Monday, November 26, 2012

Gain the Holiday Spirit not the Holiday Weight

Can a little too much holiday cheer add to holiday weight gain?  Holiday weight gain is a relative myth, it’s not the 5-10 pounds like we often hear.  The average American only gains 1 pound over the holiday season, but that does not mean it is nothing to worry about.  Studies have shown that when we follow individuals after their 1 pound holiday weight gain, they typically don’t lose that pound over the next year leading into the next holiday season.  So do this over the next 20 years and you’ll find yourself carrying an extra 20 pounds around and some negative health risks that go with that weight gain.

Another concern is that overweight people tend to put on an average of 5 pounds for the holidays.  So if you are overweight to start with, you are more likely to put on more weight then an individual that is not.  Not a good thing if you already have weight to lose, because you will end up with those 20 extra pounds in just 4 years.

While eating all of those Christmas cookies and treats on top of our normal calorie intake is usually the thing blamed for the added weight gain, don’t forget that added alcohol consumption with holiday parties can be partially to blame.  An average alcoholic beverage contains between 100-150 calories and if you are having only one drink per day that is not a problem.  But remember that alcohol calories come primarily from sugar.  We should take in only 5-15% of our calories from solid fats or added sugars.  So if you are at the average calorie intake for most women, which is just over 1900 calories or for men it is 2550; you can see how you can easily exceed this amount with a couple drinks and then throw in some food with extra sugars added to them.  Plus alcohol does impair our thinking and our willpower to say no to an extra cookie and some fudge.  This can create a double whammy with the added calories of the alcohol along with decreased willpower to say no to over eating. 

Unfortunately the added stress of the holidays can be to blame as well.  A short acute stress response from our body is helpful when we have a true emergency that should last a few minutes.  Long chronic stress is not good, which is what many of us live with daily and especially over the holidays.  When we get into a chronic stressed state we often tend to use poor strategies to relieve that stress such as drinking and eating compared to good strategies like meditation, prayer and exercise.  Also our willpower is decreased in a stressed state, just like it is under the influence of alcohol.  A time of acute stress is not a time to worry about your waist line in upcoming years; it is a time of survival to get through to the next day. But when that acute stress becomes chronic daily stress you can start to see how that can derail us and our future health needs.

So control your eating over the holidays, it is okay to have a few tasty holiday treats, but remember to try and do it with some moderation.  Also be careful with your alcohol intake, as it can lead to extra calories and decreasing your willpower.  Also try to meditate on the “reason for the season” to help decrease a little stress.  Get away from the TV and watching reruns of “It’s a Wonderful Life” and get out for a walk and some exercise to make it a wonderful life.  And after the New Year begins, start working to take off any weight that you might have put on so you start next holiday season where you began this one or a little less if needed.

Wednesday, October 17, 2012

Being social is good for your health

We are wired to be connected together with strong social ties for better health that much we know. Why this is, is still a bit of a mystery. There has been a pretty substantial amount of research showing that having a healthy social life is vital to improved health, maybe as much as avoiding cigarette smoking. A comprehensive analysis of 148 research studies was done in 2010 by researchers from Brigham Young University and University of North Carolina at Chapel Hill. The research review showed that having lots of strong social ties gave a boost to longevity as well as not smoking and even better than regular exercise and maintaining a healthy weight.

How these increased social ties works to improve our long term health have been demonstrated in a few studies. One such study showed how our heart rate and blood pressure will increase less during a stressful situation when we are accompanied by someone close to us. Our body seems to be able to handle and cope with the stress better with fewer extremes when we are able to be connected with those important to us. This is also seen in studies demonstrating that our immune system seems to work better to fight off illness when we have more social connections. Our immune system reacts to stress hormones, such as catecholamines and glucocorticoids. Strong social support reduces these stress hormones allowing our immune system to work more efficiently to keep us healthy.

Obviously not all relationships are healthy, so promoting healthy good relationships is important. One method to help with this is building our relationships with others around physical activity. The list of long term benefits of being physically active is long, but we forget that it also has immediate benefits of improving our mood. As soon as you start exercising you get a boost of neurotransmitters in the brain (dopamine and serotonin) that give us pleasure and boost our mood. So, if our mood is better it will help with building healthy relationships. Look for opportunities to combine adding social connections along with physical activity such as: joining a team sport (such as volleyball, soccer or biking club), do activities with friends and family (such as going for a walk, playing tennis or bike riding together), or take part in group fitness activities (such as an exercise or dance class).

So make sure you are working to build and maintain your social connections. Having a strong healthy social support system will add years and quality to your life.

Thursday, October 4, 2012

Present self versus future self Part 3, Getting to a healthier/happier you

You have seen that future self is often doomed to choices made by present self. Also how commitment devices can help future self battle the immediate gratification needs of present self. But even these tools have their limitations, so how do you overcome present self and help future self become who you want to become (a healthier and happier you)?

First realize its hard work! Yes, it does require more energy. So realize when you’re fatigued and tired you probably are not going to overcome present self wishes. It’s okay; don’t beat yourself up about it. Just get some rest and get ready for future self to battle the next day. Understand also that you are motivated by emotions, both present and future self. You need to find the emotions that motivate future self and keep those front and center as much as possible, but at times let present self emotions get what they need as well. Future self emotions maybe the joy that comes when you are able to play with your grandkids, the relief of not suffering a heart attack at 50 like a parent, or the excitement be able to travel when you get older and not be limited, or what ever might work for you. You all have different emotions and different emotions that motivate you; you need to find that emotion that is going to be your motivator for your future self.

Also realize the environment and culture you put yourself in does help, so use some commitment devices and wise choices when motivation and will power is at its peak performance to make that environment a little easier for future self. They did a neat study with college students. One group of students had to sit in a room full of fresh baked chocolate chip cookies and they were told they could not eat them. The other group was allowed to eat as much as they pleased. After 15 minutes in the room each was taken to a different room to do a math problem. This math problem was unsolvable, so eventually students from both groups gave up. The ones that had to use more will power to not eat the cookies gave up a lot sooner then those that were allowed to eat as many cookies as they wished. Moral of the story, don’t put yourself in situations that are going to make you use up your will power energy source. You need to create a healthy culture to help future self battle present self.

Some of you will have less will power then others, but it can be built up in all of us by being aware of its limitations and improving the culture that it works in. This increases your self-efficacy in knowing that you have some control over working to becoming the future self you want to be.

Tuesday, October 2, 2012

Do you kiss your mother with that mouth?

I recently had an editorial in the ISPI Newsletter (I am an instructor with International Spine and Pain Institute).  I wanted to reprint it here as well for readers.

I’m sure many of us used the phrase, “sticks and stones may break my bones, but words will never hurt me” as a child, heck maybe you still use it as an adult. This catchy phrase may be slightly inaccurate based on current pain neuroscience understanding and I propose we offer this more correct version in the future: “sticks and stones may break my bones and words will never harm me, but they can hurt me”. This is of course a play on the popular pain neuroscience metaphor of “hurt does not always mean harm”. We have a good understanding that harm (physical injury or illness producing nociception) is not the same as hurt (the brains output of pain). We actually have evidence showing that the words we use can change the hurt people experience.

In a recent study (Ott J, 2012) researchers found that words associated with pain increase the perception of pain during venous blood sampling. The authors came to the conclusion that words have an impact on the individual evaluation of external stimuli. This finding has been found in other research and fits into Melzack’s pain and the neuromatrix in the brain theory with cognitive related brain areas being inputs into the body-self neuromatrix that can produce outputs of pain perception.

Another interesting study (Beck JG, 2001) used a modified Stroop procedure to assess processing of threat
words in motor vehicle accident (MVA) survivors. The traditional Stroop color-word interference test looks
at reaction time while a participant is asked to name the color the word is printed in, but ignore the word itself. For example the word “red” might be printed in blue ink and your job is to say blue. You will see if
you do this you are inclined to say red and your response of blue is slowed, thus you experience interference.
You can check out Wikipedia for more on Stroop Effect, it’s kind of fun to do (well that is if you’re a nerdy nerve head like myself). So back to the study, they had three groups of MVA survivors one had no problems, the other had persistent pain and the third group had persistent pain and post-traumatic stress disorder (PTSD). The PTSD and pain group had slowed responses with both accident and pain words. While those with just pain had slowed response with just pain words not accident words and those individuals that had no symptoms saw no changes in their responses for either pain or accident words.
This study shows that there was some specificity to processing of words by an individual based on their condition.

So what can we, and should we, take away from such studies? The words we use can “hurt” our patients more than they already are. As health care providers we need to be aware of the choice of words that we use on a regular basis with our patients in pain. While using threat words such as herniation, rupture, tore, etc. with a person in no pain may not affect their neuromatrix to produce pain, but for those in pain it actually could.

Adriaan, along with Ina, David and Louie recently finished a paper that is waiting for submission (Louw, 2012) looking at the difference in the words we use with pain patients with pre-operative education. They looked at two different post-surgery pain education booklets. Booklet A had been shown to have no added benefit to outcomes or cost from previous research with surgical patients. Patients receiving Booklet B have
shown initial signs (from a case series and preliminary multi-center RCT data) to have improvement in function and decrease in pain catastrophization upon using pain neuroscience education approach (Yes, this is Adriaan’s PhD project and the same booklet you are aware of “Your Nerves are Having Back Surgery”).
They had a group of seventeen expert PT’s compare the use of provocative terms in each booklet. What was found that Booklet A had three times the use of provocative terms associated with fear, pain and anxiety compared to Booklet B that utilized the latest pain neuroscience education. The original study of Booklet A did not list the use of pain words as a possible reason why the study failed to show a difference in outcomes with or without the additional patient education. This study suggests that possibly the words we use during our patient education may make a difference in the outcomes we get.

So understanding this important piece of information, that words can hurt our patients, I get a little agitated with the choices some of my fellow health care providers choose to use when it comes to their words. Have you ever seen a patient that reports to you that the physician or some other health care provider stated that their back, shoulder or knee was the worst they had ever seen. Isn't it amazing how patient after patient we here this from, is each patient actually getting worse than the one before? After almost 20 years of practice it is amazing that patients somehow consistently seem to be progressively become the worst case month after month. A statement like this does not help a patient in pain in any way and only has downside as it is laden with fear and anxiety (two of the things we should be trying to reduce). While this kind of statement does give us, the health care provider, with lots of upside. Consider if they don’t get better it’s not our fault because it was the worst case ever; and if they do get better it only shows how good we must be to help the worst case ever. I think we can and should be able to do better for our patients.

As physical therapists we need to be aware and improve the therapist portion of our care just as much, if not more, then the physical portion of our interventions. One area of this can be done by paying attention to the words we use during our interaction with our patients. Avoid using threatening words in our explanations to patients in regards to diagnosis, etiology and prognosis from their current condition. These terms only provide the opportunity for the individual to perceive greater threat through the fear and anxiety interwoven into the meaning of them and enhancing the defender response (pain) from the patient.

Proper interaction and education can instill positive expectations and hope through the use of our language to our patients and not create negative connotations or threatening inputs to their body-self neuromatrix. The choice of the non-threatening language and words we use may be another avenue to provide input into the neuromatrix as an adjunct to our management and treatment of their painful condition.


  1. Beck JG, F. J., Shipherd JC, Hamblem JL, Lackner JM. (2001). Specificity of Stroop Interference in Patients with Pain and PTSD. Journal of Abnormal Psychology, 110(4), 536-543. 
  2. Ott J, A. S., Nouri K, Promberger R. (2012). An Everyday Phrase May Harm Your Patients: The influence of Negative Words on Pain During Venous Blood Sampling. Clin J Pain, 28, 324-328.
  3. Louw A, Diener I, Butler D, Puentedura L. (2012). The Lanugage of Patient Education for Lumbar Radiclopathy. unsubmitted research.

Friday, September 28, 2012

Commitment devices - helpful but still limited

Commitment devices have been around for centuries. One of the most famous is how Odysseus, as recalled in Homer’s the Odyssey, had himself tied to the mast of the ship while the crew had beeswax in their ears. This allowed Odysseus to hear the Siren’s enchanting music and voices but he could not shipwreck the boat because he was tied up and the crew could not hear his cries to release him or the Sirens because they had beeswax in their ears.

It has been well studied that using will-power is hard work. Your brain and nervous system uses glucose, one of the main power sources of the body, to help us consciously overcome temptations by using our cognitive abilities to help us with what some call “free won’t”. Because if left to do things freely, we will often do the wrong thing for present self’s gain at the expense of future self, thus the term “free won’t” as compared to “free will”. The actual increase energy expenditure has been measured and thus we realize that will-power is an expendable resource. Just like going for a run, at some point everyone will deplete their energy source and not be able to continue.

Commitment devices are used to help create a better environment for us to function and reduce the energy needed for our will-power to have to work. Commitment devices are used to avoid akrasia. Akrasia is a big fancy word that you probably have never seen used before, but unfortunately have done what it means many times. Akrasia is the state of acting against one’s better judgment.

One example of a commitment device is not buying unhealthy snacks when at the grocery store. When you are tired and exhausted at night and your will-power energy stores are minimal you won’t do akrasia, by choosing an unhealthy snack because it is not in the house. It requires more energy to get in the car and drive to grocery store to get a bag chips or some ice cream so you are more prone to choose what you do have in the house. Which if you set up your commitment device properly is some fruits or vegetables. If our will-power is really low we may still drive to the store and get an unhealthy snack. In that case we may need a new commitment device such as having someone hid your car keys at night.

This brings us to a problem with commitment devices – we can almost always weasel our way around them. Also they are a reminder that we lack some self control and this takes away from our self-efficacy. So while commitment devices can be helpful, we also need to understand their limitations. Next week we will look how to help future self beyond just using commitment devices.