Joint pain (Arthralgia)

Joint pain (arthralgia) is an extremely common symptom which most people will experience at some point in their lives. Joint pain has many different causes, ranging from local injury to the joint to whole-body illnesses which include joint pain as one part of the disease.

Joint pain can be caused by a number of different mechanisms. Joint pain may be caused by damage to a structure within the joint itself (such as the joint surface) or by damage to a structure near the joint, such as a tendon. Joint pain may be due to local damage within the joint, or may be just one part of a systemic (whole-body) disease process. One of the most important distinctions to make is whether joint pain is caused by inflammation of the joint (an immune response involving swelling, redness and warmth) or whether there is joint pain without inflammation.

Inflammatory joint disorders are characterised by:

Swelling, redness, warmth and pain; Systemic (whole-body) symptoms, such as fatigue, fever or weight loss; Marked morning stiffness, or stiffness that worsens with long periods of rest and inactivity, and is improved with movement or anti-inflammatory drugs. Common inflammatory joint disorders include: Rheumatoid arthritis; Seronegative spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis; Infectious arthritis: bacterial (septic arthritis), viral (e.g. Ross River Virus) or other; Reactive (post-infectious) arthritis, e.g. Reiter's syndrome; Inflammatory osteoarthritis; Crystal arthropathies: e.g. gout or pseudogout; Systemic rheumatic illnesses causing arthritis: e.g. systemic lupus erythematosus, Behcet's disease; Other systemic illnesses, e.g. sarcoidosis, acromegaly.

Non-inflammatory joint disorders are characterised by:

Pain without swelling or warmth; Absence of systemic symptoms such as fever or weight loss; Minimal morning stiffness which is intermittent, lasts less than 60 minutes; and Stiffness which is made worse, not improved, by activity. Common non-inflammatory joint disorders include: Trauma, e.g. tears to muscles, tendons or cartilage around the joint; or Osteoarthritis. Some people may also experience joint pain as a symptom of depression.

Any unexplained joint pain which is causing you trouble should be investigated. In particular, there are certain 'warning signs' which need quick review by a healthcare professional. These include:

Joint pain with fever, not caused by the flu; Involuntary weight loss; or Unexplained joint pain which lasts longer than 3 days, or is severe.

Your healthcare professional will try to determine the likely cause of your joint pain by asking you a number of questions.

What does the pain feel like? Is it deep, on the surface, in one spot or all over? Which joints are painful? Some types of arthritis have particular patterns of joint involvement, which may help in making a diagnosis. Are there any associated joint symptoms? For example, does the joint ever feel like it is 'giving way' under you, or 'sticking'? Have you ever injured or had surgery to the joint? How long has the pain been present for? Pain which develops quickly is likely to be due to a different cause than pain which has been present for weeks. Do you feel generally well, or is the joint pain associated with tiredness, weight loss or fever? Has anyone else in your family had problems with joints? Family members with gout, rheumatoid arthritis, or other types of arthritis such as psoriatic arthritis are particularly important, as these conditions may be inherited. How is the joint pain affecting your life and your ability to manage daily tasks?

Your healthcare professional will then need to examine the joint(s) which are involved. This usually involves a careful inspection of the joint to look for swelling, redness, scars or deformity, followed by assessment of the range of movement that is possible. Special manoeuvres may also be needed to identify particular causes of joint pain.

If the likely cause of your joint pain has not been established after asking you questions and examining the joint, your healthcare professional may wish to arrange some tests.

Blood tests

Full blood picture: a raised white cell count may indicate inflammation or infection; ESR or CRP: raised levels of these tests may suggest an inflammatory cause for the joint pain; Uric acid: gouty arthritis is caused by excess levels of uric acid in the blood. In an acute attack, however, the level of uric acid in the blood is not always raised. Viral serology: if your health professional suspects that your arthritis may be caused by a virus such as Epstein Barr virus, parvovirus B19, hepatitis B or hepatitis C, he or she may order tests to look for these viruses in the blood; Special blood tests may also be done for some immune proteins such as rheumatoid factor or antinuclear antibodies (ANA). Presence of these proteins in the blood may be associated with auto-immune diseases such as rheumatoid arthritis or systemic lupus erythematosus. However, they may also be present in normal people.

Joint fluid analysis

This involves using a needle to take a sample of the fluid within a swollen joint. The fluid can be examined to look for presence of inflammation, bacteria, or crystals associated with diseases such as gout. Your health professional may order joint fluid analysis if he or she particularly suspects that you have a bacterial infection or crystals (gout or pseudogout) in the joint.

Imaging

Plain x-rays can be useful in the diagnosis of some joint disorders such as trauma or osteoarthritis. In inflammatory joint disorders, it may take much longer for the joint changes to be seen on plain x-ray. In these cases your health professional may arrange for you to have an ultrasound or MRI scan of the joint.

The treatment for your joint pain will depend on the cause. The best sort of analgesia (pain relief) for your joint pain is also partially dependent on the cause - inflammatory joint pain is likely to respond well to corticosteroids or non-steroidal anti-inflammatory drugs such as ibuprofen, whereas non-inflammatory joint pain is better managed with paracetamol. Other techniques to manage joint pain include physiotherapy.

It is not possible to prevent the development of many diseases which cause joint pain, including rheumatoid arthritis and other auto-immune causes of joint pain. Osteoarthritis is a common cause of joint pain which is thought to result from 'wear and tear' on a joint over a number of years. Some simple lifestyle changes can help reduce this wear and tear, including weight loss, wearing comfortable shoes, or learning safe techniques for lifting, and these may reduce the likelihood of developing osteoarthritis later in life.

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 16th Edition. McGraw-Hill. 2005. Pinals, RS. 'Evaluation of the adult with polyarticular pain' [online]. UpToDate.com. 2006. Available at URL: http://www.uptodate.com (last accessed: 2/9/06) Solomon L, Warwick DJ, Nayagam S. Apley's Concise System of Orthopaedics and Fractures. London, Hodder Headline Group, 2005.

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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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GORD: Managing the Symptoms

Gastro-oesophageal reflux disease (GORD or GERD) is a common and chronic gastrointestinal disorder. Nearly 80% of the population will experience symptoms of reflux at some stage in their lives. GORD is associated with prolonged exposure of the lower oesophageal mucosa to gastric contents, leading to symptoms of heartburn, regurgitation (feeling like the stomach contents are coming back up) and waterbrash (excess saliva in the mouth). Symptoms are often made worse by lying flat, are related to meals (especially fatty foods), and may be worsened by hot liquids or alcohol.

The severity of your symptoms does not always correspond to how badly your oesophagus is scarred or damaged. It is therefore important that you see a doctor so your condition can be properly investigated. GORD often requires life-long and regular use of anti-reflux therapies.

Treatment tends to pursue three main aims:

Healing the damage to the oesophagus;Preventing complications such as Barrett's oesophagus, strictures (narrowing), and oesophageal cancer; andAlleviating your symptoms and improving your quality of life.

In general, a step-wise approach is used in the management of GORD symptoms. Usually you will be trialled on simple lifestyle measures, and then slowly have more aggressive treatments added if your symptoms don't improve.

Before starting anti-reflux therapies, it is important that other causes of similar symptoms have been excluded. In particular, cardiac chest pain from angina can present quite similarly to reflux. Failure to treat an underlying heart problem could have serious consequences.

If your GORD is mild it is likely that you will respond satisfactorily with simple lifestyle changes and over-the-counter antacids. In many cases, people are able to control their own symptoms and do not necessarily need to see a doctor. It is quite common for people to go to the doctor only when their symptoms become so severe that they interfere with daily functioning. However, it is important that you realise that reflux symptoms may be a marker of more serious underlying conditions. GORD can cause nasty complications, including oesophageal cancer, which need to be monitored throughout your treatment. In general, the longer you have symptoms of reflux, the greater risk you have for additional complications.

There are a number of symptoms that may suggest more serious problems and require urgent investigation. These are referred to as "alarm symptoms". It is important to see your doctor so they can conduct further investigations if you notice any:

Difficulty swallowing; Pain when swallowing;Blood in your vomit;Dark, tarry stools (melaena); Weight loss; Anaemia: You may notice you are more pale (particularly in the skin creases and conjunctiva of the eyes), or fatigue more easily.

Lifestyle changes

Lifestyle changes that can help manage GORD symptoms include:

Losing weight (if you are overweight); Elevating your head in bed; Avoiding lying down or sleeping for 3 hours after a meal; Reducing alcohol consumption; Quitting smoking;Avoiding fatty foods and foods that typically trigger symptoms, such as: Avoiding medications that trigger your reflux symptoms (discuss with your doctor).

Although some of these lifestyle changes can be difficult to achieve, they are excellent therapies as they are low cost and have few side effects. These measures are recommended for virtually everyone with GORD and should be continued even when using other therapies.

Over-the-counter and antacid therapy

Depending on the severity of your symptoms, your doctor may prescribe medications or recommend over-the-counter (OTC) preparations. These may be needed for a short time while you have symptoms or on a long-term basis, depending on the features of your symptoms.

Many people self-treat themselves with over-the-counter medications. These include simple antacids and alginates. Antacids work by neutralising the gastric acid so that it is no longer damaging to the oesophagus. Alginates, on the other hand, work by forming a thick gel coating on the surface of the stomach contents to stop them from refluxing. Lots of studies have confirmed these agents produce rapid symptom relief, but their effects only last for a short time so they need to be taken frequently. Furthermore, these treatments do not change the underlying amount of acid secretion or prevent complications, so they may be a more temporary measure.

Histamine-2 receptor antagonists (H2RA) such as cimetidine (e.g. Tagamet) and ranitidine (e.g. Zantac) are also available over-the-counter. These agents have been proven in clinical trials to reduce gastric acid levels. The different drugs of this class vary slightly in their potencies and onset of action. H2RAs can be taken before activities known to trigger reflux, such as eating heavy meals or exercising, to prevent the onset of symptoms.

Antisecretory medications

Suppressing the amount of acid produced in the stomach has been shown to be the most successful treatment for GORD. Proton pump inhibitors (PPIs) work by inhibiting a special enzyme on the surface of acid-producing cells in the stomach. This blocks acid production and reduces the overall level of acid in the stomach. PPIs are considered the most effective medications for symptom relief and may be used in nearly all cases, except perhaps if your disease is very mild. PPI medications are available via a prescription from your doctor.

PPI drugs available in Australia include:

Pantoprazole (Somac); Rabeprazole (Pariet); Omeprazole (Losec);Esomeprazole (Nexium);Lansoprazole (Zoton).

Clinical trials have confirmed that these medications treat symptoms such as heartburn, acid regurgitation and painful swallowing. They are effective in approximately 80% of patients. PPIs are able treat symptoms and heal oesophageal damage more rapidly than any other therapy available. There is still debate over which PPI is the most effective, so different doctors may prescribe different medications based on their experience.

If you have severe reflux, you will probably be treated long-term with a PPI medication. Often the maintenance dose is smaller than that prescribed in an acute period of symptoms. If you are on long-term treatment and suddenly stop taking your medication, it is likely you will experience a recurrence or relapse in your symptoms. Even with adequate therapy, it is not uncommon to have some occasional flares of symptoms. PPI medications should be taken before meals, as prescribed by your doctor. Usually the daily dose will be split into a morning and evening dose.

PPI medications are generally well tolerated and tend to have few side effects. However, the following adverse effects may occasionally occur (in approximately 5 out of 100 patients taking these medications):

Most side effects are only mild and temporary during the start of treatment. A more serious side effect of vitamin B12 deficiency has been reported, but this is exceedingly rare. Overall, PPIs are excellent medications in terms of efficacy and minimal side effects. Perhaps the only factor limiting more widespread use is cost, as some of the agents can be quite expensive.

Prokinetic medications

Some drugs such as metoclopramide and domperidone (Motilium) may be used as add-on therapies to help control symptoms. These agents work by enhancing the contractions of the stomach and increasing its rate of emptying. This essentially reduces the contents of the stomach so that less is available to reflux back into the oesophagus, thus reducing damage. 

Surgery

Surgery is usually only used in cases of very severe reflux symptoms, particularly in younger patients who would otherwise need long-term drug therapy to manage symptoms. Approximately 80% of patients undergoing surgery will demonstrate improvement in symptoms. However, controversy exists over the long-term effectiveness of this mode of treatment, and indications for surgery are less clear-cut than for other types of treatment.

Endoscopic therapy

Occasionally reflux symptoms may be treated endoscopically by inserting a tube down the throat and either sewing, burning or injecting damaged areas of the mucosa (lining). Unfortunately the long-term efficacy of these treatments is unknown so their role is limited to a very select number of patients. In addition, endoscopic treatment can cause significant complications such as pain, gastrointestinal injury and short-term dysphagia.

Reflux is a very common condition in children but the symptoms are often non-specific. To date there is no ideal method of diagnosing or treating the problem in infants and children. However, you may gain some comfort from knowing that the symptoms of reflux are extremely common and that the condition is not due to any fault on your part. Often simple reassurance from a medical practitioner is helpful in improving both your and your child's quality of life.

As demonstrated above, there are many different treatments available for symptoms of reflux. Unfortunately there is limited experience with these therapies in children. Therefore when considering treatment for your child it is very important that you consider the potential side effects of the medications. You should remember that mild reflux is generally not a serious condition and that your child is otherwise well and healthy.

In most cases, symptoms of reflux will resolve spontaneously by approximately 12 months of age. Your doctor can help explain the condition more so that you understand that it is usually better for your child NOT to have extensive investigations or multiple drug therapies. This will avoid unnecessary side effects from unnecessary treatments.

Some management options for reflux symptoms in children are:

Reassurance and education: Learning more about your child's condition can allay some of your fears about the seriousness of the condition. Support groups such as RISA can help provide reassurance and educational materials; Posturing: There is some evidence that being in certain positions while feeding increase the incidence of reflux. Laying your child prone (on their stomach) with their head slightly elevated during feeding is associated with the least amount of reflux. It can be helpful to keep your child upright for about half an hour after feeds. However, caution should be taken positioning your child on their stomach, as there is an increased risk of SIDS;Dietary treatment: Milk thickeners and thickened feeds can reduce regurgitation, but there is limited evidence that they reduce reflux. Infants with mild acid reflux may respond well to simple thickening of their feeds; Alginates: There is limited experience with antacids in infants, but they may have some benefit in improving symptoms of mild GORD. However, side effects on bone metabolism (including rickets), diarrhoea and constipation can occur from these medications; Proton pump inhibitors: These are the recommended treatments for severe reflux in children. These treatments can cause side effects which should be discussed with your doctor. The pros and cons of treatment should be weighed up on an individual basis.

Children with very severe reflux symptoms and persistent vomiting can develop more serious complications such as failure to thrive and malnutrition. In these cases, more drastic measures may be required such as feeding through a nasogastric tube (a tube passed through the nose and down into the stomach, through which nutrient-rich puréed foods can be fed) or, very rarely, surgery.

For more information on acid reflux and heartburn and related investigations, treatments and supportive care, see Acid Reflux and Heartburn.

Biddle W. Gastroesophageal reflux disease: Current treatment approaches. Gastroenterol Nurs. 2003;26(6):228-36. [Abstract]DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100(1):190-200. [Abstract | Full text]Goyal R. Diseases of the esophagus. In: Braunwald E, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal Medicine (15th edition). New York: McGraw-Hill Publishing; 2001. [Publisher]Ip S, Bonis P, Tatsioni A, et al. Comparative effectiveness of management strategies for gastroesophageal reflux disease [online]. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services; 13 December 2005 [cited 10 June 2007]. Available from: URL link Kumar P, Clark M (eds). Clinical Medicine (5th edition). Edinburgh: WB Saunders Company; 2002. [Publisher] Somac [online]. MIMS Online; 2003 [cited 10 June 2007]. Available from: URL link Tutuian R. Castell DO. Management of gastroesophageal reflux disease. Am J Med Sci. 2003;326(5):309-18. [Abstract]Vandenplas Y. Gastroesophageal reflux: Medical treatment. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 1:S41-2. [Full text] 

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Male Condom

Male condoms are latex or (less commonly) polyurethane sheaths which are put on the erect penis prior to sexual activity. They provide a barrier to the mixing of the partners' sexual fluids during sexual activity. Male condoms are more commonly used than their female counterparts (the female condom) and are usually referred to simply as condoms.

A male condom prevents the male partner's semen from entering their partner's vagina, anus or rectum, and also protects the male partner from coming into contact with a female partner's vaginal fluids or male or female partner's blood (e.g. from abrasions to the rectum which can tear easily during anal intercourse) during anal or vaginal penetration.

As semen and vaginal fluids are the predominate routes by which sexually transmitted infections (STIs) are spread, male condoms play an important role in preventing the spread of STIs, during heterosexual and homosexual intercourse. While condoms are primarily promoted as devices for preventing STIs, they are also an effective method of contraception.

The use of condoms can be traced back to the ancient Egyptians, who used linen sheaths primarily as protection against disease. In the 1500s when syphilis was becoming an epidemic in Europe, the use of linen soaked in a solution of salt and herbs was documented. In the 1700s, condoms made from animal intestines became available but they were very expensive and often reused. The Chinese used oiled silk paper while the Japanese used leather and tortoise shell sheaths. It was not until 1839 and the development of rubber by Charles Goodyear that the first rubber condom was manufactured.

Since the nineteenth century, condoms have been one of the most popular methods of contraception in the world. Condom use as a contraceptive method declined after the advent of the oral contraceptive pill, sterilisation and other contraceptive methods. However, condom use for the prevention of STIs has increased significantly since the discovering in the early 1980s that HIV is sexually transmitted.

The male condom works to prevent pregnancy and STIs because the latex or polyurethane with which it is made cannot be penetrated by sexual fluids. As it creates an impervious barrier, condoms provide protection against pregnancy and the spread of STIs which are transmitted via sexual fluids (e.g. HIV, hepatitis B, chlamydia and gonorrhoea).

While male condoms do protect against some skin to skin content, they do not provide complete anatomical coverage of the genital skin during sexual intercourse. This means they are less effective in preventing STIs transmitted through skin contact (e.g. herpes).

Male condoms are used throughout the world as contraceptive and STI prevention devices. They are used by individuals who wish to prevent pregnancy and/or STI, either with steady or casual partners. More than 12 billion male condoms were distributed in 2007.

In Australia, individuals who are young and those who have sex with casual or non-cohabiting partners are more likely to use condoms than their older counterparts and those individuals who live with their sexual partners. Women who do not use other forms of contraception are also more likely to use condoms.

A recent study in Australia reported that about 7% of people used condoms consistently with regular partners and 40% used them with consistently with casual partners. While condom use in casual relationships is much higher than in steady relationships, it remains strikingly low, given Australia's high prevalence of STIs (more than 50,000 cases of chlamydia were reported in Australia in 2007, and over 4% of Australian men and women report experiencing genital warts in their lifetime).

In order to protect against STIs, condoms should be used at every act of sexual intercourse (including vaginal, anal or oral sex). In order to protect against pregnancy, condoms should be used at every act of vaginal intercourse.

The effectiveness of male condoms depends on the purpose for which they are being used and the extent to which individuals use condoms correctly. While intact latex and polyurethane are completely impenetrable by sexual fluids, condoms may break or slip off during sexual activity, and are therefore not 100% effective.

Condom users should also be informed that, due to the limited anatomical coverage of condoms (they cover only the penis and not external genitalia), they provide much less effective protection against STIs which spread through skin contact (e.g. herpes).

Despite the incorrect use of condoms reducing their effectiveness as a contraceptive or STI prevention device, studies of condom use within sexual partnerships still report fairly high rates of effectiveness.

As a contraceptive device, condoms are typically regarded as being less effective than permanent contraceptive methods (in particular hormonal methods) when user error is taken into account but still provide a high level of protection compared to no contraceptive use. Condoms provide 98% contraceptive protection, when used consistently and correctly.

As an HIV prevention method for heterosexual couples, male condoms have been estimated to be 80% effective when used consistently and 95% effective when used correctly and consistently. These estimates are based on the study of infections in couples who use condoms consistently and where one partner is HIV positive and the other does not have HIV (sero-discordant couples).

While no studies have monitored the incidence of other STIs amongst sero-discordant couples, studies reporting lower incidence of chlamydia and gonorrhoea amongst consistent condoms users suggest that condoms are also effective in preventing these STIs. Condom use also reduces the risk of contracting herpes simplex virus type 2 in females by around 15%.

As condoms are more likely to break or slip off during sexual intercourse if they are used incorrectly, it is important that users are knowledgeable about their proper use. Health professionals should counsel their patients on the importance of correct and consistent use of condoms and other factors which can affect condom efficacy.

Expiry date

Condoms have a limited shelf life and an expiry date will be printed on each condom packet. Users should be advised to check the expiry date prior to use. They should also be advised that exposure to heat reduces the shelf life of condoms, and to discard any condoms that have been exposed to heat (e.g. in a pocket or in sunlight).

Packaging

Condoms come individually wrapped in foil packaging. Users should ensure that the packet is in good condition and has not been opened or damaged. They should open the packet carefully, taking care not to tear the condom with nails or teeth.

Appearance

The condom will be rolled up in the packet. There will be a thick rim and a circle of loose fine rubber.

Disposable

Condoms are designed for single use only. Users should never attempt to use a condom for more than one act of sexual intercourse in which the penis remains erect. If the penis loses its erection during sexual activity, the couple should remove the condom and wait until the penis is erect again, before applying a new condom. Men who suffer from erectile dysfunction may find female condoms more appropriate, as their use is not contingent on an erection.

Applying and using a condom

Wait until the penis is fully erect before attempting to apply a condom.Hold the condom so that the rim can unroll towards you.The closed end of the condom will have a loose, nipple shaped tip. Hold and squeeze the tip between thumb and forefinger to remove any trapped air. This will create a space for the semen to collect.While holding the tip and with the condom still rolled up, place the condom on the head of the penis.Using the free hand, unroll the condom all the way down to the base of the penis. The condom should unroll easily. If it does not, the condom may be on backwards, may be damaged or too old. Discard the condom and use a new one.Lubricant can be put on the condom prior to sexual intercourse if desired although most brands of condoms are already lubricated. The lubricant may wear off during sexual intercourse. If this occurs, it is important to apply additional water based lubricant (not oil based lubricant as this can damage latex) to reduce the chance of the condom breaking. This point is particularly relevant for patients using condoms for protection during anal sex, as, unlike the vagina, the anus has no natural lubricating mechanism.The condom should be removed immediately after ejaculation and while the penis remains erect. The user should hold the condom at the base while withdrawing the penis from the vagina or anus, and carefully withdraw the penis, taking care not to spill any semen.The user should then remove the condom from the penis and tie a knot at the open end to keep the semen inside.Dispose of the condom by wrapping it in tissue and putting it in the bin. Do not flush it down the toilet.

The main reasons that a condom will fail to protect against STIs is because it either breaks or slips off during sexual intercourse. Condoms which become damaged prior to sexual intercourse (e.g. by teeth or fingernails while opening or applying the condom) will also provide inadequate protection. Factors which can increase the risk of slippage or breakage include:

Not holding the condom firmly at the base while the penis is being withdrawn from the vagina;Not completely unrolling the condom onto the penis;Using a condom which has been exposed to heat or sunlight (such as in a car's glove box or individual's pocket) or has passed its expiry date;Using oil based lubricants, as this can weaken latex condoms and cause them to break more easily;Use of some vaginal preparations or drugs at the same time as condoms.

It is also important to highlight to patients that condoms are only effective while they are being worn. If genital contact occurs prior to the application of a condom, there is a risk that STIs will be transmitted through this genital contact, even if the man has not yet ejaculated his semen. Current research indicates that in Australia, one in eight condoms used are not applied until after genital contact has occurred.

For greater protection against pregnancy, condoms can be combined with other forms of contraception such as the pill. They should not be used in conjunction with female condoms.

There are a number of vaginal preparations which may weaken latex condoms and increase the likelihood of a condom breaking. Women should not use latex condoms at the same time as any of the following preparations:

Dalacin V cream (clindamycin hydrochloride). (Metronidazole gel is safe.) Nilstat vaginal cream (nystatin). (Canesten cream (clotrimazole) is safe.) Fungilin (amphotericin) Pro-feme (progesterone) Monistat vaginal (miconazole nitrate) Prevaryl vaginal (econazole nitrate) Ecostatin (econazole) Nizoral cream (ketoconazole) Premarin (oestrogen cream). (Ovestin and Vagifem (oestradiol) are safe.)

If the condom breaks during intercourse, the penis should be withdrawn immediately. If the sexual partners still wish to continue having sex, a new condom should be applied prior to any further genital contact.

As a precautionary measure against unwanted pregnancy, women who experience condom breakage should visit their doctor to get a prescription for an emergency contraception pill which can be used up to 120 hours after intercourse, to reduce the risk of pregnancy.

Patients should also be informed to test for a range of STIs if they experience condom breakage. Many STIs are easily treated with antibiotics once detected. However, as many STIs remain asymptomatic for extended periods of time, leaving them untreated can lead to infertility and other complications.

STI prevention

The male condom is one of only two biomedical devices (the other being the female condom) which provides a high level of protection against a range of STIs in sexually active individuals. Condoms enable individuals who choose to be sexually active, and particularly those who choose to be sexually active with multiple partners, to reduce the risk of adverse health effects associated with sexual activity. They offer a degree of sexual freedom to individuals living in a world characterised by numerous health risks stemming from sexual activity.

Widely and cheaply available

Male condoms are available from most pharmacies, supermarkets and even petrol stations, meaning that they can be accessed most of the time. Unlike most contraceptive methods, users do not require a prescription to purchase condoms. Free condoms are also distributed by many student services and family planning clinics for individuals with budget constraints.

Temporary or permanent use

As condoms are applied immediately prior to sexual intercourse, an individual does not need to plan condom use in advance as they do for many other methods of contraceptives (e.g. hormonal contraceptive pills must be taken for extended periods). When used consistently and correctly, condoms provide a high level of protection against unwanted pregnancy.

Limited side effects

The only known side effect of the male condom is allergic reaction to latex, which occurs in a small proportion of users (estimated 1-3%). On the contrary, many hormonal contraceptive methods produce a wide range of side effects.

Condoms provide a theoretically high level of protection against both pregnancy and STIs, and the side effects of condom use are negligible. While a small proportion of condoms users (1-3%) report an allergic reaction to the latex with which condoms are made of, the allergic symptoms are temporary and there are no other known side effects of use.

There remain however, numerous barriers to the use of male condoms which mean that male condoms are often used inconsistently or not at all, even in situations where individuals are aware that their sexual activity may involve health risks (e.g. sexual activity with unknown partners) if a condom is not used. The key barriers which limit the use of condoms are discussed below.

User satisfaction

While user satisfaction with male condoms is higher than with female condoms, satisfaction remains poor, particularly amongst men. One study found that less than half of women reported the male condom felt "good" or "very good" during sexual intercourse and that women reported their partners were even less likely to be satisfied with the feel of male condoms. Common reasons cited for reduced satisfaction with male condoms is the associated reduction in sensitivity and sexual enjoyment and the disruption to natural sexual activity (i.e. the need to interrupt sexual activity to apply a condom).

Breakage and slippage

Even when used correctly, condoms can break or slip during sexual intercourse. In Australia, some 23.8% of male condom users responding to the Sex in Australia survey reported at least one incident of condom breakage during sexual intercourse in the year prior to the survey, while 18.1% reported at least one incident of a condom slipping off during sexual intercourse. Breakage and slippage was associated with less experience using condoms, indicating that a significant proportion of these failures were induced by user error.

Need for correct and consistent use

To effectively prevent STIs and pregnancy, condoms must be used correctly at every act of sexual intercourse and applied prior to any genital contact. While many Australians use condoms at some point in their life, only 40% use them consistently with casual partners and one in eight condoms are not applied until after genital contact has occurred.

Condom use is less likely when the sexual partners have consumed alcohol at intoxicating levels (according to Australian guidelines- for more information see Alcohol Intoxication).

Reliance on male partner

Condoms are user dependent and rely mainly on the male partner agreeing to use and applying the condom correctly (despite the female partner being at higher risk of STI and bearing most of the responsibility for unwanted pregnancy).

Condoms are available in variety of sizes, shapes, textures, colours and flavours to suit personal preference. The majority of condoms available are made of latex rubber.

Polyurethane condoms known as Duran (brand name: Avanti) were introduced to the market in the mid-1990s. They provided an alternative for those who were allergic to latex or who did not like the feel and reduced sensitivity that latex condoms produced.

In comparing latex to non-latex condoms, a large proportion of people appear to prefer polyurethane condoms. Polyurethane condoms are thinner, conduct heat better than latex and are less restrictive around the glans of the penis, therefore increasing sensitivity. Users report that the polyurethane condom has a more natural feel, look and smell than latex. Polyurethane is more durable than latex in that it can withstand exposure to heat and is suitable for use with oil or water based lubricants. One study reported no significant differences in the rate of breakage or slippage between latex and polyurethane male condoms.

Male condoms provide effective protection against STIs and pregnancy when they are worn correctly and consistently.Male condoms must be applied prior to every act of vaginal, anal or oral sex to provide protection.Male condoms should be applied to a fully erect penis, prior to any genital contact.A new condom should be applied if the condom slips or breaks.For more information on different types of contraception, male anatomy and related health issues, see Contraception.Padian NS, Buvé A, Balkus J, Serwadda D, Cates W Jr. Biomedical interventions to prevent HIV infection: Evidence, challenges, and way forward. Lancet. 2008; 372(9638): 585-99.Family Planning NSW. Male condom fact sheet [online]. 31 March 2008 [cited 1 March 2009]. Available from URL: http://www.fpnsw.org.au/ fs.020_male_condom08.pdf Centres for Disease Control and Prevention. Male latex condoms and sexually transmitted disease: Fact sheet for public health personnel [online]. 16 December 2008 [cited 1 March 2009]. Available from URL: http://www.cdc.gov/ condomeffectiveness/ latex.htm de Visser RO, Smith AM, Rissel CE, Richters J, Grulich AE. Sex in Australia: Experience of condom failure among a representative sample of men. Aust NZ J Public Health. 2003; 27(2): 217-22.Gilliam ML, Derman RJ. Barrier methods of contraception. Obstet Gynecol Clin North Am. 2000; 27(4): 841-58.United Nations Population Fund (UNFPA). Donor support for contraceptives and condoms for STI/HIV prevention 2005 [online]. 22 March 2007 [cited 1 March 2009]. Available from URL: http://www.unfpa.org/ upload/ lib_pub_file/ 681_filename_dsr_2005.pdf  National Centre in HIV Epidemiology and Clinical Research (NCHECR). HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2008 [online]. University of New South Wales. 14 September 2008 [cited 1 March 2009]. Available from URL: http://www.nchecr.unsw.edu.au/ NCHECRweb.nsf/ resources/ SurvReports_3/ $file/ ASR2008-revision.pdfGrulich AE, de Visser RO, Smith AM, Rissel CE, Richters J. Sex in Australia: Sexually transmissible infection and blood-borne virus history in a representative sample of adults. Aust NZ J Public Health. 2003; 27(2): 234-41.Macaluso M, Blackwell R, Jamieson DJ, Kulczycki A, Chen MP, Akers R, et al. Efficacy of the male latex condom and of the female polyurethane condom as barriers to semen during intercourse: A randomized clinical trial. Am J Epidemiol. 2007; 166(1): 88-96.World Health Organization. Family planning: A global handbook for providers [online]. 31 August 2007 [cited 20 June 2009]. Available from URL: http://www.who.int/ entity/ reproductivehealth/ publications/ family_planning/ 9780978856304/ en/ index.html Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission. Soc Sci Med. 1997; 44(9): 1303-12.Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002; (1): CD003255.Shlay JC, McClung MW, Patnaik JL, Douglas JM Jr. Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic. Sex Transm Dis. 2004; 31(3): 154-60.Wald A, Langenberg AG, Link K, Izu AE, Ashley R, Warren T, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA. 2001; 285(24): 3100-6.Valappil T, Kelaghan J, Macaluso M, Artz L, Austin H, Fleenor ME, et al. Female condom and male condom failure among women at high risk of sexually transmitted diseases. Sex Transm Dis. 2005; 32(1): 35-43.Farmer L, Everett S. Non-hormonal contraception. Obstet Gynaecol Reprod Med. 2008; 18(2): 33-8. Australian Government Department of Health and Ageing. National sexually transmissible infections strategy 2005-2008 [online]. Commonwealth of Australia. 27 June 2006 [cited 1 March 2009]. Available from URL: http://www.health.gov.au/ internet/ main/ publishing.nsf/ Content/ 0333DF52D0E2F3EDCA25702A0025132F/ $File/ sti_strategy.pdf  Kulczycki A, Kim DJ, Duerr A, Jamieson DJ, Macaluso M. The acceptability of the female and male condom: A randomized crossover trial. Perspect Sex Reprod Health. 2004; 36(3): 114-9. Sheary B, Dayan L. Contraception and sexually transmitted infections. Aust Fam Physician. 2005; 34(10): 869-72.Mantell JE, Dworkin SL, Exner TM, Hoffman S, Smit JA, Susser I. The promises and limitations of female-initiated methods of HIV/STI protection. Soc Sci Med. 2006; 63(8): 1998-2009.Rosenberg MJ, Waugh MS, Solomon HM, Lyszkowski AD. The male polyurethane condom: A review of current knowledge. Contraception. 1996; 53(3): 141-6.

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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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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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This Is More Fun Than Getting Fat!

What if in the next 3 weeks you designed and followed a very simple exercise routine? What if in the next 3 weeks you developed the habit of eating smaller meals? Essentially, you learned to "eat to live and not live to eat"? You might be amazed at how your body responds.

If you start a tiny little, stress-free exercise routine and follow it daily for 21 days, you might just have created a habit that will benefit you for a lifetime. The key here is that it must be so easy that you have not reluctance in doing it each day. Don't be intimidated by all those TV ads that show people panting and sweating as they try to be super-fit. You will be very impressed at what just a few simple exercises and possibly a daily stroll will do for your physique.

How about food? If you could learn to be happy with meals less than 500 calories each, combined with your simple exercise program, you would lose weight and re-shape your body. At the end of 3 weeks your life could very well be changed forever.

Three weeks is such a short time to create life changing habits. We can all do it. It's really no giant thing. But it does provide giant payoffs.

What if your morning exercise routine became as natural as brushing your teeth? Keep it simple enough and it can be. What if you made a list of meals you enjoy that are less than 500 calories each and you stuck with those meals most days for 3 weeks? Does that sound hard? Of course it's not.

The physical and mental rewards of slimming down and firming up are priceless. Not only are you being kind to your body but you are enjoying a more attractive appearance, more energy, and much more self confidence. Losing weight and getting back in shape is definitely more fun than getting fat!

In this day of instant gratification people think they can drop pounds fast by purchasing magical pills, machines and potions. That's stupid! You are making no life changing habits. You aren't enjoying the experience of using your body's own functionality to get down to a weight it is comfortable with.

Try the suggestions above for 3 weeks. See for yourself that your body is ready, willing and even eager to get stronger, slimmer, more agile and more attractive. Don't compare yourself with anyone else. Don't be intimidated by anyone else. Just allow yourself to enjoy the ride.

The author is just wrapping up 3 weeks of playing Joe's Fat Book - The Weight Loss Game. It has been tremendously rewarding and is documented on his site http://joesfatbook.com/ The rewards of simple exercise and eating smaller meals are priceless. Not only that, but you will find that using simple tools to monitor your progress provides you a win almost every day.

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