Watching Women's Health

Spend more of your day moving, having fun

More than two-thirds of adult Americans are overweight or obese, according to a recent national survey. Approximately 10% of children are also above a healthy weight. Fortunately, among both adults and children, the percentage who are overweight and obese is no longer increasing.

One way to address this national public health challenge is to get Americans moving again, through both individual and societal changes. Here are nine ways an individual can be more physically active.

1. Find physical activities you truly enjoy. This is the most important suggestion of all. If you are doing something you like to do, you are not working out, you are having fun. It takes planning, but not really discipline, to make an enjoyable activity part of your day.

2. Find ways to be active in all seasons. In Minnesota, staying active in the winter is a challenge. Many women occupy the summer with gardening, yard work, walking and cycling, but these activities fall by the wayside in the winter. It is actually not hard to dress for the weather and continue usual activities or switch to winter sports. Even in my state, only a handful of winter days are unbearable.

In other parts of the country, a hot and humid summer limits most outdoor exercise to early morning. Be realistic about where you live and either find ways to be out in all kinds of weather or move your activities indoors for part of the year.

3. Be active with friends. I first started exercising as a young adult by swimming at noon with a work friend. We later switched to running when the community pool became too crowded to swim laps. Our friendship made it easy for us to get fit together.

Most of my close adult friendships have been formed because we share physical activities as well as sensibilities. For the past two years, I have admired from afar four women who walk together every morning, regardless of weather. They are always happy and animated - clearly getting together is not a chore for them.

4. Go places under your own power. Day to day, most of us feel pressed for time.  Perhaps the most time-efficient way of getting more exercise is combining it with transportation. Try walking or cycling to work, run errands or get together with friends. To cover long distances, find ways to combine self-locomotion with public transportation.

Many baby-boomers who are downsizing houses would also like to downsize their car fleet as well as their clothing size. When moving, look for neighborhoods that are pedestrian and bicycle-friendly. At least one helpful website lets you analyze the walkability of any address in larger US cities.

Similarly, consider vacation spots that allow you to get around under your own power. This is not only economical but will help counteract the weight gain that seems inevitable with most vacations.

5. Get a dog and give it a great life.  A great life for a dog is a healthy, active life for you. A recent study showed people who walk their dogs see more improvement in their fitness than people who walk with humans. Unlike human companions, dogs don't come up with excuses not to walk. Dogs will happily go out in almost any weather and you find out you can, too.

6. Spend less time sitting. Sitting at a desk at work, watching TV, or at a home computer occupies most of the day for a lot of people. Along with sleeping, sitting in a comfortable chair is the least active thing our bodies can do. Most calorie expenditure charts show standing uses roughly twice as many calories as sitting, and calorie expediture goes up from there with more intense activities. Be creative about finding ways to sit less; when you do sit, try using an exercise ball part of the time (even though the TV comedy The Office made huge fun of this).

Wearing a pedometer is an easy way to quantify how much you are moving around during an average day and has been shown to increase sedentary women's activity levels.

7. Increase your activity gradually. Once you've made up your mind to be more active, don't risk injury by overdoing it in the first several weeks. Remember you're in this for the long haul. Give the weakest parts of your body time to catch up to the strongest. 

8. Mix things up. Humans like variety. If you involve yourself in a variety of activities, you are less likely to get tired of what you are doing and to have overuse injuries. Part of the beauty of living in a place with distinct seasons is engaging in different seasonal activities. For instance, here in Minnesota, we never get tired of cross-country skiing because, believe it or not, the winter is too short.

9. Have a mindset that exercise is a priority, not a luxury. To be healthy, we need physical activity just as we need fluids, nourishment, mental stimulation and sleep. Physical activity should be a normal part of virtually every day, not something we'll do if we have time and inclination. Each day, figure out a way to fit some sort of exercise into even the busiest schedule. 

I've gathered these ideas from talking with my friends and patients, and from my own experience of being physically active throughout my adult life. Even if you have never liked to "exercise," you'll do good things for your health (and have fun) if you move more and sit less.

Obesity replaces smoking as top US health burden

The good news is that smoking is no longer the biggest health threat to Americans.  The not-so-good news is that, while fewer people are smoking, many more, including record numbers of children, have become obese.

The medical definition of obesity is a body mass index (BMI) greater than 30. For example, for a woman who is 5'5", any weight above 180 lbs is in the obese range. BMI for normal weight ranges from 18.5-24.9; the overweight range is from 25-29.9. To be in the normal range, a 5'5" woman would weigh between 112 and 150, a fairly generous spread.

While smoking rates in the US have declined in recent years, obesity has been on the rise. Between 1993 and 2008, obesity in the US increased by 85%.

The risks from smoking and obesity are different. Smoking increases risk of premature death whereas obesity increases risks of morbidity, or ill health.  Both can result in fewer years of quality living, with obesity now edging out smoking as a robber of quality years.

If everyone in our country miraculously became a nonsmoker of normal weight, on average Americans would gain 5 quality years of life.

Obesity can limit normal activities through early arthritis, diabetes and heart disease.  And these progressive conditions lead to less and less physical activity. Like smoking, the problem of obesity is best addressed by prevention. Once a woman has become obese, it is a difficult condition to change.

Physicians regularly encourage smokers to quit and discuss approaches to weight loss with our overweight and obese patients. In my practice, I see smokers quitting and overweight women getting back into a normal weight range far more often than I see obese women succeed in losing weight. Their lack of success seems in large part due to the obesity-related physical ills that do not allow them to be physically active. 

Much has been written about the causes of obesity in the US. At or near the top of everyone's list is a sedentary life style that is so much more common now than even a few decades ago. In my next post, I'll discuss practical approaches to being more physically active.

Screening for ovarian cancer — focus on genetic risks

Most women have just over a 1% lifetime risk of developing cancer of the ovary. However, in some families, there are multiple cases of ovarian and/or breast cancer, and risks are much greater. What do we know about inherited susceptibility to ovarian cancer?

The biggest breakthrough has been the discovery of harmful mutations in the BRCA 1 and BRCA 2 genes. BRCA 1 and 2 are tumor suppressor genes located on chromosome 17 that prevent uncontrolled cell growth. With certain mutations, BRCA genes are less effective in regulating cell growth, and ovarian, breast and other cancers are more likely to occur.

A BRCA mutation can be detected through a blood test. There are well-accepted recommendations about which family cancer histories should trigger genetic counseling and possible BRCA testing. Genetic counseling is helpful, so an accurate family medical tree is constructed and appropriate candidates for BRCA testing are identified. Before getting the blood test, it is important that women fully understand the implications of both positive and negative BRCA results, and also of declining to do the test.

When possible, it makes sense first to test a family member who has been diagnosed with breast or ovarian cancer. If a BRCA mutation is found, other family members can undergo limited testing for that specific mutation.

Both females and males can inherit BRCA mutations. Men with BRCA mutations have an increased risk of breast cancer, as well as pancreatic, early-onset prostate, and possibly, testicular cancer.

Women with BRCA mutations have an increased lifetime risk of ovarian cancer ranging from 20-50%. Risks for developing breast cancer are even higher, in the 60-80% range.

If a harmful BRCA mutation is found, most physicians recommend prophylactic removal of the ovaries after childbearing is complete, in most cases by age 40. (Along with removal of the ovaries, additional steps would be taken to reduce breast cancer risk.)

Prior to completion of childbearing, BRCA positive women should be aware of ovarian cancer symptoms and have regular vaginal ultrasounds and CA-125 testing — though imperfect, these tests are the best we have for screening high risk women. We also recommend younger women use oral contraceptives when feasible. Oral contraceptives can reduce ovarian cancer risk by 50%, though the exact benefit in BRCA positive women is not known.

What if BRCA testing is negative? That means cases of ovarian and/or breast cancer in a particular family are not due to a BRCA mutation, but may be associated with other mutations that have not yet been identified. With high risk family histories, the same risk reducing strategy is appropriate.

Improving ovarian cancer screening in the future, for both high and average risk women, will almost certainly involve more accurate serum markers and better ultrasound discrimination between normal and abnormal ovarian structure.

Does recognizing symptoms lead to early diagnosis of ovarian cancer?

I wrote earlier about the difficulties of diagnosing early ovarian cancer by routinely screening asymptomatic women at average risk for this disease. But what if physicians did a better job of screening women with symptoms linked to ovarian cancer? Could we make the diagnosis at an earlier, more treatable stage?

A recently published study looked at these questions. 

813 women with ovarian cancer (including 212 diagnosed in an early stage) and 1313 otherwise similar women were interviewed about symptoms they experienced before their date of diagnosis (or comparable date for the control group).

Symptoms included early satiety, bloating, abdominal or pelvic pain and urinary changes. A woman was considered symptomatic if she had new onset of any of these symptoms in the year before diagnosis, with symptoms occurring daily for at least a week.

Women who had been diagnosed with ovarian cancer were 10 times more likely than women in the control group to report having had at least one of these symptoms. However, most women reported having symptoms for a relatively short time before diagnosis, regardless of whether their cancer was found in an early or late stage.

(One limitation of the study is that it relied on accurate recollection of symptoms. And, women with a cancer diagnosis may recall symptoms differently than the control group.)

Like other current screening approaches for ovarian cancer, the authors' symptom index had a low positive predictive value. Using their approach, 100 symptomatic women would have to be evaluated to identify one woman with early ovarian cancer.

The other 99 women would undergo ultrasounds, blood work and in some cases, unnecessary surgery, looking for a disease they did not have. At the same time, women who had early ovarian cancer but no symptoms, would not be recognized.

The editorial accompanying the article concludes

Importantly, these findings remind us that wide recognition of symptoms alone will not incrementally improve the overall survival from ovarian cancer. Rather, they highlight the urgent need to develop better molecular markers and improved imaging modalities for ovarian cancer screening. The recognition of specific symptoms associated with ovarian cancer has value. However, to truly affect the cure of ovarian cancer, we need better diagnostic tools for asymptomatic women.

Next, I'll look at what we know about inherited susceptibility to ovarian cancer.