will then insert their index and middle finger into the woman's vagina to determine the required diaphragm size. A diaphragm will then be selected and inserted into the woman's vagina by the health practitioner, so that it covers the cervix. The practitioner will then check that the device fits correctly.

Women using diaphragms should be aware that a new diaphragm must be fitted after childbirth or a second trimester abortion. A new diaphragm should also be fitted if the woman experiences weight gain of >5kg. Women who do not need to have a new diaphragm refitted should replace their device every two years.

The diaphragm must be inserted prior to each act of intercourse. The health practitioner who fits the device will explain to women who are new users of the diaphragm, how to use the device. They may also give the women additional information about her genital organs, which will assist her to correctly insert the device. For example the health practitioner may show women the position of the cervix and pubic bone, using a diagram or model.

To correctly insert a diaphragm a woman should:

Begin by washing her hands;Check the diaphragm for cracks by holding it up to the light;Insert spermicide into the dome and around the rim of the diaphragm. It is important to always check the expiry date of spermicides before using them;Press the rims of the diaphragm together and insert the device deep into the vagina. The woman should choose a comfortable position for insertion, for example lying down;Insert her finger into her vagina and feel to check that the diaphragm is in the correct position, that it is covering the cervix. The cervix feels similar to the tip of the nose, and can be felt through the diaphragm;Remove and reinsert the diaphragm if she can feel it inside her vagina when she moves;If the woman has sexual intercourse several times, she should not remove and reinsert the diaphragm between sex acts. Rather the diaphragm should be left in place and additional spermicide added each time.

It is very important that the diaphragm is left in place for at least six hours following intercourse, but not for more than 24 hours. Leaving the diaphragm in place for more than 24 hours may result in unpleasant odour or vaginal discharge, and in rare cases, toxic shock syndrome. Once at least six hours has elapsed since the last sexual intercourse, a woman should remove the diaphragm according to the following procedure:

Before commencing, the woman should wash her hands;She should then insert a finger into her vagina until she feels the rim of the diaphragm;She should gently slide the finger under the rim and pull the diaphragm down and out. Care should be taken to ensure the diaphragm does not tear or break;Finally, she should wash the diaphragm using mild soap and water. The diaphragm should then be dried and stored in a cool dry place.

Benefits of the diaphragm include:

Use of a diaphragm is controlled by the woman and can be used without the knowledge or consent of her male partner;A diaphragm is effective even if it is inserted up to six hours before intercourse and thus can be inserted in advance to avoid disrupting sexual activity;Using a diaphragm may enable a woman to become more familiar with her genital organs, for example she will learn where her cervix is, and become more comfortable inserting her fingers into her vagina;The diaphragm is a relatively low cost contraceptive method, which does not require frequent visits to a medical practitioner.

Diaphragm use is commonly associated with urinary tract infections. This means that between 1-10% of users experience this side effects.

Candidiasis and bacterial vaginosis are uncommon side effects of diaphragm use, that is, they are side effects experienced by between 0.1%-1% of women who use the device. When the diaphragm is used in conjunction with a spermicide, these side effects are more likely.

Very rare cases of toxic shock syndrome have been reported in diaphragm users. Less that 0.01% of users experience this side effect.

Limitations of the diaphragm include:

The diaphragm must be inserted prior to every act of intercourse;The contraceptive protection of a diaphragm is much less effective than other methods (e.g. hormonal methods are typically >99% effective);To insert a diaphragm a woman must be comfortable with inserting her finger/s into her vagina. Women who have cultural or other objections to touching their genitals cannot use the method;Diaphragms do not provide adequate protection against sexually transmitted infections (STI). Women who have sexual partners of unknown STI status, should use male or female condoms if this is possible. Condoms offer high levels of protection against both pregnancy and STI.

For more information on different types of contraception, female anatomy and related health issues, see Contraception.

Association of Reproductive Health Professionals. Non-hormonal contraceptive methods- a quick reference guide for clinicians. 2007. [cited 2009, October 30] Available from: www.arhp.org/guide World Health Organisation. Family Planning: A global handbook for providers. 2007. [cited 2009, June 20] Available from:  www.who.int/entity/reproductivehealth/publications/family_planning/en/ Amy, J. Tripathi, V. Contraception for women: an evidence based review. BMJ. 2009. 339:563-8.Farmer, L. Everett, S. Nonhormonal contraception. Obstetric, gynaecological and reproductive medicine. 2007.18(2):33-8.Richters, J. Grulich, A.E. de Visser, R.O. et al. Sex in Australia: Contraceptive Practices in a representative sample of women. Aust NZ J Pub Health. 2003;27:210-6.

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Biomarkers of colorectal cancer

Tumour biomarkers are chemicals that are made by tumour cells or other cells of our body, in response to cancer or other benign conditions. Different types of cancers or tumours may be associated with different tumour biomarkers. Colorectal cancer (CRC), which includes colon cancer and rectal cancer is responsible for half a million deaths worldwide every year. There are also about one million new cases diagnosed annually, making it the third most common cancer in the world. Early detection, accurate diagnosis and intensive surveillance are important for best improving a patient's prognosis and response to therapy.

There are a number of methods that doctors use to detect CRC including sigmoidoscopy, colonoscopy and barium enema. Some newer techniques being investigated for effective detection and monitoring of CRC are CT colonography and molecular biomarkers. The use of tumour biomarkers gives doctors a non-invasive way of detecting and monitoring CRC.

Doctors can use tumour biomarkers in the detection, prognosis and management of some types of cancer, including CRC. An abnormal level of tumour biomarker is usually not enough for a complete diagnosis of cancer and is usually combined with other tests such as a biopsy. The type of biomarker detected and its levels can give an indication to what type of cancer may be present, whether or not it is malignant and what the best treatment may be.

Tumour markers are used during the treatment of cancer in order to monitor the effectiveness of a therapy and how the patient may be responding to the treatment. If levels of a tumour biomarker decrease it may mean that the cancer is responding to treatment. If levels remain the same or increase after treatment it may be an indication that the therapy is not working. Continued monitoring of tumour biomarker levels following treatment can be used to check for recurrence of the cancer.

Different tumour biomarkers are measured in different ways and from different sources. Some markers are found in blood or urine, so these would require you provide a small amount of blood or a urine sample. Other tumour biomarkers such as those involved in faecal occult blood testing (FOBT) can be isolated from faecal matter and require a stool sample. Tissue samples can also contain tumour biomarkers and may involve a tissue biopsy. This is a more invasive procedure than urine or stool sampling. After a doctor takes the sample they are sent to a laboratory for testing using various methods to determine biomarker levels. Particular foods such as red meats or fruits and vegetables can influence the assay and cause false positive results.

Two key factors for an effective tumour biomarker assay are:

The assay must be sensitive in its ability to accurately detect disease; andThe assay must be specific for the particular malignancy.

In the early detection or screening of patients for CRC, stool based markers are widely used. Tissue-based markers have been studied as possible prognostic or predictive markers of disease, while CRC biomarkers obtained from serum (blood) are primarily used for the postoperative surveillance of patients.

Tissue based markers

Tissue based markers have been investigated as possible prognostic markers and predictors of response to treatment. Thymidilate synthase (TS) is an enzyme involved in the processing of the cells genetic material and has been studied as a marker that can predict how well a patient may respond to treatment with drugs such as 5-fluorouracil (5-FU) and 5-fluorodeoxyuridine. The transcription factor p53 has also been widely investigated as a biomarker that may predict the severity of cancer how it may respond to particular anticancer drug.

The K-ras oncogene is often associated with cancer as abnormalities in this gene have been found in many tumours. K-ras is involved in sending signals that can regulate how much cells grow or multiply. K-ras mutations are linked to approximately half of all CRCs and have been found to be important in the early stages of the disease. Studies have identified an association between K-ras mutations and poor disease outcome in patients with CRC.

Stool based markers

Faecal occult blood testing (FOBT) is the most commonly used screening test for CRC. There are two main types of FOBT, the guaiac test and the immunochemical test. Both tests detect proteins that may be indicators of colorectal cancer.

The advantages of FOBT for CRC are that the tests are simple and affordable, non-invasive, require very little patient preparation and have the capability of examining the entire colorectal tract. They do however have relatively low specificity and sensitivity for both benign (or precancerous adenomas) and malignant CRC.

Faecal DNA tests are used in screening for CRC on the basis that abnormal DNA is excreted in cells shed from cancerous colorectal lesions. Tests usually use a panel of DNA markers in order to identify mutant genes. DNA markers can provide a more accurate test than FOBT and there are no restrictions on diet or medication. The test is however quite laborious, expensive, also lacks specificity. Examples of stool based DNA markers include K-ras, APC (adenomatous polyposis coli) and p53.

Serum based markers

Serum-based markers of colorectal cancer are mainly used for monitoring patients following the surgical removal of malignant tumours. Patients are monitored regularly following surgery in order to detect any cancer recurrences or metastases. As up to 50% of patients develop recurrent disease or metastases following surgery, this is an important part of CRC management. CEA (carcinoembyonic antigen) was the first serum marker used in patients with CRC, and although it's the oldest, it still remains the most widely used. CEA is mainly used to monitor patients following surgery for primary CRC. A number of studies have shown that intensive monitoring after cancer surgery is associated with an improved outcome if regular CEA measurements were taken. Other serum-based tumour biomarkers used for CRC include markers called CA-19-9, TPA, TPS and TIMP-1

There are three main types of the mammalian ras genes: K-, H- and N-ras. Each of the ras genes makes proteins that are involved in relaying signals between different regions of the cell. These signals play important roles in a number of important biological functions including cell division and cell growth. As mentioned above, the K-ras oncogene is one of the most frequently altered in human cancers, with approximately 50% of CRCs containing mutant K-ras.

While many early investigations suggested that K-ras abnormalities were strong signs of serious disease and poor outcome for patients, more recent studies have found that this may not be correct in all cases. This meant that K-ras might not be very suitable as a prognostic marker.

While there is little evidence that K-ras mutations can be used as an effective screening tool or indicator of prognosis for CRC patients, recent research shows that the gene as a potential marker for prediction of response to specific therapies. Studies have shown that cases of CRC that are associated with mutations in K-ras will not respond well to particular treatments. For example, it has been shown that anticancer drugs such as panitumumab and cetuxamib are not effective in patients with K-ras abnormalities. While these studies do not specifically identify which therapies should be used in the treatment of K-ras associated CRC, they are able to help in the selection of an appropriate therapy.

Tumour Markers: Questions and Answers [online]. 2006 [cited 01/05/08]. Available from: http://www.cancer.gov/cancertopics/factsheet/Detection/tumor-markersDuffy MJ, van Dalen A, Haglund C, Hansson L, Holinski-Feder E, Klapdor R, Lamerz R, Peltomaki P, Sturgeon C, Topolcan O. Tumour markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines for clinical use. European Journal of Cancer. 2007;43:1348-1360.Duffy MJ, van Dalen A, Haglund C, Hansson L, Klapdor R, Lamerz R, Nilsson O, Sturgeon C, Topolcan O. European Journal of Cancer. Clinical utility of biochemical markers in colorectal cancer: European Group on Tumour Markers (EGTM) guidelines. 2003;39:718-727.Hassan C, Laghi A, Zullo A, Iafrate F, Morini S. Q&A on diagnosis, screening and follow-up of colorectal neoplasia. Digestive and Liver Disease. 2008;40:85-96.Ehrhardt, A., Ehrhardt, G. R. A., Guo, X., and Schrader, J. W. Ras and relatives—job sharing and networking keep an old family together. Exp. Hematol., 30: 1089 – 1106, 2002.Amado RG. Panitumumab (pmab) afficacy and patient-reported outcomes (PRO) in metastatic colorectal cancer (mCRC) patients (pts) with wild-type (WT) KRAS tumour status. Proceedings of the 2008 Gastrointestinal Cancers Symposium. 2008. ASCO.



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An Introduction to Obesity Treatments

Obesity is a chronic health problem that has become a worldwide epidemic. Recent estimates suggest that over 70% of Australian males and fover 50% of Australian females are overweight or obese. Furthermore, rates of obesity are increasing at alarming rates due to increasingly sedentary lifestyles combined with easy access to cheap, tasty high fat foods. Rates of obesity in Australia have doubled in the last two decades to make Australia one of the fattest developed nations in the world! Of particular concern are the rising rates of obesity in children. Now almost a quarter of Australian children are considered overweight or obese.

Obesity is a serious medical condition and can lead to considerable health consequences including heart disease, diabetes, high blood pressure, high cholesterol, obstructive sleep apnoea and arthritis. Therefore it is very important that you seek appropriate treatment.

Obesity is essentially a disorder of your metabolism and is caused by an imbalance between energy intake and energy expenditure over a long period of time. In other words, you are consuming more calories or energy than you are burning through exercise and daily activities.  Treatment of obesity therefore aims to restore this energy balance.

There are numerous different treatment options available which are described briefly below. Further information can be obtained by following the links to each of the treatments. In addition you can view the following video which provides an overview of the different management options.

Traditional methods for weight loss include reducing calorie intake, increasing physical activity, and behaviour therapy. However, increasing levels of obesity and associated medical conditions has heightened interest in both pharmacological (drug) and surgical treatments for weight loss. In most cases you will be treated with a combination of therapies. The aim of therapy is to try to restore your normal weight and reduce co-morbidities without causing significant side effects or morbidity. In general, the greater the degree of weight loss achieved, the greater health benefits gained. However, even small amounts of weight loss (of 5-10% of body weight) can significantly improve your health. Therefore you should set realistic goals and be satisfied with even small amounts of weight loss.

Lifestyle modification remains the mainstay of treatment for obesity and is an essential component of all forms of weight loss programs. Lifetime changes in eating and exercise behaviour may be the only treatment that produces long term and sustained reductions in weight. Lifestyle changes can include the following components:

Dietary changes

Overall the aim of diet therapies are to reduce caloric intake. There are countless different types of commercial diets available and it is important that you find one that is suited to you and safe. Diets can be broadly categorised into reduced energy, low energy or very low energy diets based on how much they restrict your daily caloric intake. If you are severely obese and have obvious weight related medical conditions, your doctor may suggest a more restrictive very low energy diet for a short period of time. Very low energy diets can produce rapid and marked weight loss by limiting your daily intake with set meal plans, pre-prepared meals or meal replacements. However, following cessation of the program much of this weight will be regained so it is important you try to adhere to other lifestyle changes in the long term. You may also need other treatments such as drugs and behavioural therapy to help you maintain the weight loss. For this reason less restrictive diets are sometimes preferred as you have more freedom and must learn how to select and prepare healthy meal options. The long-term outcomes of the different diets are therefore quite similar.

Meal replacement programs

Recently meal replacement programs have been developed that replace normal meals with prepared meal plans or meal supplements (such as vitamin- and mineral-fortified shakes, soups and bars). These diets operate on the principles of a low calorie diet and induce a mild state of ketosis to produce weight loss. These diets limit your carbohydrate intake so your body switches to other forms of energy, in particular the fat stores in your body. Burning your fat stores eventually leads to weight loss. (Please refer to our metabolism write up for further information). These diets are specially formulated so that they provide a safe level of carbohydrates and continue to supply essential vitamins and minerals.

Physical activity

Increased physical activity is often used in conjunction with diets to increase energy expenditure. Using exercise alone for weight loss is however often unsuccessful. You can try to increase your physical activity by walking places rather than driving and climbing the stairs rather than using the escalator or lift. You should aim to engage in 30 minutes of moderate intensity exercise (such as brisk walking) at least 3-5 days per week. You should try to do activities you enjoy as this will increase the likelihood you will adhere to them in the future. If you are very obese and have difficulty exercising you could try swimming, cycling or walking in water until your fitness level improves. You may be referred to a physiotherapist or exercise physiologists to help you devise an appropriate exercise program.

Behavioural therapy

Behaviour modification methods (such as Cognitive Behavioural Therapy (CBT)) can help improve treatment compliance and improve long-term weight loss. These treatments analyse your behaviours and habits that contribute to poor eating and lack of physical activity. You are encouraged to take responsibility for your weight loss and lifestyle changes. However, these methods however can be very time consuming and expensive.

Lifestyle changes are extremely challenging and you must be highly motivated to achieve success. Most patients will achieve weight loss by the above methods but long-term maintenance of weight loss remains an issue. Approximately 90% of people will regain their weight lost in supervised programs in the next few years. Lifestyle changes however remain the most hopeful treatments for long-term weight loss if you adhere to them correctly. If you are only mildly overweight (i.e. a body mass index (BMI) less than 30), lifestyle treatments alone are often sufficient to achieve weight loss. If however you are obese (BMI greater than 30) lifestyle treatments may be insufficient to achieve satisfactory weight loss and additional treatments such as pharmacotherapy may be necessary to maintain weight loss.

Several weight loss drugs have been marketed to date which work by either suppressing the appetite (e.g. Sibutramine - Reductil) or reducing absorption of fats (e.g. Orlistat - Xenical). These drugs should always be prescribed by a medical professional. These agents can cause weight loss of up to 10% of body weight. However, following cessation of treatment much of this weight will be regained. In addition many of these drugs can have nasty side effects (such as diarrhoea) and are still being investigated in clinical trials. Some older drugs such as fenfluramine have been withdrawn form the market due to bad side effects on the heart.

In order for medications to really work, they need to be combined with lifestyle modifications such as a low fat diet and regular exercise. Medications for weight loss should only be taken for short periods (up to 3 months) and always be used with caution as they have the potential for abuse. At present they are only indicated if you are morbidly obese, have significant co-morbidities or if you have failed other lifestyle treatments.

Surgical treatments tend to be considered if you are morbidly obese (defined as a BMI greater than 40). You must however consider the operative risks associated with each of the procedures. In most cases however, the benefits to your mental and physical health and appearance will outweigh the risks of surgery. If you are markedly obese with co-morbidities, surgery is considered the only available treatment that can reliably produce significant and sustained weight loss. Surgical procedures may help you lose up to 30-40kg of excess weight; however this is only achieved if you adhere to the required lifestyle changes.

A variety of surgical procedures have been used which can be broadly classified into restrictive and mal-absorptive procedures. The former includes procedures such as the old fashioned gastroplasty and laparoscopic gastric banding. The latter is the most common procedure performed in Australia because it is safe and reversible. By means of a silicone band around the stomach, gastric banding physically limits the amount of food that can be consumed before you become full. Mal-absorptive procedures (such as gastric bypass) typically involve bypassing a segment of small intestine to reduce the absorption of calories and hence lead to weight loss. Both methods produce similar long term results in terms of weight loss with patients losing approximately 50-70% of their excess weight. However, bypass operations may be more risky and can interfere with absorption of essential vitamins and minerals.

Whilst surgery is becoming increasingly common for the treatment of obesity, diet, exercise and long-term lifestyle changes remain the cornerstone of treatment. Surgery should only be considered if you are morbidly obese with significant weight related health problems. Successful treatment of obesity therefore requires an integrated and multidisciplinary approach with input from a variety of health professionals including dieticians, physicians, physiotherapists, surgeons and psychologists/psychiatrists.

In order to achieve long term weight loss you are required to make lifetime changes in your eating and exercise behaviours. In the future, the government may also be able to help treat the obesity epidemic by altering the environment we live in. Strategies and public health campaigns to produce an environment that supports healthy eating and physical activity throughout the community are needed.

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. About overweight and obesity [online]. Canberra, ACT: Australian Government Department of Health and Ageing; 2005 [cited 9 August 2007]. Available from: URL linkThe Obesity Society: Fast facts [online]. University of Sydney, NSW: Australasian Society for the Study of Obesity; 2005 [cited 9 August 2007]. Available from: URL linkFlier J, Maratos-Flier E. Chapter 242: Obesity. In: Braunwald E, Fauci AS, Kasper DL, et al (eds). Harrison's Principles of Internal Medicine (16th edition). New York: McGraw-Hill Publishing; 2006. [Book]Hamdorf J. Obesity Management [video]. Osborne Park, WA: Virtual Medical Centre; 2007 [cited 9 August 2007]. Available from: URL link Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Book]Clinical practice guidelines for the management of overweight and obesity in adults [online]. Canberra, ACT: Australian Government Department of Health and Ageing; 18 September 2003 [cited 9 August 2007]. Available from: URL linkProietto J, Baur L. Management of obesity. Med J Aust. 2004;180(9):474-80. [Abstract | Full text]Wilding J. Science, medicine, and the future: Obesity treatment, BMJ. 1997;315(7114):997-1000. [Abstract | Full text]

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Intrauterine Device (IUD)

An intrauterine device (IUD) is a small T shaped plastic device that is placed inside the uterus to prevent pregnancy. It is a long lasting and easily reversible method of contraception and is currently the second most commonly used method worldwide following sterilisation. The intrauterine device comes in two types, a copper IUD which is made of plastic and copper (Multiload 375 or Copper T 380), and a hormone releasing IUD (Mirena) which is made of plastic and contains levonorgestrel, a synthetic progesterone, that is released slowly into the uterus.

It is believed that the concept of IUDs first arose from the practice of putting stones in the uterus of camels in order to prevent pregnancies during long journeys. The first human intrauterine device was introduced in the 1960s and was made of inert plastic.  In the late 1960s it was discovered that adding copper to the plastic IUD made it a more effective contraceptive while also reducing the risk of bleeding. Thus, later versions increased the amount of copper in the devices as this helped to raise its contraceptive efficiency. These early IUDs required replacement every 2-3 years.

IUD popularity peaked in the late 1970s as women became concerned about the hormonal effects of oral contraceptives. However one particular IUD introduced in the 70s known as the Dalkon shield resulted in numerous infections of the uterus giving IUDs a bad reputation which resulted in a large decline in their use. These concerns still prevail today particularly in the western world where IUD use is the lowest. Therefore it is important be aware of the advantages and disadvantages of modern IUDs.

Overall, the IUD is one of the safest, and most tolerated methods of birth control available and its low failure rate (1-3%) makes it one the highest contraceptive efficiency of all contraceptive methods.

There are essentially two types of IUDs available; the copper IUD one and the newer hormonal levonorgestral releasing IUD (LNG, IUS or Mirena).

Copper IUD

The copper IUD consists of a polyethylene plastic frame with copper wire coiled around the stem and arms. It also has a plastic monofilament thread attached at the end of the stem which hangs from the cervix into the vagina. This thread aims to assist in the placement and removal of the IUD. The two main brands available in Australia are the copper T 380 and the multiload 375. The copper IUD has been approved for use for up to 10 years and can be effective for up to 12 years.

It can be inserted at any time during the menstrual cycle as long as pregnancy has been excluded. Further, it can be inserted immediately after abortion and immediately postpartum (within 48 hours of giving birth). The advantage of the copper IUD is that it is hormone-free providing a suitable option for women who experience problems with hormonal methods. Another role of the copper IUD is as an emergency contraceptive. It can prevent up to 99% of pregnancies when inserted within 5 days of unprotected sex.

Hormone releasing IUD/ Levonorgestrel IUD (LNG-IUD)

The more recently developed hormone releasing IUD has been available in the US since 2000 but was widely used in Europe since 1990. In Australia it was listed on the PBS for use as a contraceptive in 2003. This IUD is also made of plastic but contains within it a progestogen hormone called levonorgestrel. It is a 32mm long t shaped device with a monofilament thread attached to a loop on the bottom of the stem. Instead of copper it contains 52mg of levonorgestrel which is released at a rate of 20 micrograms per day. This IUD has more restrictions in its use and when it can be inserted and must be replaced after 5 years.

The hormone releasing IUD (Mirena) also has many other uses apart from its role as a contraceptive. This IUD is also useful alternative to hysterectomy for the treatment of menorrhagia, dysfunctional uterine bleeding and leiomyomas however, it cannot be used for emergency contraception.

Both types of IUDs work by preventing sperm from fertilising the ovum (egg). This is achieved by inhibition of sperm and/or ovum motility or viability. The early IUDs which were made of inert plastic worked by inducing a foreign body response in the uterus which resulted in the body's own immune system destroying the sperm. These early devices were characterized by a significant increase in menstrual blood loss.

Copper IUDs act by impairing sperm function and movement through the uterus, as copper is toxic to sperm. They do this by instigating a reaction which induces cellular and humoural inflammatory response to the presence of the copper within the cervical mucous, uterine cavity and fallopian tube. The copper and the inflammatory response are both spermicidal. They also cause changes in the lining of the uterus which prevents an egg attaching to the endometrium if it does happens to get fertilised. It is this irritation that leads to the increased bleeding and heavier periods. The more modern copper IUDs are associated with less blood loss and are also more efficacious.

Since the earlier devices, IUDs have become smaller, have incorporated larger amounts of copper and are more effective and acceptable to users. Depending on the type of copper IUD used, they generally last for about 5-10 years, although effectiveness up to 12 years has also been found. One of the main advantages of copper IUDs is that they can be removed any time and once removed, the likelihood of becoming pregnant returns to normal immediately.

The hormone releasing IUD (Mirena) works by releasing a progestogen hormone that causes thickening of the mucous of the cervix thereby inhibiting penetration of sperm. It also makes the lining of the uterus thinner and hence less likely for a pregnancy to occur. In contrast to the copper IUD, most women find that with the hormone releasing IUD their periods become shorter, lighter and less painful. This device lasts for 5 years and can also be removed quickly and easily. Hormonal side effects are rarely experienced because the amounts of progestogen released is so small and is predominantly localized to the uterus that very minimal amounts enter the blood stream. This IUD can also be used to treat painful or heavy periods and as an alternative hormone replacement therapy (HRT) treatment instead of progestogen tablets.

IUDs are currently the second most popular method of contraception around the world following sterilisation with 13% of women using IUDs. However, there is a great disparity between its use in developed versus developing countries. In western countries IUDs are used on average by 7.6% of women while in developing countries it is almost double at 15%. China is one of the largest users of IUDs with over a third of women using them as form of contraception. Scandanavian countries such as Finland and Norway are the highest users of IUDs among the developed nations.

Although they are highly effective and safe, IUDs are still not incorporated into many family planning programs. In western countries this is due to the past history and misconceptions IUDS have of causing pelvic infection and other complications such as bleeding, pain and ecotopic pregnancy. In Australia only 1.5% of women use IUDs as a method of birth control. The IUD is highly underutilized primarily due to the misconceptions of the risks associated with it such as infertility and pelvic infections and that the earlier copper IUDs caused longer and more painful and heavy periods. This adverse publicity has given IUDs a bad reputation and explains their limited use.

IUDs are one of the most effective forms of contraception. They are more than 99% effective at preventing pregnancy with less than one pregnancy occurring per 100 women using an IUD in the first year. Over ten years use this increases slightly to about 2 pregnancies for every 100 women. The Tcu-380A is effective for 12 years. Copper IUDs are effective for 10 years while Mirena is effective for 5 years. Once the IUD is removed, fertility returns to normal immediately.

The IUD is an effective, safe and reliable method of contraception. To determine whether an IUD is suitable for you, your doctor will take a detailed medical history. It is an ideal method of contraception for women who have already had a child and is not recommended for women who have never given birth because their smaller uterus makes the IUD difficult to insert and they also have high rates of expulsion.

IUD use is not suitable for women who:

May not be suitable for women who:

Have never had a child;Have more than one sexual partner or a partner who has other partners;Have a bleeding disorder;Vavular heart disease;Have a uterine abnormality such as fibroids;Painful or heavy periods;Unexplained vaginal bleeding;Moderate to severe anaemia;Previous ectopic pregnancy;Recent history of Pelvic Inflammatory Disease (PID);Uterine or cervix abnormality;Difficulties with vaginal examination and procedures.

Intrauterine devices can be inserted any time as long as pregnancy can be excluded, and once in place the IUD is effective immediately. The copper IUD can be fitted between the first day of period and ovulation. The LNG-IUD (Mirena) can be inserted between day 1 (first day of menstrual bleeding) to day 7 of the menstrual cycle or at other times provided there is no possibility of pregnancy.
It is recommended that women be screened for genital infections prior to insertion of IUD.

An IUD can also be inserted during a termination of pregnancy as long as no there is no evidence of infection. As an emergency contraceptive the copper IUD must be fitted within 120 hours following unprotected sex or within 5 days of the earliest date of ovulation (day 19 in women with regular 28 day cycles).

Copper IUDs can be inserted up to 48 hours post partum while the hormonal IUD can also be inserted safely in women four weeks post partum without any effect on breastfeeding.

Insertion of IUDs inside the uterus is carried out as a minor surgical procedure performed under local anaesthetic. A doctor or nurse will conduct an internal exmination to determine size and position of the uterus. A speculum is put into your vagina so that the doctor can see the cervix. After measuring the length of the uterus with a small metal rod the device is inserted. During insertion you may experience dizziness or cramping similar to period pain. It is recommended that women take some pain medication such as neurofen about an hour before insertion. Women who have not given birth before may find the IUD insertion more uncomfortable than those who have.

After an IUD is fitted into the uterus a women should avoid inserting anything into the vagina for 48 hours to reduce the risk of infection. That is, no tampons, intercourse, swimming or baths for two days after insertion.

You will need to see a doctor for check up after the next period then once every two years. In a very small percentage of women, the IUD may be expelled by the uterus. This usually occurs in the first month after insertion and is more common in women who have never given birth.
Always check the thread of your IUD as this can tell you if it is still in place. Pregnancies usually occur when using IUDs do not notice it has been expelled.

Women should never try to remove the IUD themselves as this can cause serious damage. A doctor can remove an IUD by pulling the string ends at a certain angle. This causes the IUD arms to fold up and the IUD to slide out through the cervix.

The IUD provides a long lasting, highly effective contraception and is easily reversible;Although it has a higher initial cost, there are no ongoing costs involved following insertion making it the most cost-effective contraceptive in the long term;Convenient;Rapidly reversible making it an ideal method for women who want long term birth control and want to retain fertility;Very effective and safe;It has no effect on breast milk or breast feeding;Does not interfere with sexual intercourse;Does not interfere with any medication;Once it is in place it can be forgotten and so there is no need to rely on the memory of the user;Requires minimal input by user and therefore minimising user error;Does not interfere with normal hormonal cycles;Suitable for women who are unable to take the pill;Is as effective as sterilisation, injectable contraception and sub-dermal implant;1-2% failure rate;Hormone releasing IUD (Mirena) is suitable for women who have heavy menstrual bleeding;Private and discreet method;There is some evidence to suggest that the copper IUD may reduce the risk of endometrial cancer. This may also be the case for levonorgestrel IUD;The hormonal IUD can also be used as an alternative to surgical or oral hormonal treatments for women with heavy menstrual bleeding and by menopausal women taking estrogen who cannot tolerate other forms of progestogen.Must be inserted and removed by a trained medical professional;They can produce longer, heavier and sometimes painful menstrual period especially during the first 3-6 months of use. Spotting and light bleeding in between periods may also be experienced, however this is normal and reduces over time;Unpredictable bleeding also common with the levonorgestrel system which can last about 4 months of use. As duration of use increases there is reduction in menstrual flow. Around 20% of women experience amenorrhea (absence of menstrual bleeding) in the first year.Other side effects noted occasionally with levonorgesterel IUD include lower abdominal pain, complexion changes, back pain, breast tenderness, headache, mood changes and nausea although these decline with time and present in less than 3% of patients. As with other progestin only methods benign follicular cysts are common occurring in 8-12% of users. Most cysts resolve spontaneously and do not require any medical treatment;Some women may experience hormonal side effects such as mood changes or breast tenderness;Occasionally they can be expelled;Women using IUDs are at an increased risk of developing pelvic inflammatory disease (PID) within the first three weeks following insertion (which may cause infertility);In a small number of cases an IUD may perforate the wall of the uterus. This is usually the result of improper insertion.

Pelvic infection

Development of PID is very rare despite earlier beliefs that they occur commonly in women using IUDs. The risk of PID is highest within the first 3 weeks following insertion, while after that the risk is minimal. Women with cervical infections caused by chlamydia or gonorrhoea at the time of insertion have a 3-5% chance of developing an infection in the first 20 days. Screening for vaginal and cervical infections should be carried out prior to insertion to reduce risk of infection being passed to the uterus.

PID among IUD users is also strongly related to the insertion process. Provision of skillful technique in aseptic settings for IUD insertion is critical for the prevention of PID. Pelvic infection may cause damage to the fallopian tubes which can lead to infertility and can also cause chronic pelvic pain.

Symptoms of infection to watch out for include:

Pain or tenderness in lower abdomen;Unusual bleeding from vagina;Fever or chills;Discharge from vagina;Pain during intercourse;Burning sensation when passing urine.
 

Pregnancy

Less than 1 out of 100 women who have been using an IUD for one year will fall pregnant. If you become pregnant see your doctor immediately to have the IUD removed. If the device is left in there is a high risk of miscarriage later in the pregnancy.

Perforation and Expulsion

In a small no of cases, about 1/1000 the IUD may be pushed through the wall of the uterus and require removal by operation. Perforation of uterus occurs most commonly if an IUD is inserted in the first 6 months after giving birth and can be increased as a result of provider inexperience.

Expulsion rates are between 2-3% for the copper IUD and 3-4% for the LNG intrauterine system. Expulsions usually occur in the first 3 months after insertion and are more likely to occur when IUDs are inserted in women who have not had a term pregnancy.

Women should check strings for changes in length and feel for the presence of the IUD stem. Around 4 weeks post-insertion a follow up visit to your doctor should be made. In women with the LNG-IUD resumption of normal periods may indicate that the IUD has been expelled.

Miscarriage

Miscarriage and premature birth can occur in the rare occurrence that a woman becomes pregnant whilst an IUD is in place.

For more information on different types of contraception, female anatomy and related health issues, see Contraception.

Family Planning W.A Sexual Health Services. Intra-uterine devices. URL: http://www.fpwa.org.au/healthinformation/informationsheets/iud/ (Accessed 12 July 2008)d’Arcangues C. Worldwide use of intrauterine devices for contraception. Contraception 2007;  75 : S2–S7.WHO. Progress newsletter No. 60 .The intrauterine device (IUD)-worth singing about http://www.who.int/reproductive-health/hrp/progress/60/news60.html Morgan KW. The Intrauterine Device: Rethinking Old Paradigms. Journal of Midwifery & Women's Health 2006 51; 6: 465-472.Farmer L and S Everett. Non-hormonal contraception. Obstetrics Gynecology and Reproductive Medicine 2007 18(2): 32-38.Bilian X. Intrauterine devices. Best Practice & Research Clinical Obstetrics and Gynecology 2002; 16(2): 155-168.World Health Organisation, John Hopkins School of Public Health and US Agency for International Development. 2007. Family planning:  a global handbook for providers. Chapter 9: Copper bearing intrauterine device Available from: http://www.infoforhealth.org/globalhandbook/handbook.pdfFamily Planning NSW. May 2003. A new kind of intrauterine device. http://www.fpahealth.org.au/news/20030501_mirena.htmlMazza D. Take a fresh look at IUDs: things have changed. Australian Family Physician 2002; 31(10): 903-907.Thonneau PF and TE Almont. Contraceptive efficacy of intrauterine devices. American Journal of Obstetrics & Gynecology 2008; 248-252

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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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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

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Morbid obese women on the rise

A Deakin University study has found that the rate of morbid obesity in women increased by almost 70 per cent over a 10 year period.

Researchers with Deakin’s School of Medicine monitored the height and weight of 1,494 women in 1993-1997 and 1,076 in 2004-2008 to determine any shift in body mass index (BMI). They found the average BMI increased from 26 to 27.1, while the rate of morbid obesity rose from 2.5 per cent to 4.2 per cent of the women in the study.

With obesity continuing to be one of the biggest health issues facing Australians, Deakin’s Associate Professor Julie Pasco said it was important that we monitor not only the growing rates of obesity generally, but also keep a close eye on the rates of morbid obesity.

“We tend to monitor obesity based on the proportion of the population whose BMI exceeds 30. What this fails to measure is the number of people who are morbidly obese, that is those whose BMI in greater than 40,” Associate Professor Pasco explained.

“It is important that we monitor the growing number of people who are morbidly obese as the adverse health risks amplify as the level of obesity increases.

“Obesity-related health expenditure exceeded $8billion in 2008 and we are seeing service providers increasingly having to invest in equipment designed to accommodate the morbidly obese. It is therefore not unreasonable to expect that with rates of morbid obesity on the rise, the direct and indirect costs will also increase.”

For this study the researchers set out to determine how the prevalence of morbid obesity, as indicated by a BMI greater than 40, had changed over a decade among women living in south-eastern Australia.

The study looked at the BMI of women involved in the Geelong Osteoporosis Study (see more about this study below), during two time periods, ten years apart. Height and weight measurements for 1,494 women (aged 20—94 years) during 1993—1997 and for 1, 076 women (aged 20—93 years) during 2004—2008, to see if there had been any changes in BMI.

The researchers found that average BMI increased from 26 in 1993-7 to 27.1 in 2004-8. The prevalence of morbid obesity increased from 2.5 per cent to 4.2 per cent of the women in the study. The increase in BMI and prevalence of morbid obesity were seen for all ages and across the socioeconomic spectrum.

“The results of our study highlight the growing problem of morbid obesity,” Associate Professor Pasco said.

“The challenge continues to be to identify and implement effective strategies for the whole community that will shift the scales in the direction of lowering the rates of obesity and most particularly morbid obesity.”

Source: Deakin University Australia

Article Date: 23/4/2013

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Consumers largely underestimating calorie content of fast foodnbsp;

People eating at fast food restaurants largely underestimate the calorie content of meals, especially large ones, according to a paper published on bmj.com.

From 2006 to 2010 many American states and cities passed laws requiring chain restaurants to print calorie content on menus. The US Patient Protection and Affordable Care Act of 2010 included a provision that will require all restaurant chains with more than 20 US Sites to print calorie content on menus.

Previous research has shown that adults and children underestimate calorie content often by large amounts. However, these studies did not monitor consumer choices at restaurants or focused on a narrow range of fast food restaurants or individuals.

Researchers therefore carried out a large cross sectional study of repeated visits to fast food restaurant chains in 89 restaurants across the New England region of America: McDonald’s, Burger King, Wendy’s, KFC, Subway and Dunkin’ Donuts. At the time of data collection, none of the chains routinely printed calorie content on menus.

Researchers enrolled a diverse group of adults (>18 years old), adolescents (aged 11-20) and school age children (3-15 years old). They collected receipts from participants to calculate the calorie content of their meals, and they administered a short questionnaire which included a question asking participants to estimate the calorie content of their meal. Parents provided answers for the school age children. The final sample size was 1877 adults, 1178 adolescents and 330 school age children.

Among adult participants, 65% were either overweight or obese, as were 34% of adolescents and 57% of school age children. Less than one quarter of participants reported noticing calorie information in the restaurants, and less than 5% reported using it to help them choose their meal.

The mean calorie content of meals was 836 for adults, 756 for adolescents and 733 for children. On average, adults, adolescents, and parents of school-age children underestimated calorie content by 175 calories, 259 calories and 175 calories, respectively. Two thirds of all participants underestimated the calorie content of their meals with approximately one quarter underestimating the calorie content by at least 500 calories. Participants consuming high calorie meals underestimated by a greater amount than small calorie meals. Underestimation was greater among Subway diners than at any other chain. Adults and adolescents eating at Subway underestimated by 20% and 25% more than those at McDonald’s.

(Source: BMJ)

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.For more information on nutrition, including information on types and composition of food, nutrition and people, conditions related to nutrition, and diets and recipes, as well as some useful videos and tools, see Nutrition. 
Article Date: 24/6/2013

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7 Breakfasts Under 500 Calories

At only 70 calories, an egg is a great way to get lean protein into breakfasts under 500 calories.

Image: Clipart.com Listen up breakfast skippers -- it's time to start eating that all-important morning meal. Get your day off to a great start with these ideas for breakfasts under 500 calories.

PB and Apple
Natural peanut butter, 1 Tbsp.
Whole-wheat English muffin
Apple, 1
1% milk, 1 c.
416 calories

Waffle and Yogurt
Whole-grain waffles, 2
Light syrup, 1 Tbsp.
Light vanilla yogurt, 6 oz.
Banana, 1, small
414 calories

Starbucks
Fruit, Yogurt & Granola Parfait
Nonfat cappuccino, tall
400 calories

Jamba Juice
Bright Eyed & Blueberry yogurt blend smoothie
380 calories

Oatmeal with Cherries
Oatmeal, 1 c.
Dried tart cherries, ¼ c.
Brown sugar, 1 tsp.
Cinammon, dash
1% milk, 1 c.
371 calories

McDonald’s
Fruit and yogurt parfait
Fruit and walnut salad, snack size
370 calories

Bagel Breakfast
Whole-wheat mini bagels, 2
Whipped cream cheese, 2 tsp.
Egg, 1, hard-boiled
Orange, 1
369 calories

Brown Betty for Breakfast
Apple, cored and sliced, microwaved for three minutes and topped with:
Raisins, 1 Tbsp.
Almonds, chopped, 1 Tbsp.
Walnuts, chopped, 1 Tbsp.
Light vanilla yogurt, 8 oz.
362 calories

Did you know? You can plan your own calorie-controlled breakfasts using the simple, free tools at About.com's Calorie Count.

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Xenical vs Alli: What's the Difference Between...

Choosing to take a weight loss medication is a serious decision. When an over-the counter version of Xenical (orlistat) became available for dieters as Alli (orlistat), access to the drug became easier. But just because the drug is easier to get doesn’t mean that you should necessarily take it.

Find out more about this diet medication before you make a decision about which weight loss treatment is right for you. Also, be sure to talk to your health care provider as new medications for weight loss, Belviq and Qsymia have recently become available.

What is Xenical?

Xenical is the prescription dose (120 mg) of orlistat. This type of medication is called a lipase inhibitor because it helps your body to absorb less fat from the food that you eat. The undigested fat is removed from the body in your stool.

Xenical is designed to be used along with a low-fat, low-calorie diet. The higher, prescription dose of the drug is often used for patients who have weight-related illnesses like type 2 diabetes, high blood pressure or heart disease. Xenical can also be used for people who lost weight and want to prevent weight regain.

What the Difference Between Alli and Xenical?

You’ll see boxes of Alli displayed in pharmacies, drug stores and other locations. Alli is a lower dose (60 mg) of the same medication, orlistat, that is in Xenical. Alli works the same way that Xenical works by blocking the absorption of fat. Alli is also meant to be used in partnership with a low-calorie, low-fat diet.

What Are Side Effects of Taking Orlistat?

For most people, the most noticeable side effect of Xenical or Alli is the change in their stool and bowel habits. Because fat is removed through the stool, bowel movements can become loose and oily. If you eat too much fat while taking the medication, the side effects can become more severe and can interfere with typical daily activities.

Because fat content is important, dieters taking the medication need to be especially careful about dividing their fat and calorie intake evenly throughout the day. No single food that you eat should contain more than 30% of the total calories from fat. In addition, since food and nutrient absorption is affected by this medication, the FDA recommends that users take a multivitamin while on the diet drug.

Other side effects may include hives, itching or stomach pain. Talk to your doctor about your medical history to determine which side effects may impact you.

How Much Does Orlistat Cost?

A starter pack of Alli, that contains 60 pills costs about $40 at your local drug store. If you compare prices you may also find 120-pill bottles for slightly more. A 30-pill prescription of Xenical may cost significantly more, ranging from $150-160. Patients are usually directed to take one pill with each main meal to help them lose weight.

In some cases, insurance providers may pay for a weight loss medication if your weight is the cause of a related illness. But all policies vary, so be sure to check with your own insurance carrier to find out if the drug is covered for you.

Should I Take Alli or Xenical?

Orlistat has been shown to be effective at helping some people lose weight and keep it off. But significant lifestyle modifications must be made, or the consequences can be uncomfortable and embarrassing. Think about the changes you are willing to make before talking to your health care provider. Then discuss further potential side effects and medical considerations with your doctor before making a final decision.

Sources:

Medline Plus. Orlistat. National Institutes of Health. Accessed: February 19, 2013. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601244.html

Kopelman P, Groot Gde H, Rissanen A, Rossner S, Toubro S, Palmer R, Hallam R, Bryson A, Hickling RI."Weight loss, HbA1c reduction, and tolerability of cetilistat in a randomized, placebo-controlled phase 2 trial in obese diabetics: comparison with orlistat (Xenical)" Obesity January 2010 .

Torgerson JS, Hauptman J, Boldrin MN, Sjöström L. "XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients." Diabetes Care March 2004 .

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5 Biggest Weight Loss Workout Mistakes

Sometimes, exercisers with the best intentions lose the least amount of weight. What's worse is that they often see their friends slim down just weeks after starting a new workout program. It can be frustrating and confusing.

So what makes one weight loss workout plan effective and another one fail? There could be a number of factors involved. But in many cases, the cause can be traced to one of these blunders. If you've been struggling to shed a few pounds and your exercise plan isn't yielding any results, see if you are making one of these common workout mistakes.

Doing the same workout day after day. It's not a bad thing to exercise every day, and it's not necessarily a bad to do the same workout everyday to maintain heart health. But if you want to lose weight, repeating the same workout mode, intensity, or duration day after day won't work. Why? Your body adjusts to the daily workload and you hit a dreaded plateau.

Fix this blunder: Develop a workout schedule that involves different activities, different intensity levels and different session lengths. For example, if you normally do 40 minutes of walking, keep that activity on your workout schedule two or three days per week. But as an added challenge, walk for 60-75 minutes one day during the week. On the remaining days, mix in a cycling workout and a day of walk/run intervals. If you are healthy enough for vigorous activity, add HIIT workouts, which have been shown to be effective at burning fat.

Compensating by eating more. When you add exercise to your daily routine, you are likely to become more hungry than usual and want to eat more. Dealing with that hunger can be an uphill battle, because there is often a little voice inside your head that says, "I can eat whatever I want because I exercised today."

That rationale makes sense. But if you are trying to lose weight with exercise, you need to achieve a calorie deficit at the end of the day. If you satisfy your post-exercise hunger with high calorie foods or with too much food, you'll end up replacing all of the calories you burned. Then, your calorie deficit and your potential weight loss disappears.

Fix this blunder: Before you start or change your workout program, monitor your calorie intake or get your total daily expenditure evaluated by a professional such as a personal trainer or registered dietitian. When you begin your exercise program make sure that you only increase your food intake so that you still maintain a calorie deficit at the end of the day. A deficit of 500 calories per day or 3500 calories per week should result in a one pound weight loss each week.

Lopsided training. A good fitness schedule includes cardiovascular (aerobic) training, strength training and flexibility work (stretching). This balanced workout program ensures that your body stays healthy and fit. But each of these three components also has weight loss benefits . If you skimp on one or two of them, you'll end up with a lopsided workout program and you won't reap the full weight loss rewards of your exercise sessions.

Fix this blunder: Most weight loss workout programs include aerobic activity so it's unlikely that you'll have to add cardio. But you should also make sure that you do 2-3 days of strength training, as well. If time is an issue, do a circuit workout and complete short intervals of strength exercises between 5-10 minute bursts of cardio. Then, finish every workout with 10-15 minutes of stretching so that you maintain healthy joints and an injury-free body.

Decreasing non-exercise physical activity. It's great if you go to the gym every day and complete a killer workout - unless the payoff is that you spend the rest of the day on the couch. If you compensate for your workout by decreasing the amount of non-exercise physical activity that you do during the day, your total daily caloric expenditure may end up being the same as if you hadn't gone to the gym at all.

Fix this blunder: Non-exercise activity thermogenesis (NEAT) should account for a significant percentage of the calories that you burn each day. When your NEAT decreases, your metabolism slows, you don't burn as many calories each day and you don't lose weight.

If your workouts drain you to the point of exhaustion, it may be time to re-evaluate your program. Make sure that your high intensity workouts are relatively short and that you include some easy recovery days during the week to give your body a chance to recuperate and rebuild.

Also, keep in mind that it's not always the workout that is causing the lack of NEAT. Sometimes the choice to lay on the couch or sit in a chair all day is made out of habit rather than genuine fatigue. Try to skip the afternoon nap and go for an energizing walk instead. Stuck at work? See if you can use a standing workstation or take short breaks to get out of your chair and move around.

Using supplements/sports drinks. Do you refuel during your workout with sports drinks or bars? Do you grab a high calorie, high sugar supplement drink or bar after the workout is complete? If so, you're probably erasing the calorie deficit that you just earned. In some cases, athletes need sports drinks, but for most exercisers water is the best choice for hydration. And your post workout diet supplement is probably not helping either. There are hundreds of products on the market and, sadly, most of them do nothing but make empty promises and drain your wallet.

Fix this blunder: Instead of investing in bars, drinks, or supplements, invest in a visit with an accredited sports nutritionist or registered dietitian. They will help you to make sure you are getting enough of the right kind of calories to recover adequately from your workout. They can also help you to decode and perhaps debunk the claims of the supplement that you want to use.

Regardless of your size, exercise should always be a part of your daily routine. You'll experience countless health benefits if you participate in physical activity every day. But if you are engaging in a workout program specifically to lose weight you need to be especially careful to optimize your plan to meet that goal. Make just a few small adjustments, avoid these common mistakes, and you're more likely to see the results on the scale.

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What You Need to Know About The 90/10 Diet

The 90/10 diet can be found in a book written by nutritionist Joy Bauer called The 90/10 Weight-Loss Plan: A Scientifically Designed Balance of Healthy Foods and Fun Foods. The book can be purchased for approximately $18 online or at other book retailers. There are no required foods or expensive recipes necessary to follow this plan. The basic premise of the 90/10 plan is that you eat a healthful diet 90 percent of the time, and enjoy what Bauer calls “fun foods” 10 percent of the time. Bauer’s theory is that by allowing yourself your favorite foods some of the time, you will feel less deprived and more able to stick with the healthy changes the rest of the time. The book outlines diets for three different daily calorie levels -- 1,200, 1,400, and 1,600. There are two weeks worth of meals outlined in this plan. Once you are accustomed to practicing portion control, monitoring your calories, and planning your fun foods, you will also be able to customize your meals to your own preferences as long as you stay within your caloric allowance.

During my trial of the diet, a typical day’s menu was oatmeal with fruit for breakfast, a tuna melt with low-fat cheese for lunch, an apple for snack, chicken and vegetables with brown rice for dinner, and chocolate chip cookies as my fun food.

What I liked about this diet was being able to continue to allow myself a controlled portion of nearly any food as long as I followed the guidelines the rest of the time. I was able to enjoy “old favorites” that other diets forbid. (So many other diets ask you to go "cold turkey" on favorite foods, especially during the first week or so, or during the first “phases” of the plan. I often find those diets too difficult to stick to for any period of time, but did not have that problem with this plan.) The only "catch" to this plan is that you have to work the fun foods into your daily calorie allotment; I was on the 1,600 calorie plan, so those 260 calories from my cookies left me 1,340 calories to utilize for the rest of the day. Since my calorie allotment was on the higher end, I did not often have a problem working in everything I needed to round out my day’s food intake.

However, I can see that this may be challenging to someone on the lower end of the spectrum, at 1,200 calories, especially if you are not accustomed to monitoring your food or calorie intake. For example, let’s say you plan tomorrow morning for a 300 calorie treat as your "fun food" and then you decide to have a soda with it, too. If you only have 750 calories remaining for your entire day after your treat, you have used too many calories and did not allow sufficient calories for other more nutritious, filling choices. That’s why planning is so important so you “spend” your calories the best way possible.

During my 30-day trial of this plan, I lost just under eight pounds. I found this plan to be effective and reasonably easy to follow.

You can easily track your daily calories and search for foods’ caloric content at a free Web site such as Calorie Count Plus. I searched their food database on a daily basis to find out the calorie counts of foods that I did not have a nutrition label for.

In my opinion, the inclusion of “fun foods” makes this diet ideal for people who have found other diets to be too restrictive. I think most people would be able to stick to this plan. If you are allowed 1,600 or 1,800 calories you will undoubtedly have enough calories to eat plenty of the healthy foods recommended on the plan and still have your “fun foods”.

Maintenance may be a little more challenging for some after following this plan; you will need to continue being conscious of your food choices and caloric intake. Once you’re at your goal weight, you will need fewer calories than you were previously accustomed to eating before you lost weight, so it is important that you continue monitoring you caloric intake (You can do so easily by tracking your food intake with Calorie Count Plus.). Remember, if you return to consuming more calories than you need -- after this or any other diet -- you will begin to gain weight again.

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