Articles from the magazine and website of



Simple Steps for Increasing Activity and Losing Weight
Why Exercise? What's in It for You
Controlling Blood Lipids. Part 1: A Practical Role for Diet and Exercise
Healing Heel Pain - Help for Plantar Fasciitis








Simple Steps for Increasing Activity and Losing Weight
Ross E. Andersen, PhD
THE PHYSICIAN AND SPORTSMEDICINE
VOL 27 - NO. 10 - OCTOBER 1, 1999

It's probably no surprise that being inactive or overweight increases the risk of heart disease and other diseases. And most people know that regular exercise (combined with healthy eating, of course) helps fight excess weight.
What you might not know is what, exactly, "regular exercise" means. For years we have been told that for exercise to "count," it had to be done for at least 30 minutes, three or more times a week. Also, it had to be hard enough to cause you to sweat and breathe hard. This type of exercise is definitely effective. However, day-to-day activities like playing with the kids, housework, or gardening are exercise, too--and they can also help you boost fitness and shed pounds.

Boost Exercise
For those striving to lose or maintain weight, regular physical activity--whether traditional exercise like walking or lifestyle activities like yard work--is important because it:
Burns calories; Slows down the loss of muscle that typically comes with aging; May speed your metabolic rate, which is how fast your body burns calories, even at rest; and Is strongly associated with successful long-term weight control.

If you are able to participate in and enjoy traditional aerobic exercise like brisk walking, running, swimming, in-line skating, aerobics classes, or bike riding, by all means do so. But being overweight may make it harder to do these more traditional workouts regularly. You may find that you get out of breath quickly or simply do not enjoy them.
If so, it may help to focus first on how you can burn more calories by building more motion into your daily activities.

Some examples:
Parking the car at the far end of the parking lot;
Gardening, mowing, and doing other yard work;
Vacuuming, dusting, and doing other housework;
Using stairs instead of elevators and walking instead of using moving walkways;
Walking during lunch breaks; and Playing with children.

The goal is to be active for 30 minutes on most, if not all, days. To make it easier, remember that your 30 minutes can be broken into shorter periods of 8 to 10 minutes or more. For instance, you could pull weeds for 10 minutes in the morning, walk for 15 minutes at lunchtime, and vacuum for 10 minutes in the evening. This is especially helpful to those who have busy schedules.

The key is to choose activities you will enjoy or can easily plug into your routine and then do them regularly. You may find that your exercise program is easier if you pick a variety of activities. The more you increase your daily activities, the fitter you'll become. As you gain fitness, you may find that you can add regular walks or another aerobic activity to your regimen. Stretching exercises and strength exercises like weight lifting will round out your program. Increasing your fitness is good even if you don't lose weight: It'll mean more stamina, less tiredness, and even a shot at a longer life!

Decline Reclining
Cutting back on TV watching and other physically inactive pursuits is another important change for adults and children trying to lose weight. A physical activity log can help in identifying active and inactive times. Make copies of the log and keep a record for a few days. The results will surprise you. The log can help you identify times when you could work activity into your day.

Daily Physical Activity Log
Hours Minutes of
Physical Activity		 Notes
12:00 midnight-1:00 am __________ __________
1-2:00 am __________ __________
2-3:00 am __________ __________
3-4:00 am __________ __________
4-5:00 am __________ __________
5-6:00 am __________ __________
6-7:00 am __________ __________
7-8:00 am __________ __________
8-9:00 am __________ __________
9-10:00 am __________ __________
10-11:00 am __________ __________
11:00 am-12:00 noon __________ __________
12-1:00 pm __________ __________
1-2:00 pm __________ __________
2-3:00 pm __________ __________
3-4:00 pm __________ __________
4-5:00 pm __________ __________
5-6:00 pm __________ __________
6-7:00 pm __________ __________
7-8:00 pm __________ __________
8-9:00 pm __________ __________
9-10:00 pm __________ __________
10-11:00 pm __________ __________
11:00 pm-12:00 midnight __________ __________
Total Activity _____ minutes
Date: ______________________________

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

Dr Andersen is an assistant professor of medicine in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine in Baltimore. He is a fellow of the American College of Sports Medicine.


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Why Exercise? What's in It for You
 HEALTHTRACK - JULY 96
A SUPPLEMENT TO THE PHYSICIAN AND SPORTSMEDICINE FOR THE WAITING ROOM

 If a miracle drug existed that could help you lose weight, live longer, build muscles, avoid heart disease, prevent cancer, lower your cholesterol and blood pressure, stave off bone loss, and improve your mental health, would you take it? Before you answer, you should know that it does require a time commitment. You need to take the drug three to five times a week, and each dose takes about 30 to 45 minutes to administer. Also, the drug causes most people to sweat and breathe heavily, but only during its administration.
Still interested? With benefits like that, who could refuse?
The "drug," of course, is exercise. And if a real drug produced the results that exercise can, scores of people would flock to buy it--despite the minor side effects. So why don't more people exercise? Good question.
Maybe exercise needs a good ad agency. An ad for exercise would tell you that physical activity--even moderate exercise like walking--will improve your health. And vigorous activity can get you even more fit. Coupled with proper nutrition, physical activity is the cornerstone of healthy living and can help prevent and control many diseases (see "Exercise: Better Than Any Pill" at the end of this article).
Many women of all ages are becoming more physically active. Care to join them?

Activity in All Things
If, after reading all the great tips in this article, you still can't decide on an exercise program, try walking. Walking is safe, cheap, and accessible. You can also boost your activity level by adjusting everyday activities:
Walk briskly during chores, shopping, or errands.
Take the stairs rather than the elevator, or park your car far away from the entrance of a mall or your job.
Restrict sitting to activities that require it, like eating, learning, keyboarding, and essential driving.
Contract and relax all your muscle groups while sitting.
Get up and move for 5 to 10 minutes for each hour of sitting, or use breaks to walk or stretch.
Exercise is one of the most important steps you can take to ensure a long, healthy, and prosperous life. So get started!

Getting Started
If you have a hard time starting an exercise program, you probably have good reasons. But millions of people do exercise routinely and seem to enjoy it. Here are some tips.
Realize that all physical activity counts and is good for you. Even chores, like cutting the grass or washing windows, count as exercise.
List physical activities you enjoy, from walking with a friend to playing catch. Don't exclude anything. Remember that milder activities like walking the dog, weeding the garden, or playing a relaxing sport can pay big health dividends--as well as be fun.
Make a plan. Decide when, where, how often, and with whom you are going to exercise. Have a backup plan in case of bad weather or conflicts.
Participate daily in one or more of your enjoyable activities, or at least three times a week.
Exercise at moderate intensity (you don't need to huff and puff). If you've been inactive, begin slowly at 10 to 15 minutes per session and work up to 45 to 60 minutes.
Garner support from friends and family--and believe in yourself. This will help keep your motivation high.
Wear comfortable shoes and clothing to prevent injury.
Squeeze some physical activity into your day, no matter how busy you are. Exercising in snippets is one option: Ten 3-minute bursts count as much as one 30-minute session.
If you have questions about your health, check with your doctor before starting an exercise program.

Sticking With It
Staying motivated is tough for all exercisers--even true jocks. A variety of techniques, though, can help you stick with it. Pick and choose the ones below that suit you.

Victory celebration. Reward yourself for sustaining an exercise program. Eat a special meal, or treat yourself in some other way--a new jogging outfit, perhaps.
Spicing it up. Use a variety of activities to keep things interesting. For instance, walk on 2 days, swim laps on 1 day, and lift weights on 2 days. Also, change the duration or intensity of your workout. Or try new scenery.

Quick change. Change directly from work clothes into workout clothes. This will keep you from getting sidetracked.

Unrivaled competition. Gain satisfaction from achieving goals. Try to jog a bit farther or for a bit longer than the session before. (But don't fret over minor setbacks--improve over weeks and months.)

Logging in. Keep a diary of daily exercise accomplishments. It will help you track your progress and can serve as reinforcement.

Driven by distractions. When working out on an exercising machine, read, watch TV, or listen to tunes. (But don't wear earphones when exercising outside near traffic.)
Buddying up. By working out with a partner, you can inspire and encourage one another--and spend more time with a friend.

Wake-up call. Exercising first thing in the morning means only one shower and dressing session. But remember that not everyone's body--or mind!--is suited for it. (If you have a heart problem or may be at risk for one, check with your doctor first.)

Bait 'n' switch. If you're feeling lethargic, tell yourself you'll do only a little exercise. Then, once you are up and out, you probably will decide to do a full-blown workout.

Straight expectations. Fitness takes time. If you've put on weight, don't expect it to disappear in 3 weeks!
Exercise - Better Than Any Pill
Regular exercise can help improve your mind and body in a variety of ways and help you avoid several serious diseases.

Strength and fitness. Physical activity helps build muscle strength, endurance, and flexibility, which will contribute to the health of your muscles and bones. This, in turn, can help you avoid low-back pain, prevent falls, and give you more stamina for everyday activities. Cardiovascular endurance also improves with exercise, so you can work or play harder without getting out of breath.

Weight control. Obesity is a risk factor for heart disease and can be a culprit in other diseases, as well. Exercise coupled with a healthy diet is the key to effective weight loss.

Cardiovascular diseases. Inactivity in and of itself is a significant risk factor for cardiovascular diseases. The most common of these are heart attacks and strokes--the leading causes of death in the United States. And exercise can also improve blood pressure, cholesterol, obesity, and diabetes--other major risk factors for cardiovascular diseases. In fact, regular physical activity cuts your risk of dying from cardiovascular diseases by 40%. People who exercise, eat right, and lose weight will benefit the most.

Diabetes. Because physical activity helps regulate blood sugar, it can decrease the need for medication in people who have diabetes. It also helps control obesity, which worsens some forms of diabetes.

Osteoporosis. Exercise can protect against osteoporosis (see "Boning Up for Better Health"). Women's bone mass is greatest in their mid-20s to mid-30s, then declines slowly until menopause, when bone is lost rapidly. Physical activity performed during younger years will help you have sturdy bones at menopause. And physical activity begun during menopause will help slow the loss of bone.

Arthritis. When joints wear down, causing arthritis, exercise strengthens muscles and increases joint flexibility and motion.

Cancer. Some studies show that cancers of the ovaries, cervix, uterus, vagina, breast, and colon are lower in active women as compared with inactive women.

Mental health. Physical activity can improve self-esteem and your general sense of well-being. It can also supplement medications in battling depression and anxiety.

Prepared by James R. Wappes

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Controlling Blood Lipids. Part 1: A Practical Role for Diet and Exercise
Tedd L. Mitchell, MD; Larry W. Gibbons, MD, MPH
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 10 - OCTOBER 98

This is the first of two articles on controlling blood lipids. The second article, on medication, will appear in a subsequent issue.

In Brief: Dietary measures that can improve blood lipids include limiting consumption of saturated fats, trans fatty acids, simple sugars, and stearic acid and consuming adequate amounts of vitamins C and E and beta-carotene. Eating certain fish once a week may significantly lower the risk of sudden cardiac death. Aerobic exercise three times per week for 20 to 30 minutes at 60% to 80% of the age-predicted maximum heart rate may also improve lipid levels. Research indicates that modest fitness reduces overall mortality, and higher levels benefit those who have abnormally high cholesterol. Moderate alcohol consumption may influence a person's lipid profile favorably but is not recommended for nondrinkers.

The advances of the past 40 years have given us an effective armamentarium for managing coronary artery disease (CAD) and have increased our understanding of its progression. Yet CAD continues to be the No. 1 killer in the United States. This is especially ironic in that most of the major risk factors for CAD are modifiable.
In particular, decades of clinical studies have shown an association between cardiovascular disease and cholesterol abnormalities (1), and the American Heart Association (AHA) has classified cholesterol abnormalities as one of the major modifiable cardiovascular risk factors. By managing cholesterol levels, physicians and patients can reduce the threat of cardiovascular disease.

This article focuses on controlling blood lipids through diet and exercise, two important lifestyle elements that patients can control. (Also see "Alcohol and Cholesterol," below and "Triglycerides and Heart Disease," below.) Part 2, to appear in an upcoming issue, will cover the role of medication in modifying blood lipids.

Dietary Measures
The revised National Cholesterol Education Program (NCEP) guidelines (2) establish a practical, clear-cut, and useful framework for treating abnormal low-density lipoprotein cholesterol (LDL-C) levels with diet therapy (table 1). (The guidelines also present a coordinated framework for drug therapy that will be discussed in part 2 of this series.)
Saturated fats. The dietary guidelines call for decreasing fat consumption in general and saturated fats in particular, since the latter are directly related to the development of atherosclerosis. While intake of monounsaturated fats has an inverse relationship with atherosclerosis development, saturated fats, more than any other component of the diet, raise LDL-C (3). Additionally, diets high in saturated fats tend to be high in calories and low in other nutrients.

Stearic acid is a saturated fat found in foods such as beef and chocolate. Although it may not raise LDL-C, it is contained in foods--such as cocoa butter, beef tallow, lard, butter oil, chicken fat, and to a lesser extent, palm, soybean, coconut, and cottonseed oils--that are high in other types of saturated fats. Thus, limiting foods that contain stearic acid is recommended.

Can dietary therapy alone improve cholesterol profiles? Absolutely. The NCEP Step 2 Diet is designed to reduce serum cholesterol by limiting the intake of total fat and saturated fat to 30% and 7% of total calories, respectively, and the intake of cholesterol to 200 mg/day--guidelines also supported by the AHA (4). (Another method is to limit fat intake to 30 g/1,000 calories consumed, not to exceed 50 g/day.)

For CAD patients who change from an average American diet to the NCEP Step 2 Diet, dietary equations predict a drop of 10% to 20% in LDL-C. For patients whose diets include more fat than the average American diet, greater reductions in LDL-C can be expected. However, patients who have extremely high LDL-C levels (above 190 mg/dL) usually require medical therapy to control their abnormal cholesterol profiles. Dietary therapy is also appropriate in these patients. In fact, studies have shown that medication and diet work synergistically for such patients (5).

Other fats.
In addition to saturated fat, certain other types of fat can affect cholesterol profiles and cardiovascular disease risk, according to recent research.

Trans fatty acids. Trans fatty acids are partially hydrogenated fats derived from vegetable sources, such as those in margarine. Because these acids are not fully hydrogenated, they have been thought to be less atherogenic than fully hydrogenated (saturated) fats, which typically are derived from animal fats. For this reason, margarine has been widely used in cooking, particularly in foods such as cookies, pastries, breads, and french fries.
Unfortunately, trans fatty acids can negatively affect blood lipids, raising LDL-C levels and perhaps lowering high-density lipoprotein cholesterol (HDL-C). Furthermore, studies have implicated trans fatty acid intake in heart disease and myocardial infarctions (6,7). Although some smaller studies have not shown as significant a trend, it stands to reason that trans fatty acids should be limited according to the same criteria used for other fats.

Fish oils. Fats derived from fish have received attention for many years because of their potential for reducing cardiovascular disease risk. A recent report (8) suggests that healthy men who consume at least one serving of fish per week could reduce the risk of sudden cardiac death by 52% relative to those who never or rarely consume fish. This association held even after other cardiovascular risk factors were controlled.
Interestingly, subjects who consumed more than one serving of fish per week did not enjoy significantly more benefit than those who ate one serving per week, suggesting a threshold effect. The study suggests that a component of fish may have antiarrhythmic properties that reduce patients' risk of life-threatening arrhythmias during cardiac ischemia, thus decreasing sudden cardiac death.

Sugar. Another element of diet that is important in individuals who have abnormal cholesterol--and triglyceride--levels is sugar. Because of the emphasis on reducing dietary fat, many individuals have worked to decrease their fat consumption, but have actually increased their overall calorie intake because they have not paid attention to the amount of sugar they eat. This adversely affects their cholesterol profile, and the resulting calorie surplus can lead to weight gain. Patients need to know that dietary programs target fat consumption because fats are calorie dense and raise LDL-C, but low-fat diets that are high in sugar can cause problems as well.
We recommend that patients obtain 50% to 60% of their total calories from carbohydrates but limit simple carbohydrates (sugars) to 10% of total calories.

Antioxidants. In the past several years, the role of antioxidant supplements in preventing atherosclerosis and its progression has been of significant interest. Although much remains to be discovered, some effects of antioxidants are emerging.
Antioxidants do not work by lowering LDL-C or altering the cholesterol profile in general. Rather, they seem to decrease the incorporation of cholesterol particles into atherosclerotic plaque. Because oxidation of LDL-C is part of the process of generating luminal plaques, it stands to reason that substances that reduce this oxidation could favorably alter the cellular environment, decreasing the risk of plaque formation. Antioxidants are such substances because they can reduce the oxidative stress of tissues without themselves becoming pro-oxidative. Antioxidants may also play a role in decreasing the risk of plaque rupture, which leads to occlusion of the vessel and subsequent infarction.
Research regarding this role of antioxidants focuses particularly on vitamins E and C and beta-carotene. Studies are ongoing, but the preliminary data are sufficient to recommend the use of antioxidants, particularly in secondary prevention (9,10). Our standard recommendation is that patients take vitamin C, 500 mg twice daily; vitamin E, 400 IU once daily; and beta-carotene, 25,000 IU once daily. (Smokers should not take beta-carotene because current data show that it is not helpful and may be problematic (11,12). These recommendations are general guidelines and should be tailored to individual patients.
Patients should preferably receive most of their antioxidant vitamins through diet. With some attention, much of the daily vitamin C can be obtained through diet. However, taking in enough vitamin E through diet is much more difficult, since the foods that contain it also tend to be high in fats, so supplementation is typically necessary.
Although numerous other substances--such as selenium and ubiquinone--have been shown to have antioxidant properties, research on their effectiveness is limited and inconclusive.

Follow-up. In our experience, patients follow dietary guidelines well only if they have a specific, structured plan. Consequently, our nutrition staff works with each person to outline an appropriate and workable diet. Physicians who do not have nutritionists at hand should refer patients to a nutrition program in the community, especially those patients who are overweight or who have abnormal LDL-C, triglycerides, blood pressure, or blood sugar.
Further follow-up is important. We generally repeat lipid profiles after patients have followed a diet for 2 to 3 months. We use the opportunity to motivate patients who are making progress, adjust recommendations, and undertake more aggressive treatment for those whose lipids remain elevated.

Exercise
The role of exercise in reducing long-term cardiovascular risk is multifaceted. Regular aerobic exercise simultaneously improves cholesterol, blood pressure, blood sugar, and body fat percentage, so it is an important part of an ongoing preventive health program. However, patients considered to be high risk should undergo exercise test screening before beginning an exercise program.

Amount and type. Most of the data that deal with the effect of exercise on cholesterol metabolism focus on aerobic exercise. Research indicates that the volume of exercise may be more important than intensity in changing cholesterol profiles (13). More specifically, studies show that the volume of exercise--eg, miles run per week--has the most consistent effect on HDL-C levels.

A study (13) published by the Stanford Heart Disease Prevention Program suggested that reaching a threshold of running 10 miles per week for at least 9 months--or its equivalent in energy expenditure from other aerobic exercise--was necessary to produce a significant increase in the HDL-C level. Kokkinos et al(14) drew similar conclusions; they found that statistically significant increases in HDL-C occurred at distances of 7 miles or more per week and that the most important changes in HDL-C occurred in those who ran from 7 to 14 miles per week.

Though reaching an exercise threshold may significantly improve HDL-C levels, going beyond that threshold does not necessarily result in higher HDL-C levels. A 1989 study (15) from Japan evaluated runners who ran 30, 60, and 100 km/wk. It found that those who ran more than 30 km/wk did not have significantly higher HDL-C levels.
Other types of exercise, such as nonaerobic strength training, do not seem to increase HDL-C levels significantly. Furthermore, most of those doing research in this area believe that aerobic exercise, rather than anaerobic exercise, is necessary to raise HDL-C levels. Thus, physicians should emphasize the need for a foundation of aerobic exercise, even for athletes involved in strength training programs (13-15).

FIT guidelines. Predicting the effect of aerobic exercise on HDL-C in a given patient is difficult because of the many variables involved. Nevertheless, the "FIT" training principle (for frequency, intensity, and time or duration of exercise) (16) is useful for patients who are beginning an aerobic exercise program.

Frequency is the first consideration. Beginning with 3 days per week is appropriate for patients who are not overweight. Obese patients who want to use exercise to help control their weight may need to exercise 5 days per week.

Duration is the second consideration. Each session should involve at least 20 to 30 minutes of sustained aerobic exercise, such as walking, jogging, cycling, or swimming. In addition, individuals should spend 5 to 10 minutes in warm-up and cool-down exercise.
After frequency and duration, patients should focus on exercise intensity. This may be gauged in a variety of ways, but, in general, a heart rate between 60% and 80% of the age-predicted maximum capacity is a good goal. Too often patients exercise less frequently and more intensely (the "weekend warrior" syndrome), but studies have shown that such an exercise pattern does little to reduce mortality (17,18).

Physicians should consistently reinforce the need for a consistent, moderate aerobic exercise program as an ongoing part of patients' cholesterol treatment plan.
Fitness, Cholesterol, and Mortality

Exercise is also important in lowering the risk of mortality. Blair et al (19) have examined the relationship of physical fitness to cholesterol abnormalities and mortality. They found that patients who have low levels of fitness and abnormal cholesterol profiles are the most likely to die prematurely, while those who have high levels of fitness and normal cholesterol profiles are the least likely.

Their data include two striking scientific findings: (1) Patients who were only modestly fit had a 55% reduction in overall premature mortality compared with the rate of premature mortality in unfit individuals; and (2) highly fit patients who had high cholesterol had lower premature mortality than unfit patients who had normal cholesterol profiles. A follow-up study (20) revealed that subjects who improved their level of fitness thereby lowered their risk of early death, further supporting the theory that physical fitness affects mortality.

Back to Basics
Though sophisticated technology has been important in developing modern means for treating patients who have CAD, basics such as diet and exercise are obviously essential. Physicians and patients who focus on these two areas can work as partners to promote cardiovascular health.

Medications are also an important part of the modern armamentarium. Part 2 of this series will focus on the role of bile acid sequestrants, fibric acid derivatives, statins, and niacin in controlling blood lipids.

References
LaRosa JC, Hunninghake D, Bush D, et al: The cholesterol facts: a summary of the evidence relating dietary fats, serum cholesterol, and coronary heart disease: a joint statement by the American Heart Association and the National Heart, Lung, and Blood Institute. Circulation 1990;81(5):1721-1733
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Summary of the Second Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel II). JAMA 1993;269(23):3015-3023
Butter or margarine? Harvard Heart Letter 1997;8(2):1-2
Smith SC, Blair SN, Criqui MH, et al: Preventing heart attack and death in patients with coronary disease: consensus panel statement. Circulation 1995;92(1):2-4
Pearson T: Diet alone versus diet plus lipid-lowering drugs. Presented at American Heart Association National Meeting, New Orleans, Nov 11-14, 1996
Women and risk: some findings from the Nurses' Study, Harvard Heart Letter 1996;7(4):3
Ascherio A, Hennekens CH, Buring JE, et al: Trans-fatty acid intake and risk of myocardial infarction. Circulation. 1994;89(1):94-101
Albert CM, Hennekens CH, O'Donnell CJ, et al: Fish consumption and risk of sudden cardiac death. JAMA 1998;279(1):23-28
Hodis HN, Mack WJ, LaBree L, et al: Serial coronary angiographic evidence that antioxidant vitamin intake reduces progression of coronary artery atherosclerosis. JAMA 1995;273(23):1849-1854
Rapola JM, Virtamo J, Haukka JK, et al: Effect of vitamin E and beta-carotene on the incidence of angina pectoris: a randomized, double-blind, controlled trial. JAMA 1996;275(1):693-698
The effect of vitamin E and beta-carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med 1994;330(15):1029-1035
Omenn GS, Goodman GE, Thornquist MD, et al: Risk factors for lung cancer and for intervention effects in CARET, the Beta-Carotene and Efficacy Trial. J Natl Cancer Inst 1996;88(21):1550-1559
Williams PT, Wood PD, Haskell WL, et al: The effects of running mileage and duration on plasma lipoprotein levels. JAMA 1982;247(19):2674-2679
Kokkinos PF, Holland JC, Narayan P, et al: Miles run per week and high-density lipoprotein cholesterol levels in healthy, middle-aged men: a dose-response relationship. Arch Intern Med 1995;155(4):415-420
Higuchi M, Iwaoka K, Fuchi T, et al: Relation of running distance to plasma HDL-cholesterol level in middle-aged male runners. Clin Physiol 1989;9(2):121-130
American College of Sports Medicine: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 1990;22(2):265-274
Norris JN, Clayton DG, Everitt MG, et al: Exercise in leisure time: coronary attack and death rates. Br Heart J 1990;63(6):325-334
Linsted KD, Tonstad S, Kusma JW: Self-report of physical activity and patterns of mortality in Seventh-Day Adventist men. J Clin Epidemiol 1991;44(4-5):355-364
Blair SN, Kohl HW III, Paffenbarger RS Jr, et al: Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA 1989;262(17):2395-2401
Blair SN, Kohl HW III, Barlow CE, et al: Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995;273(14):1093-1098


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Healing Heel Pain - Help for Plantar Fasciitis
Michael Shea, MD; Karl B. Fields, MD
Practice Essentials Series Editors:
Kim Harmon, MD; Aaron Rubin, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 7 - JULY 2002

If your feet, especially the heels and arches, hurt when you step out of bed in the morning, you may have plantar fasciitis. It may take 6 months or longer for the pain to go away, but there are some things you can do in the meantime to cope with the pain and heal faster.

Q. What is plantar fasciitis?
A. Strong, fibrous bands connect the bones inside the bottom of your foot (figure 1). "Plantar" means the sole of the foot, and "fascia" means band (like a rubber band). When the plantar fascia is injured or irritated, it's called plantar fasciitis. The damage leads to pain in your heels and arches.



Q. What causes plantar fasciitis?
A. Sometimes it is caused by overuse, but other factors may contribute, such as improper footwear, flat feet, or high-arched feet. If your calf muscles are weak or your feet are not flexible, you may develop the condition. Runners often suffer from plantar fasciitis if they increase the distance or intensity of their workouts too fast.

Q. What can I do to lessen the pain?
A. Follow your doctor's instructions and apply ice for 10 minutes several times a day (especially after activity and at bedtime), using an ice bath or cubes in a bag. If ice cubes aren't available, a bag of frozen peas works well, or you can roll your feet on frozen juice cans or chilled soda cans. If you do this while standing, hold a chair for balance.
Your doctor may prescribe painkillers, such as aspirin or ibuprofen. Foam heel cups or shoe inserts (called orthotic devices) may also be helpful. You may need an injection into the heel, or you may need to wear a splint at night. Your doctor may recommend surgery, but this is usually a last resort.
In addition to other therapies, stretching and strengthening exercises for the Achilles tendon (the cord you can feel at the back of your ankle) and the calf muscles will help you heal faster. These exercises are done barefoot.
Do heel raises on the stairs to help stretch and strengthen the Achilles tendon and the plantar fascia (figure 2).



Walk on your toes only, then walk on your heels only, then walk backward to the starting point. Carry hand weights (10 to 20 pounds) to increase the value of these exercises.
Walk or run barefoot whenever possible.

As the pain decreases and your strength improves, gradually return to your usual activities. Exercises that keep your full weight off your feet, such as bicycling or swimming, will help you maintain fitness during recovery.
Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

Dr Shea and Dr Fields are family practice physicians at Moses Cone Family Practice in Greensboro, North Carolina.


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