Monday, November 29, 2010

Cigarettes, Wrinkles and Pimples

You are, of course, aware that smoking can speed up the normal aging process of your skin, contributing to wrinkles.

How does smoking lead to wrinkles?

The nicotine in cigarettes causes narrowing of the blood vessels in the outermost layers of your skin. This impairs blood flow to your skin. With less blood flow, your skin doesn't get as much oxygen and important nutrients, such as vitamin A. Many of the over 4,000 chemicals in tobacco smoke also damage collagen and elastin, which are fibers that give your skin its strength and elasticity. As a result, skin begins to sag and wrinkle prematurely because of smoking.

In addition, repeated exposure to the heat from burning cigarettes and the facial expressions you make when smoking — such as pursing your lips when inhaling and squinting your eyes to keep out smoke — may contribute to wrinkles.

Smoking Also Causes PIMPLES!

Now, if you need another reason to motivate you to quit smoking, add pimples to the list.

Bruno Capitanio, M.D., of the Istituti Fisioterapici Ospitalieri in Rome, and colleagues examined 226 adult women with acne and found that 192 of the women (85 percent) had CPAA, and 34 had papulopustular postadolescent acne. One hundred fifty of the women (66.3 percent) were smokers, but smoking was identified in 72.9 percent of those with CPAA and only 29.4 percent of those with papulopustular postadolescent acne.

CPAA is comedonal postadolescent acne and it appears to be strongly linked to smoking cigarettes.

Nicotine is an agonist of acetylcholine (ACh) and it is thought that stimulation of ACh receptors on epidermal keratinocytes results in hyperproliferation and increased differentiation. To put it simply, nicotine causes the overproduction of skin cells which are shed more rapidly and then sticking together to plug the opening of the hair follicle. Sometimes the plugged hair follicles rupture leading to the formation of pustules, nodules, abscesses and cysts.

References

Data from Mayo Clinic.

Capitanio B, Sinagra JL, Bordignon V, Cordiali Fei P, Picardo M, Zouboulis CC. Underestimated clinical features of postadolescent acne. J Am Acad Dermatol. 2010 Nov;63(5):782-8.

Acetylcholine: A key chemical in neurons (nerve cells) that acts as a neurotransmitter and carries information across the synaptic cleft, the space between two nerve cells.

Picture Credit 1; Picture Credit 2

CLICK HERE for more than 25 posts on Smoking Cessation.

Saturday, November 27, 2010

DHA dan Strok

Asid Docosahexaenoic (DHA), suatu asid lemak omega-3 esensial, dapat melindungi pesakit strok dari kerosakan otak dan kecacatan dan membantu pemulihan lebih cepat.

Penelitian yang diketuai oleh Nicolas Bazan di Louisiana State University Health Sciences Center telah menunjukkan bahawa komponen minyak ikan dapat memperbaiki otak sehingga lima jam selepas bermula terjadinya stroke.
Strok iskemik hasil dari kehilangan aliran darah ke kawasan otak akibat penyumbatan seperti gumpalan atau aterosklerosis. Kerosakan merangkumi kecederaan sel-sel teras yang kekal di lokasi penyumbatan. Kawasan sekitar sel-sel teras, yang disebut penumbra, juga rosak tetapi berpotensi diselamatkan. Penumbra ini mempunyai jangka hayat yang terhad dan kelihatannya mengalami kerosakan kekal dalam beberapa jam kecuali aliran darah dibina semula dan terapi saraf dilakukan. Satu aliran bahan kimia yang membanjiri sel-sel bersama-sama dengan aliran darah yang dikembalikan, termasuk radikal bebas yang merosakkan dan enzim pro-inflamasi akan menyebabkan kerosakan lebih lanjut dan menyebabkan kematian sel.

Strok menyebabkan kecacatan jangka panjang, dan rawatan dengan ubat pencegah darah beku (trombolisis) harus diberikan segera setelah gejala-gejala muncul. Namun kerana tetingkap terapeutik yang sempit dan pentadbiran yang kompleks, hanya 300% dari pesakit bermanfaat dari trombolisis.

Dalam kajian tersebut, para saintis diberikan sama ada DHA atau normal saline secara intravena kepada tikus pada 3, 4 dan 6 jam dari bermulanya strok, kemudian dibandingkan kesannya pada pemulihan pembengkakan otak dan neurobehavioral.

Magnetic Resonance Imaging (MRI) menunjukkan bahawa volume otak yang rosak akibat strok menurun sekitar 40 peratus pada 3 jam, 66 peratus pada 4 jam, dan 59 peratus pada 5 jam apabila DHA diberikan selepas bermulanya strok.

Analisis lebih lanjut menunjukkan DHA mengurangkan kawasan kerosakan otak dengan mencetuskan Neuroprotectin D1 (NPD1, molekul pelindung otak).

Dr Bazan mengatakan "Kami hanya baru mula untuk memahami kesan signifikan dari asid lemak omega-3 esensial pada strok. Tidak ada penyelesaian sederhana lagi, namun setiap penemuan baru membawa kita lebih dekat untuk melawan penyakit strok dan melemahkan neurodegeneratif lain.. Dari terapi titik pandang, kita sekarang dapat melihat cahaya di hujung terowong. "

Jurnal rujukan: Ludmila Belayev, Larissa Khoutorova, Kristal D. Atkins, Tiffany N. Eady, Song Hong, Yan Lu, Andre Obenaus, Nicolas G. Bazan. Docosahexaenoic Acid Therapy of Experimental Ischemic Stroke. Translational Stroke Research. Published online 04 November 2010; TEKS LENGKAP

DHA adalah asid lemak omega-3 esensial dan sangat penting untuk fungsi otak yang sempurna. Hal ini juga diperlukan untuk pembangunan sistem saraf, termasuk penglihatan. Selain itu, asid lemak omega-3, dijumpai dalam lemak ikan laut dalam, termasuk salmon, tuna, mackerel, sarden, kerang, dan ikan haring, merupakan sebahagian daripada diet yang sihat yang membantu menurunkan risiko penyakit jantung. DHA mempunyai kesan anti inflamasi yang kuat. Kerana keradangan adalah akar dari banyak penyakit kronik, rawatan DHA telah banyak menunjukkan kesan menguntungkan pada pesakit jantung koroner, asma, rheumatoid arthritis, osteoporosis, sepsis, kanser, penyakit mata kering, dan degenerasi makula berkaitan usia. Dan sekarang adalah alasan yang baik untuk melengkapi diet kita dengan asid lemak Omega-3.

PANDUAN PENCEGAHAN STROK


Panduan pencegahan strok dari National Stroke Association
dapat membantu anda mempelajari bagaimana anda dapat menurunkan risiko strok pertama:

  1. Tahu tekanan darah anda.
  2. Cari tahu apakah anda mempunyai atrial fibrilasi.
  3. Jika anda merokok, berhenti.
  4. Jika anda minum alkohol, lakukan secara sederhana.
  5. Cari tahu apakah anda mempunyai kolesterol tinggi
  6. Jika anda mengidap diabetes ...
  7. Bersenam.
  8. Nikmati diet rendah natrium (garam), diet rendah lemak.
  9. Masalah peredaran (pergerakan darah melalui jantung dan pembuluh darah).
  10. Mengenal Gejala Stroke.

Regular Exercise Keeps Dementia and Other Diseases at Bay – 5

What is the point I’ve never been able to lose weight or give up smoking?

Ideally, to gain maximal health benefits, men should exercise, not smoke, eat a healthy diet and have a body mass index (BMI) of <>

The more of these healthy traits an individual has the less likely they are to develop a range of chronic disorders.

It is obviously desirable for an individual to give up smoking and maintain a healthy weight range, but if they can not, they will still gain health benefits from increasing their physical activity (3,34–36).

It is important to explain the health benefits of losing weight or giving up smoking, but if a patient can not, they should still be encouraged to be more physically active.

The above is an extract from a paper by Leslie Alford from the University of East Anglia on the impact of regular exercise on our physical and mental health. You can obtained the references by clicking on FULL TEXT.

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731

Thursday, November 25, 2010

DHA, Memory and Cognitive Function in Older Adults

Memory loss, dementia and the development of Alzheimer's disease are prominent health concerns for older individuals

DHA is the principle omega-3 fatty acid in the brain. It is well known that that low DHA levels are associated with cognitive decline in healthy elderly and Alzheimer's patients, and high DHA levels help reduce the risk of Alzheimer's disease.

The "Memory Improvement with Docosahexaenoic Acid Study" (MIDAS) was a randomized, double-blind, placebo-controlled study to evaluate the effects of DHA -- the principle omega-3 fatty acid in the brain -- on improving cognitive functions in healthy older adults with age-related cognitive decline.

485 subjects, aged 55 and older were randomly assigned 900 mg/d of algal DHA orally or a placebo for 24 weeks.

The study found that DHA taken for six months improved memory and learning in healthy, older adults with mild memory complaints.

These findings underscore the importance of early DHA intervention. While the MIDAS study focused on a population of healthy adults with age-associated memory impairment, a study recently published in the Journal of the American Medical Association (JAMA), conducted in a population that had previously been diagnosed with Alzheimer's disease, did not indicate DHA provided a statistically significant benefit to cognitive function. Joseph Quinn, lead author of the JAMA study, also highlighted that their results may have been different had DHA been administered before the participants' disease progressed.

This is indeed very encouraging news for those of us who are concerned about maintaining memory.

Journal References:

  1. Karin Yurko-Mauro, Deanna McCarthy, Dror Rom, Edward B. Nelson, Alan S. Ryan, Andrew Blackwell, Norman Salem Jr., Mary Stedman. Beneficial effects of docosahexaenoic acid on cognition in age-related cognitive decline. Alzheimer's and Dementia, 2010; 6 (6): 456
  2. Quinn JF, Raman R, Thomas RG, Yurko-Mauro K, Nelson EB, Van Dyck C, Galvin JE, Emond J, Jack CR Jr, Weiner M, Shinto L, Aisen PS. Docosahexaenoic acid supplementation and cognitive decline in Alzheimer disease: a randomized trial. JAMA. 2010 Nov 3;304(17):1903-11.
Randomised Double-Blind, Placebo-Controlled Study: A study in which people are allocated at random (perhaps by flipping a coin) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. The control may be a standard practice, a placebo ("sugar pill"), or no intervention at all and neither the researchers nor the participants know which is which until the study ends (they are thus both “blind”).

Randomised double-blind, placebo-controlled study seek to measure and compare the outcomes after the participants receive the interventions. Because the outcomes are measured, randomised double-blind, placebo-controlled studies are quantitative studies.

BiO-LiFE Salmon Oil 1000mg Vegicaps® supplies 120mg DHA per capsule

Pristin Omega-3 supplies 264mg DHA per capsule

Regular Exercise Keeps Dementia and Other Diseases at Bay – 4

Is it too late?/Am I too old to start?

The scientific evidence suggests that those who are middle aged or elderly and physically active should continue to be so. Those who are not should increase their physical activity levels (12).

Stessman et al. (31) found that continuing and indeed commencing physical activity once very old was associated with better survival and function.

King et al. (32) found those in middle age who adopted a healthy lifestyle (five fruit and vegetables, exercise, healthy weight and no smoking) had statistically significant reduction in cardiovascular disease (CVD) and all cause mortality.

Similarly, Yates et al. (1) found that smoking abstinence, weight management, blood pressure control and regular exercise were associated with extended lifespan, good health and improved function during older age.

Byberg et al. (33) found that a cohort of 50-year-old men who increased their physical activity levels achieved a similar reduction in mortality to that of men who had always been physically active. It took 10 years, however, for the groups to reach parity. In

addition to the benefits previously mentioned, there is growing evidence that physical activity helps to maintain cognitive performance and decreases the risk of dementia in the elderly (12).

The above is an extract from a paper by Leslie Alford from the University of East Anglia on the impact of regular exercise on our physical and mental health. You can obtained the references by clicking on FULL TEXT.

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731

Picture Credit

Monday, November 22, 2010

Poor Sleep Quality and Cardiovascular Diseases

Growing evidence links sleep quality to cardiovascular disease (CVD) risk, and an increased production of inflammatory hormones and changes in blood vessel function may be one mechanism by which sleep deprivation affects CVD outcomes.

Previous researches into the body’s response to lack of sleep have looked at subjects who have been acutely sleep deprived for more than 24 hours in experimental sleep laboratories.

In contrast, Alanna Morris et al investigated the association of chronic lack of sleep with inflammation in 525 middle-aged people in a community-based setting.

Their report presented on Nov. 14 at the American Heart Association Scientific Sessions in Chicago confirmed that individuals who reported six or fewer hours of sleep had higher levels of three inflammatory markers: fibrinogen, IL-6 and C-reactive protein.

In particular, average C-reactive protein levels were about 25 percent higher (2 milligrams per liter compared to 1.6) in people who reported fewer than six hours of sleep, compared to those reporting between six and nine hours.

That difference was still significant even when the data is corrected for known risk factors such as smoking, blood pressure, diabetes and obesity, and this is further underlined by the fact that the study population represents a community-based population [as opposed to patients in the hospital or with known cardiovascular disease].

Picture Credit

Definitions

C-reactive protein is used extensively as a marker of inflammation and heart disease risk. People whose C-reactive protein levels are in the upper third of the population (above 3 milligrams per liter) have roughly double the risk of a heart attack, compared with people with lower C-reactive protein levels, according to the American Heart Association and Centers for Disease Control and Prevention.

The major CardioVascular Diseases include:

  • Coronary (or ischaemic) heart disease (heart attack)
  • Cerebrovascular disease (stroke)
  • Hypertension (high blood pressure)
  • Heart failure
  • Rheumatic heart disease
An estimated 16.7 million - or 29.2% of total global deaths - result from the various forms of cardiovascular disease (CVD), many of which are preventable by action on the major primary risk factors: unhealthy diet, physical inactivity, and smoking.

Good night. Sleep tight. Don't let the bedbugs bite
:)

SLEEP HYGIENE TIPS

If you have problem sleeping, here’s an updated Hints to Help You Sleep by the University of Maryland Medical Center

Poor sleep habits (referred to as hygiene) are among the most common problems encountered in our society. We stay up too late and get up too early. We interrupt our sleep with drugs, chemicals and work, and we overstimulate ourselves with late-night activities such as television.

Below are some essentials of good sleep habits. Many of these points will seem like common sense. But it is surprising how many of these important points are ignored by many of us.

Your Personal Habits

Fix a bedtime and an awakening time. Do not be one of those people who allows bedtime and awakening time to drift. The body "gets used" to falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.

  • Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a "sleepy time." Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30-45 minutes and can sleep well at night.
  • Avoid alcohol 4-6 hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in your blood start to fall, there is a stimulant or wake-up effect.
  • Avoid caffeine 4-6 hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.
  • Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime. These can affect your ability to stay asleep.
  • Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the 2 hours before bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
  • Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.
  • Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.
  • Block out all distracting noise, and eliminate as much light as possible.
  • Reserve the bed for sleep and sex. Don't use the bed as an office, workroom or recreation room. Let your body "know" that the bed is associated with sleeping.
Getting Ready For Bed
  • Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.
  • Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.
  • Don't take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a "worry period" during the evening or late afternoon to deal with these issues.
  • Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
  • Get into your favorite sleeping position. If you don't fall asleep within 15-30 minutes, get up, go into another room, and read until sleepy.
Getting Up in the Middle of the Night

Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.

A Word About Television

Many people fall asleep with the television on in their room. Watching television before bedtime is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good idea.

Other Factors

  • Several physical factors are known to upset sleep. These include arthritis, acid reflux with heartburn, menstruation, headaches and hot flashes.
  • Psychological and mental health problems like depression, anxiety and stress are often associated with sleeping difficulty. In many cases, difficulty staying asleep may be the only presenting sign of depression. A physician should be consulted about these issues to help determine the problem and the best treatment.
  • Many medications can cause sleeplessness as a side effect. Ask your doctor or pharmacist if medications you are taking can lead to sleeplessness.
  • To help overall improvement in sleep patterns, your doctor may prescribe sleep medications for short-term relief of a sleep problem. The decision to take sleeping aids is a medical one to be made in the context of your overall health picture.
  • Always follow the advice of your physician and other healthcare professionals. The goal is to rediscover how to sleep naturally.
Picture Credit

Regular Exercise Keeps Dementia and Other Diseases at Bay – 3

What should I do?

Walking, cycling, running, aerobic sports, land ⁄ water based aerobics classes, dancing, swimming, stair climbing, gym, gardening ⁄ yard work and other similar activities performed at an appropriate intensity all count towards physical activity.

Which is most appropriate depends on an individual’s lifestyle, what is enjoyable to the individual and presence of other pathologies.

An example of a pathology that might influence the type of advised physical activity could be osteoarthritis (OA). For a patient with severe knee OA, it may be better to recommend cycling/pool based exercise rather than jogging or high impact running sports (27). Other factors such as osteopenia should also be taken into account.

Weight bearing impact exercise such as running based sports, high impact aerobics or walking with a weighted back pack are better for maintenance of bone density than swimming or cycling (28,29). If sarcopenia is a concern, the addition of a strengthening programme may be appropriate.

Exercise prescription may also vary with age, an example being the addition of balance training exercises in older adults (7,12).

Recommending increased physical activity is the first step, but for motivated individuals tailored programmes can be designed to best match individual needs (7).

The current evidence base suggests that even in those with health problems, there should be some performance of exercise/physical activity (16,30).

The above is an extract from a paper by Leslie Alford of the University of East Anglia on the impact of regular exercise on our physical and mental health. You can obtained the references by clicking on FULL TEXT.

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731

Definitions

Osteoarthritis is the most common form of arthritis. It causes pain, swelling and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. Osteoarthritis breaks down the cartilage in your joints. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage absorbs the shock of movement. When you lose cartilage, your bones rub together. Over time, this rubbing can permanently damage the joint. Source: MedlinePlus

Osteopenia refers to bone mineral density (BMD) that is lower than normal peak BMD but not low enough to be classified as osteoporosis. Bone mineral density is a measurement of the level of minerals in the bones, which indicates how dense and strong they are. If your BMD is low compared to normal peak BMD, you are said to have osteopenia. Having osteopenia means there is a greater risk that, as time passes, you may develop BMD that is very low compared to normal, known as osteoporosis. Source: WebMD

Sarcopenia is the loss of skeletal muscle mass and strength with age. It is common in men and women, with prevalence ranging from 9% to 18% over the age of 65. Recognition of its serious health consequences in terms of frailty, disability, morbidity, and mortality is increasing. Source: BMJ

Picture Credit

Saturday, November 20, 2010

DHA and Stroke

Docosahexaenoic acid (DHA), an essential omega-3-fatty acid, can protect stroke victims from brain damage and disability and aid in a speedier recovery.

Research led by Nicolas Bazan at Louisiana State University Health Sciences Center has shown that the fish oil component can repair the brain up to five hours after the onset of stroke.

Ischaemic strokes result from loss of blood flow to an area of the brain due to a blockage such as a clot or atherosclerosis. The damage includes an irreversibly injured core of tissue at the site of the blockage. The area of tissue surrounding the core, called the penumbra, is also damaged but potentially salvageable. The penumbra has a limited life span and appears to undergo irreversible damage within a few hours unless blood flow is reestablished and neuroprotective therapy is administered. A cascade of chemicals floods the tissue along with restored blood flow, including damaging free radicals and pro-inflammatory enzymes which can cause further damage and cell death.

Stroke leads to long-term disability, and the current treatment with clot-busting drugs (thrombolysis) has to be administered soon after symptoms occur. But due to a narrow therapeutic window and complexity of administration, only 300% of patients benefit from thrombolysis.

In the study, scientists administered either intravenous DHA or saline to mice at 3, 4 and 6 hours of onset of stroke, comparing the effects on brain swelling and neurobehavioral recovery.

Magnetic resonance imaging (MRI) showed that the volume of brain destroyed by stroke was reduced approximately 40 percent at 3 hours, 66 percent at 4 hours, and 59 percent when DHA was given up to 5 hours after the onset.

Further analysis showed DHA reduced the area of brain damage by triggering Neuroprotectin D1 (NPD1, a brain protective molecule.

Dr. Bazan says "We are just now beginning to understand the significant impact of omega-3 essential fatty acids on stroke. There is no simple solution just yet, but each new discovery brings us closer to defeating stroke and other debilitating neurodegenerative diseases. From a therapeutic point of view, we can now see a light at the end of the tunnel.”

Journal Reference: Ludmila Belayev, Larissa Khoutorova, Kristal D. Atkins, Tiffany N. Eady, Song Hong, Yan Lu, Andre Obenaus, Nicolas G. Bazan. Docosahexaenoic Acid Therapy of Experimental Ischemic Stroke. Translational Stroke Research. Published online 04 November 2010; FULL TEXT

DHA is an essential omega-3-fatty acid and is vital for proper brain function. It is also necessary for the development of the nervous system, including vision. Moreover, omega-3 fatty acids, found in cold water fatty fish, including salmon, tuna, mackerel, sardines, shellfish, and herring, are part of a healthy diet that helps lower the risk of heart disease. DHA has potent anti-inflammatory effects. Since inflammation is at the root of many chronic diseases, DHA treatment has been widely demonstrated to have beneficial effects in patients with coronary heart disease, asthma, rheumatoid arthritis, osteoporosis, sepsis, cancer, dry eye disease, and age-related macular degeneration. And now we another good reason to supplement our diet with Omega-3 fatty acids

STROKE PREVENTION GUIDELINES

National Stroke Association's stroke prevention guidelines will help you learn how you may be able to lower your risk for a first stroke:

  1. Know your blood pressure.
  2. Find out if you have atrial fibrillation.
  3. If you smoke, stop.
  4. If you drink alcohol, do so in moderation.
  5. Find out if you have high cholesterol
  6. If you are diabetic...
  7. Exercise.
  8. Enjoy a lower sodium (salt), lower fat diet.
  9. Circulation (movement of the blood through the heart and blood vessels) problems.
  10. Know the Symptoms of Stroke.

Regular Exercise Keeps Dementia and Other Diseases at Bay - 2

How much physical activity should I do?

The American College of Sports Medicine and the American Heart Association have put out physical activity recommendations for healthy adults aged between 18 and 65 (25).

The core recommendations are that individuals should aim for a minimum of 30 min on 5 days each week of moderate intensity aerobic exercise (brisk walking is an example).

This can be substituted by vigorous intensity exercise for a minimum of 20 min 3 days each week (jogging is an example). A combination of moderate and vigorous exercise can be used to meet the guidelines. In addition, strength training 2 days a week using the major muscle groups with a load that allows 8–12 repetitions to volitional fatigue is also recommended.

For healthy older adults the recommendations are essentially the same but the addition of balance and flexibility training should also be considered.

Frequently in the research literature when advising / assessing level of physical activity, 150 min / week of moderate intensity physical activity is used as a level to aim for. For both clinical and research purposes this is a useful guide as it is clear and easily remembered.

Although these guidelines give a benchmark, there is a strong dose response rate and doing more is associated with increased benefits (25). The Cancer Research Fund/ American Institute for Cancer Research recommends at least 60 min a day of physical activity. Research findings indicate that the benefits of decreased risk of cancer are more evident at higher levels of physical activity (12,19).

It must be noted, however, that physical activity that does not reach the level of the guidelines is still beneficial (14,15). Bouts of appropriately intense activity of 10 min or more can also count towards daily quota (25). Although episodic accumulation has been shown to improve fitness to the same degree as a continuous session, it has not been firmly established whether equivalent health benefits are also gained (26).

The above is an extract from a paper by Leslie Alford from the University of East Anglia on the impact of regular exercise on our physical and mental health. You can obtained the references by clicking on FULL TEXT.

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731

Picture Credit

Degenerasi Makula, Lutein dan Zeaxanthin


Degenerasi Makula

Degenerasi makula adalah penyakit mata yang tidak boleh disembuhkan dan merupakan penyebab utama kebutaan bagi mereka yang berusia 55 tahun dan lebih tua di Amerika Syarikat, meliputi lebih daripada 10 juta orang Amerika, dari 310 juta jumlah penduduknya.

Degenerasi makula disebabkan oleh kerosakan bahagian tengah retina, lapisan belakang dalam mata yang merekodkan imej yang kita lihat dan menghantarnya melalui saraf optik dari mata ke otak. Bahagian pusat retina, yang dikenali sebagai makula, bertanggung jawab untuk memfokuskan pusat penglihatan di mata, dan ia mengawal kemampuan kita untuk membaca, memandu kereta, mengenali wajah atau warna, dan melihat benda-benda secara terperinci.

Semakin kita b
erusia, potensi untuk mendapat penyakit mata meningkat secara drastik. Malangnya, faktor-faktor khusus yang menyebabkan degenerasi makula tidak diketahui secara pasti dan kajian penyakit ini kurang difahami serta dibatasi oleh dana yang tidak mencukupi.

The American Macular Degeneration Foundation, laman web AMDF akan membantu anda untuk lebih memahami degenerasi makula. Untuk memahami degenerasi makula, anda mestilah memiliki pengetahuan dasar tentang anatomi mata manusia biasa.

Untuk animasi yang menunjukkan kehilangan pusat penglihatan dari degenerasi makula, klik di sini. (Presentasi ini memerlukan Quicktime video.)

Lutein dan Zeaxanthin

Warna kuning dari makula lutea adalah kerana kehadiran pigmen karotenoid lutein dan zeaxanthin. Berbeza dengan darah manusia dan sel-sel, tidak ada karotenoid utama yang lain termasuk Beta-karoten atau lycopene ditemui dalam sel-sel ini. Karotenoid makula dikatakan berperanan dalam melindungi retina terhadap cahaya yang menyebabkan kerosakan.

Pengajian epidemiologi memberikan beberapa bukti bahawa peningkatan pengambilan lutein dan zeaxanthin dengan diet dikaitkan dengan risiko yang lebih rendah untuk degenerasi makula yang berkaitan dengan usia, penyakit yang semakin meningkat dan terjadi pada usia lanjut1.

Lutein dan zeaxanthin bertindak melindungi sel-sel okular dengan dua cara: pertama sebagai penapis untuk cahaya biru yang merosakkan, dan kedua sebagai antioksidan yang menghapus molekul oksigen triplet atau molekul oksigen tunggal dan selanjutnya memilih oksigen reaktif seperti peroksida lipid atau anion superoksida radikal.

Makanan sumber lutein dan zeaxanthin termasuk telur, kailan, bayam, lobak hijau, Collard hijau, salad, brokoli, zucchini, jagung, kacang polong dan kubis Brussels. Untuk memaksimumkan kandungan karotenoid dalam makanan yang disenaraikan di atas, makanan mestilah dimakan mentah atau dikukus ringan.

OCCUsharp oleh Live-Well mengandungi lutein dan zeaxanthin yang berasal dari bunga Marigold. Ia datang dengan PROMOSI ISTIMEWA "Beli 2 Percuma 1".

Vitalux Plus oleh Novartis memberikan 4mg lutein dengan beta-karoten, Vit C, Vit E, Vit B2, selenium, zink dan tembaga dalam tablet 'Time-Release'.

Jurnal Rujukan

1. Stahl W. Macular carotenoids: lutein and zeaxanthin. Developments in Ophthalmology. 2005;38:70-88.

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Thursday, November 18, 2010

Regular Exercise Keeps Dementia and Other Diseases at Bay

An extensive research review summarising the key findings of 40 papers published between 2006 and 2010 finds that apart from not smoking, being physically active is the most powerful lifestyle choice any individual can make to improve their health.

Health conditions covered by the review include: cancer, heart disease, dementia, stroke, type 2 diabetes, depression, obesity and high blood pressure.

Leslie Alford from the University of East Anglia says that people who take regular exercise could reduce their risk of developing around two dozen physical and mental health conditions -- including some cancers and dementia -- and slow down how quickly their body deteriorates as they age.

Although the focus of the study was on men's health, the messages on physical activity are relevant to both sexes and all age groups.

Leslie’s paper is ivided into a number of key sections:

  1. Why should I exercise?
  2. How much physical activity should I do?
  3. What should I do?
  4. Is it too late?/Am I too old to start?
  5. What is the point I’ve never been able to lose weight or give up smoking?
  6. I’m too busy/I don’t have time

We shall present these by installments, starting below with the big question: Why should I exercise?

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731
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Regular Exercise Keeps Dementia and Other Diseases at Bay - 1

Why should I exercise?

Living a sedentary lifestyle is a risk factor for many chronic diseases and increases an individual’s chance of premature mortality (8–10).

The link between increased physical activity and reduced risk of cardiovascular disease (CVD) is well established (5,6). Regular moderate to intense physical activity is associated with decreased risk of coronary heart disease, ischaemic and haemorrhagic stroke (11,12). The benefits of regular physical activity also extend to secondary prevention in patients with established CVD (6).

In addition, a growing body of evidence suggests that increasing physical activity can also reduce risk of certain types of cancers, osteoporosis, type 2 diabetes, depression, obesity and hypertension (5,9,13).

Rhodes et al. (14) note that regular physical exercise is presently considered to be beneficial in the primary and secondary prevention of about 25 conditions.

Regular exercise and physical activity can also reduce or slow the deterioration associated with age related changes in many of the body’s systems (15).

Evidence of the beneficial effects of physical activity in the primary prevention and management of cancer is growing (6,16). Cancer mortality has been found to be inversely related to physical activity levels (17,18). In addition to decreased mortality Orsini et al. (19) found that walking or cycling for at least an hour a day was associated with a 16% reduction in overall cancer incidence. For specific cancer sites the evidence is mixed. For colon cancer in both sexes, there is a strong relationship between increased physical activity and decreased incidence (20,21).

Other cancers in men have yet to demonstrate such a clear relationship. Prostate cancer incidence seems to be less for those who are active at work, defined as not sitting for most of the day (22,23). The link with leisure time physical activity is less clear. The European Prospective Investigation into Cancer and Nutrition did not find a link between prostate cancer and leisure time physical activity (23). Orsini et al. (22), however, did find that walking or cycling for more than 30 mins a day was associated with decreased incidence. Also of note is that post diagnosis, physical activity can aid recovery and improve outcomes (16).

As men age, the risk of erectile dysfunction increases. There are many potential factors that can contribute to the problem. Amongst these a number of modifiable lifestyle variables have been identified. Physical inactivity and obesity are associated with increased risk of erectile dysfunction (24). Conversely being physically active is associated with decreased risk.

The above is an extract from a paper by Leslie Alford from the University of East Anglia on the impact of regular exercise on our physical and mental health. You can obtained the references by clicking on FULL TEXT.

Journal Reference:

L. Alford. What men should know about the impact of physical activity on their health. International Journal of Clinical Practice, 2010; 64 (13): 1731

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Wednesday, November 17, 2010

10 Common Happiness Mistakes

Gretchen Rubin shares her insights to help you avoid the 10 Common Happiness Mistakes that most of us keeping making:
  1. To delay to do something important until you have some “free time,” because you may never have any free time
  2. To retreat into isolation when you’re unhappy
  3. To neglect to make a small change because you think a big change is necessary
  4. To refuse to consider a big change because you assume you can only make a small change
  5. To “treat” yourself to something you wouldn’t ordinarily permit yourself, because you’re feeling blue
  6. To postpone something important until you’re feeling healthier, or thinner, or married, or whatever
  7. To think that you can “make” someone else be happy
  8. To imagine that what’s true for other people is true for you
  9. To spend too much time, or not enough time, thinking about the past, present, or future
  10. To ignore the truth about your own temperament, interests, and aptitudes
I had an eleventh mistake, but my computer didn't save the document properly, and now I can't remember what else I'd added. Very annoying. What have I overlooked? Wait! I just thought of another. "To think about everything you don't have, instead of everything you do have." But that wasn't the one that I forgot...

Gretchen Rubin is a best-selling writer whose new book, The Happiness Project, is an account of the year she spent test-driving studies and theories about how to be happier.

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Monday, November 15, 2010

Macular Degeneration, Lutein and Zeaxanthin


Macular degeneration

Macular degeneration is an incurable eye disease and is the leading cause of blindness for those aged 55 and older in the United States, affecting more than 10 million Americans, out of a population of 310 millions.

Macular degeneration is caused by the deterioration of the central portion of the retina, the inside back layer of the eye that records the images we see and sends them via the optic nerve from the eye to the brain. The retina's central portion, known as the macula, is responsible for focusing central vision in the eye, and it controls our ability to read, drive a car, recognize faces or colors, and see objects in fine detail.

As we age, their chances for developing eye diseases increase dramatically. Unfortunately, the specific factors that cause macular degeneration are not conclusively known and research into this little-understood disease is limited by insufficient funding.

The American Macular Degeneration Foundation, AMDF Web site will help you to better understand macular degeneration. To understand macular degeneration, you should have a basic knowledge of the anatomy of a normal human eye.

For an animation showing the loss of central vision from macular degeneration, click here. (This video presentation requires Quicktime.)

Lutein and zeaxanthin

The yellow color of the macula lutea is due to the presence of the carotenoid pigments lutein and zeaxanthin. In contrast to human blood and tissues, no other major carotenoids including Beta-carotene or lycopene are found in this tissue. The macular carotenoids are suggested to play a role in the protection of the retina against light-induced damage.

Epidemiological studies provide some evidence that an increased consumption of lutein and zeaxanthin with the diet is associated with a lowered risk for age-related macular degeneration, a disease with increasing incidence in the elderly1.

Lutein and zeaxanthin act in two ways protecting ocular tissue: first as filters for damaging blue light, and second as antioxidants quenching excited triplet state molecules or singlet molecular oxygen and scavenge further reactive oxygen species like lipid peroxides or the superoxide radical anion.

Food sources of lutein and zeaxanthin include eggs, kai lan, spinach, turnip greens, collard greens, romaine lettuce, broccoli, zucchini, corn, garden peas and Brussels sprouts. To maximize the availability of the carotenoids in the foods listed above, the foods should be eaten raw or steamed lightly.

OCCUsharp by Live-well contains lutein and zeaxanthin derived from Marigold Flower. It comes with a VERY SPECIAL “Buy 2 Free 1+1” offer.

Vitalux Plus by Novartis delivers 4mg lutein with beta-carotene, Vit C, Vit E, Vit B2, selenium, zinc and copper in a Time-Release tablet.

Journal Reference:

1. Stahl W. Macular carotenoids: lutein and zeaxanthin. Developments in Ophthalmology. 2005;38:70-88.

Multifocal Contact Lenses for Baby Boomers

Wow! There’s an ‘invisible crutch’ for Baby Boomers?

Presbyopia is caused by an age-related process. This differs from astigmatism, nearsightedness and farsightedness, which are related to the shape of the eyeball and are caused by genetic and environmental factors. Presbyopia generally is believed to stem from a gradual thickening and loss of flexibility of the natural lens inside your eye and results in the inability to focus on objects up close.

Eyeglasses with bifocal or progressive addition lenses (PALs) are the most common correction for presbyopia. Bifocal means two points of focus: the main part of the spectacle lens contains a prescription for distance vision, while the lower portion of the lens holds the stronger near prescription for close work. […then you can read the fine print and see the big picture too.. ]

Presbyopes also can opt for multifocal contact lenses, available in gas permeable or soft lens materials. However, older adults who wear multifocal contact lenses to correct problems with near vision may have greater difficulty driving at night than their counterparts who wear glasses.

According to Byoung Sun Chu, Joanne M. Wood and Michael J. Collins, older adults between ages 45-64 years wearing multifocal contact lenses resulted in significantly slower driving speeds at night than wearing progressive addition glasses. While slower driving would seem to reduce the likelihood of hitting nighttime road hazards, the authors reported a reduced ability to recognize road hazards among multifocal contact lens wearers.

The study also showed that multifocal contact lens wearers were able to see road signs, but at a much shorter distance than those wearing glasses, potentially decreasing the reaction time required for a driver to make necessary navigational decisions.

"For those patients who drive long distances and hours at night, practitioners should carefully consider the best form of correction of presbyopia for these patients," said Byoung Sun Chu, "One alternative is to prescribe the multifocal contact lenses for daytime use and a different correction for driving at night."

Journal Reference: B. S. Chu, J. M. Wood, M. J. Collins. The Effect of Presbyopic Vision Corrections on Nighttime Driving Performance. Investigative Ophthalmology & Visual Science, 2010; 51 (9): 4861

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Sex & Serangan Jantung: Apakah Ada Risiko?

Tentu saja tidak! Anggapan bahawa kehidupan seks seseorang berakhir selepas serangan jantung adalah mitos. Ahli perubatan bersetuju bahawa tidak ada alasan fisiologi mengapa sebahagian besar mangsa serangan jantung, lelaki dan wanita, tidak boleh meneruskan hubungan seksual yang memuaskan.

Malangnya, ramai doktor masih mengekalkan mitos dengan tidak memberi kaunseling kepada pesakit tentang boleh atau tidak melakukan seks selepas keluar dari hospital. (Viagra dan ubat disfungsi ereksi(ED) yang lain sudah pasti tidak boleh diambil). "Bertenang" begitulah komen ringkas yang akan membuat mangsa serangan jantung, atau rakan mereka, yakin tentang masa depan seksual mereka. Penyelidikan telah menunjukkan bahawa masalah seksual yang dialami oleh pesakit serangan jantung - dan kebanyakannya mengalami kesulitan termasuk kurangnya respon seksual atau impotensi - adalah kerana kurangnya maklumat dan ketakutan serangan jantung sekali lagi, berbanding komplikasi perubatan organik. Hubungan seksual tidaklah berat berbanding kegiatan rumah tangga biasa seperti menaiki tangga.

Tapi satu peringatan: Jangan terus lakukan seks selepas serangan jantung tanpa berunding dengan pakar kardiologi anda. Apa yang doktor syorkan akan berbeza-beza dengan tahap serangan jantung. Berdasarkan permintaan, kebanyakan pakar kardiologi akan memberikan nasihat seksual kepada kedua-dua pasangan pada hari pesakit meninggalkan hospital. Adalah penting bahawa kedua-dua pasangan dan pesakit tahu yang melakukan seks adalah tidak merbahaya.

Kebanyakan pakar kardiologi menyarankan mulai dengan perlahan-lahan, secara belaian. Dalam dua atau tiga bulan - dan setelah 'check up', anda biasanya boleh meneruskan hubungan seksual.

Robin Westen adalah seorang penulis bebas. Lebih dari dua ratus artikelnya telah muncul di pelbagai majalah termasuk Psychology Today, American Health, Glamour, Good Housekeeping, Self, dan banyak lagi. Beliau juga menulis sebuah kuiz psikologi mingguan dan kolum bulanan berkaitan seks untuk penerbitan nasional.

Saturday, November 13, 2010

Statins, Long-Term Use Unlikely To Increase Cancer Risk

Long-term use of statins is unlikely to substantially increase or decrease overall cancer risk, according to study results presented at the Ninth Annual AACR Frontiers in Cancer Prevention Research Conference, held Nov. 7-10 in Philadelphia.

Statins are a class of drugs commonly used to lower cholesterol and reduce the risk of cardiovascular disease.

Statin (generic name) Brand name(s)
Atorvastatin Lipitor, Torvast
Cerivastatin Lipobay, Baycol
Fluvastatin Lescol
Lovastatin Mevacor, Altocor
Mevastatin
Pitavastatin Livalo, Pitava
Pravastatin Pravachol, Selektine, Lipostat
Rosuvastatin Crestor
Simvastatin Zocor, Lipex

While study results to date have shown that short-term use of statins has little effect on risk of developing cancer, not much is known about long-term statin use and incidence of many cancers.

Eric J. Jacobs, strategic director of pharmacoepidemiology at the American Cancer Society, and colleagues examined the association between use of cholesterol-lowering drugs, predominantly statins, and the incidence of the 10 most common cancers, as well as overall cancer incidence.

The study included 133,255 participants in the Cancer Prevention Study II Nutrition Cohort over a period of about 10 years. During this time frame, more than 15,000 participants were diagnosed with cancer.

Using cholesterol-lowering drugs for five years or longer was not associated with overall cancer incidence, or incidence of bladder, breast, colorectal, lung, pancreatic, prostate, or renal cell cancer, but was associated with lower risk of melanoma, endometrial cancer and non-Hodgkin lymphoma.

"The lower risk of endometrial cancer and melanoma among long-term users has not been seen in most previous studies and was surprising," Jacobs said. "The lower risk of non-Hodgkin lymphoma among statin users has been seen in some, but not all, previous studies."

Common sense tells you that you should not rely on just statins to lower your cholesterol.

Yes, lifestyle changes can help reduce cholesterol, enhance the effect of your medications and may even keep you off cholesterol-lowering medications.

Here are the top five lifestyle changes to get you started.

1. Lose weight

2. Eat heart-healthy foods

3. Exercise on most days of the week

4. Quit smoking

5. Drink alcohol only in moderation

CLICK HERE for further guidance on these lifestyle changes from Mayo Clinic

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In the meantime you should consider these two oral supplements: CoQ10 and Omega-3

Statins and Coenzyme Q10 (CQ10)

Statins inhibit the synthesis of cholesterol by reducing the production of mevalonate, a precursor of both cholesterol and coenzyme Q10. Since both cholesterol and coenzyme Q10 are produced by the same pathway, it is not surprising that statins have been reported to reduce serum and muscle coenzyme Q10 levels.

Coenzyme Q10, also known as coenzyme Q, ubidecarenone, and ubiquinone, is found in all human cells, with the highest concentrations in the heart, liver, kidney, and pancreas. It is a potent antioxidant, a membrane stabilizer, and an integral cofactor in the mitochondrial respiratory chain, helping to generate adenosine triphosphate, the major cellular energy source. It may also regulate genes associated with cell metabolism.

Taking CoQ10 supplements can correct the deficiency caused by statin medications without affecting the medication's positive effects on cholesterol levels.

The recommended adult dose for CoQ10 supplementation is 30 - 200 mg daily. CoQ10 is fat-soluble so should be taken with a meal containing fat for optimal absorption. Also, taking CoQ10 at night may help with the body's ability to use it.

Journal Reference Wyman M, Leonard M, Morledge T. Coenzyme Q10: a therapy for hypertension and statin-induced myalgia? Cleveland Clinic Journal of Medicine. 2010 Jul;77(7):435-42.

Coenzyme Q10 has been used to prevent and treat statin myopathy; however, clinical trial evidence demonstrating their efficacy is limited. If you have muscle aches or other troubling symptoms after starting statin medications, talk to your doctor as soon as possible.

CLICK HERE for more details of the other potential benefits of CoQ10

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Statins and Omega-3

A recent clinical research led by Hyo-Soo Kim from the Division of Cardiology in the Department of Internal Medicine at Seoul National University Hospital suggests that combining statins with omega-3 fatty acids may be more effective at managing raised blood lipid levels than statins alone.

Sixty-two people with high triglyceride levels and total cholesterol levels participated in the six week prospective, randomized, open-label study.

Both groups received a daily poll containing 20mg of simvastatin, while half of the participants also received an addition 4 grams of omega-3 per day*.

After six weeks the group receiving simvastatin only achieved a 13.9 percent reduction. The group receiving the combination simvastatin and Omega-3 was able to reduce blood levels of triglycerides by a significant 41.0 percent without adverse reactions.

The study appears to support the already extensive data linking omega-3 intakes and improved measures of cardiovascular health. The heart health benefits of consuming oily fish, and the omega-3 fatty acids they contain was first reported in the early 1970s by Dr Jorn Dyerberg and his co-workers in The Lancet and The American Journal of Clinical Nutrition. To date, omega-3 fatty acids have been linked to improvements in blood lipid levels, a reduced tendency of thrombosis, blood pressure and heart rate improvements, and improved vascular function.

Beyond heart health, omega-3 fatty acids, most notably EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), have been linked to a wide-range of health benefits, including reduced risk of certain cancers, good development of a baby during pregnancy, joint health, and improved behaviour and mood.

The combination of omega-3 fatty acids plus simvastatin should be considered as an optimal treatment option for patients with mixed dyslipidemia.

Journal Reference S-H. Kim, M-K. Kim, H-Y. Lee, H-J. Kang, Y-J. Kim, H-S. Kim. Prospective randomized comparison between omega-3 fatty acid supplements plus simvastatin versus simvastatin alone in Korean patients with mixed dyslipidemia: lipoprotein profiles and heart rate variability. European Journal of Clinical Nutrition, (29 September 2010) | doi:10.1038/ejcn.2010.195

Lovaza is used in this study. Each 1-gram capsule of Lovaza contains at least 900 mg of the ethyl esters of omega-3 fatty acids sourced from fish oils. These are predominantly a combination of ethyl esters of eicosapentaenoic acid (EPA - approximately 465 mg) and docosahexaenoic acid (DHA - approximately 375 mg).

Lovaza is not available in Malaysia. The available Pristin Omega-3 contains per capsule EPA 396 mg and DHA 264 mg; a daily dose of 5 capsules will provide the equivalent dose of EPA and DHA used in the study.

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Wednesday, November 10, 2010

Heart Attack - Be Prepared to Help

Watch this video. It may come in useful one day.

video

It has been proven that survival of heart attack patients, whose hearts have stopped beating, improved by 22 percent when bystanders called 911 and were advised by the dispatcher to do chest compression-only CPR (cardiopulmonary resustication) until emergency medical technicians arrive.

According to principal investigator Peter Nagele, when a person goes into cardiac arrest because of a problem with the heart, that individual normally has plenty of oxygen in the body. So rescue breaths aren't as vital to survival as trying to keep blood flowing as regularly as possible.

"The heart doesn't literally stop during cardiac arrest," he says. "It gets super excited and electrically very active, and the only way to get it back into rhythm is with an electrical shock, a defibrillation. By doing chest compression-only CPR, a bystander is basically buying time until a paramedic with a defibrillator can jump-start the heart."

The MD from Washington University School of Medicine in St. Louis cautions that if it takes more than 5 to 10 minutes for help to arrive, it also may become necessary to begin rescue breaths.

Gordon Ewy and Karl Kern of the University of Arizona's College of Medicine developed this new approach to CPR.

Journal Reference:

Bobrow BJ, Spaite DW, Berg RA, Stolz U, Sanders AB, Kern KB, VadeboncoeurTF, Clark LL, Gallagher JV, Stapczynski JS, LoVecchio F, Mullins TJ, Humbel WE , Ewy GA. Chest compression-only CPR by lay rescuers andsurvival from out-of-hospital cardiac arrest. JAMA. 2010 Oct 6;304(13):1447-54

Hüpfl M, Selig HF, Nagele P. Chest compression-only CPR: a meta-analysis. The Lancet, 2010; 376 (9749) DOI: 10.1016/S0140-6736(10)61454-7