Why the concern about a change in the H1N1 influence virus?

The increased concern is due to the potential for the H1N1 virus to undergo antigenic shift, which could make it more virulent and also make the H1N1 influenza virus resistant to our current anti-viral medications and/or the upcoming H1N1 influenza vaccine die out in late October/early November.

Yes. In case you haven’t heard, several pharmaceutical companies have been steadily working on not only the annual seasonal flu vaccine, but also a second flu shot specific for the H1N1 influenza virus.

The recommendations for the regular influenza vaccine and the H1N1 influenza vaccine are slightly different.

The CDC is recommending that health care works, pregnant women and people from 6 months to age 24 years old receive the H1N1 vaccine initially. People in the 25 to 65 year old age group that have underlying health issues such as asthma or COPD should also get the H1N1 vaccine. Adults over the age of 65 are actually considered less at risk for contracting the H1N1 influenza virus due to prior exposure to prior H1N1 influenza viruses that were around in the 1960′s. However, this older age group should still get their regular influenza shots this fall since the regular influenza vaccine protects against different strains of influenza.

The FDA (Food and Drug Administration) approved the H1N1 influenza vaccine earlier this week and it is anticipated that doctor offices and pharmacies should be receiving the H1N1 vaccine by mid October. Originally, it was thought that two separate injections about a month apart were required to acquire immunity to the H1N1 virus, but the latest studies are actually showing that most healthy people are having a healthy immune response after just the first vaccination – great news, since this essentially doubles the number of vaccinations available to health officials.

Hi this is Dr. John Martinez, Medical Director of Coastal Sports and Wellness Medical Center in San Diego, California.

Today, we’ll be talking about some myths and facts about both lactate testing as it applies to our endurance training—we’re talking about:

• The lactic acid myth
• The muscle burn myth and lactic acid
• The muscle pain myth
• The lactic threshold myth

Now the first myth is about “lactic acid” and that lactic acid actually appears during exercise, so it’s really the true things, it’s more of a misnomer and that lactate is actually the proper term and it’s actually a by-product of glucose utilization and a lot of coaches and athletes are taught or told that lactic acid is something that’s actually bad, when in fact that if we look at the whole breakdown of exercise metabolism, it’s that as glucose breaks down, it’s broken down to a by-product called pyruvate and eventually into a pathway that produces lactate.

There may be some true lactic acid that’s formed very briefly, but then the lactate is actually a salt by-product that’s produced and importantly, for athletes and coaches to understand is that lactate is actually used by the body specifically, the brain and the heart for fuel and this falls into a concept termed the lactate shuttle as first proposed by Dr. George Brooks up in University of California, Berkley who’s done a lot of research on this concept.

The next myth that we’re going to talk about is that muscle burn myth and this is something that I think most athletes have been told, if you’ve ever been in a spin class, ever gone out to the track and done track workout or a speed workout and told that that burn is that that lactic acid building up and again, if you go back to that first myth that we’d already talked about, the true term we should be using is lactate, but it’s actually also false that lactic acid build up causes that muscle burn that athletes experience at the high intensity exercise.

The fact is that that muscle burn is actually more of an acidosis that occurs when hydrogen ion build up and probably some other by-products in the intense exercise. Lactate itself doesn’t seem to cause that muscle burn and if you look at the research studies, we have athletes that have much different levels of blood lactate levels that have different experiences or different complaints as far as how much muscle burn and muscle discomfort there is.

So again, that lactic acid or that lactate build up doesn’t cause that muscle burn.

The third myth we’ll be talking about is muscle pain myth and that lactate or lactic acid build up causes the muscle pain most athletes experience 24 to 48 hours after a hard workout. Well, the truth is that, lactate is actually cleared from the muscles usually within an hour of most exercise, even the more high intensity exercises, and we know this because when we do a lactate testing on our athletes, we plot out the increase in the lactate levels as we increase the exercise intensity and then as we have a recovery period after exercise, we actually do a recovery lactate test to watch how quickly the athlete’s body is able to metabolize that excess lactate.

So the truth is that, a lot of that muscle damage and muscle pain that occurs 24 to 48 hours actually probably do more to micro tearing of muscle and usually, we see more muscle pain and more micro tears when there is more eccentric muscle contraction and this should be something, as far as downhill running and the eccentric lengthening of the quadriceps muscle and if you’re in the gym during a bicep curl, this would be the negative that a lot of body builders do when they slowly extend out the bicep under a heavy weight and you get more micro tearing and therefore, more inflammation and damage to the muscle and that’s what we think that delayed onset muscle soreness is that occurs, a couple of days after a hard workout.

The final myth we’ll talk about is the lactic threshold myth and that myth is that there’s a defined point where the body switches from an aerobic to anaerobic metabolism called the lactate threshold. Well, the truth is that there’s really no defined switch from aerobic to anaerobic metabolism. There’s actually more of a mixture of aerobic and anaerobic metabolism in most exercise intensities and if you think about this at a lower intensity, you do use mostly fat as your main source of energy.

But there’s always just a little bit of glucose metabolism that’s occurring and as you slowly increase your exercise intensity, there’s more of a slow transformation or slow transition to a more heavily anaerobic metabolism, but there’s no true flip of the switch where you go completely aerobic to completely anaerobic, it’s more of a transition zone that we hit.

One of the other things that we try to measure with our athletes is what we call the maximum lactate steady state, which is that steady state exercise level for either running or cycling where the athlete can maintain a constant lactate production and lactate metabolism and that’s probably the level that most athletes can race a long distance, race out over an hour.

Interested in finding out out more about blood lactate testing?

We offer blood lactate testing in San Diego at our sports medicine center and sports medical director.

Give us a call at 858-678-0300

Upon moving to San Diego just over a year ago I was surprised at how many people were into work early so that they could be out enjoying Mother Nature in the afternoon. Being an exercise enthusiast from the North East I’ve had a blast either running 8+ miles around La Jolla cove, hopping on my bike for 40+ miles, or even the dreaded JCC Master’s swims led by full time masochists Chad, Nikee, and Rachel. The combination of any of these workouts and the preceding workday resulted in both physical and mental exhaustion, not to mention quite an appetite, which may explain why some people don’t lose as muc weight as they expect on an exercise program. And, if anyone out there has attended one of the San Diego Triathlon Club Aquathons you can attest to the caloric explosion that can occur after 30 – 50 minutes of lung burning activity followed by one of the finest post-race food spreads in the history of after-race parties.

However, a recent article in the New York Times about the timing of meals made me re-think my typical post-workout feed bag routine.

The New York Time article “Late Night Eating Linked to Weight Gain” comments on a medical study performed at Northwestern University and will be published in the peer reviewed journal Obesity next month. Researchers at the university found that mice whose feeding was restricted to daylight hours (the equivalent of our night time for our squeeky, furry, nocturnal friends) gained 28% more weight than the group that ate during their regular feeding times during the night as they instinctively do.

At first thought, you would think that the obvious reason for the weight gain in the first group of mice was because they ate more calories. Guess what? You’d be wrong! The researchers found that both groups consumed nearly equal number of calories and exercised for similar duration on each day, making the only difference between the groups the meal timing.

Now, granted this is an animal study and the results should not be immediately directed towards humans but it does give some guidance to those athletes looking to shed a few pounds.

I’m not suggesting that we all eliminate eating after our evening workouts, since re-fueling is an important part of proper recovery after a hard workout. Getting the correct amounts of protein and carbohydrates within 30 to 60 minutes after a workout (known as the glycogen window) is proven to increase muscle glycogen storage and provides a larger energy source for your next workout. However, for most of us the total calories that needs to be consumed for this effect is only around 500 calories – that maybe 2 bagels, or a turkey sandwich with a side of veggies.

I’m sure that on a semi-regular basis I approach the 1500 calorie range with my post-work meal, especially after a long workout. I have to admit, that previously I had been under the impression that in order to reduce weight, calories in had to be less than calories out. However, this new research may suggest that simply changing the time of day when these calories are consumed could help to reduce excess weight. I am even more convinced of these findings after thinking of previous research that has shown lower body weights for those individuals who ate breakfast every morning when compared to those that routinely skipped breakfast. I am sure that I’m not the only one who has over-eaten after an evening workout to the degree where breakfast isn’t even appetizing.

So once again, I’m not saying that we should stop eating when the sun goes down (we’re athletes, we need to eat). I’m saying that for the majority of us who aren’t training 30 hrs a week like the pros with a body fat percentage hovering around 6% it might be a good idea to re-distribute some of the calories. Instead of gorging yourself at the all you can eat buffet after beating yourself up with 10 x 400m with a 1 mile warm up and cool down on the track, save some of those calories for breakfast the next morning.

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Evan Johnson is a San Diego personal trainer with a Master’s Degree in Exercise Science. If you’d like a fitness consultation with Evan, give us a call at 858-678-0300

Its an unfortunate misrepresentation of some good research by some talented scientists.

I’ll be spending the week picking apart the problems with the Time Magazine article, simply because it ignores a large body or research out there.

In the first section of the Time article, Mr. Cloud references a recent research study published by scientists at Louisiana State University and The Cooper Institute (Dr Kenneth Cooper is the physician that coined the term “aerobics” back in the 1960′s). You can get a copy of the article here. The study looked at the effected of different weekly amounts of moderate exercise (cycling or treadmill) on weight loss and waist size in fairly inactive, older, post-menopausal women (average age of 57 with an average weight of 185 lbs and a body fat percentage of almost 29%)

The reality of this exercise study is that the researchers found that all three exercise groups lost weight. Interestingly, the group that exercised the most, did not lose weight at the researchers’ predicted rate – however, that group still lost weight. Here’s a look at the data from the first two exercise groups (4KKW and 8 KKW) below. These two exercise amounts are equal to 72 minutes (4 KKW group) and 134 minutes (8 KKW group) of exercise per week based on current national exercise duration recommendations by organizations like the American College of Sports Medicine.

The data from these two exercise groups actual show that both groups loss more weight than predicted by the researchers, and the 8 KKW group lost more weight that the 4 KKW group, as seen in the two graphs below:

The researchers did find that the 12 KKW group (exercising at 194 minutes per week) did not lose as much weight as predicted based on their exercise calorie expenditure. Looking at the data on the graph below, it seems that the 12 KKW group had a much slower rate of weight loss that the other two groups even in the first 4 weeks of the study. Why is that slower rate of weight loss in the first 4 weeks significant? It’s based on the study design. Since the researchers started with an older group of subjects, they started each group out at 72 minutes of exercise per week for the first week. The two middle and higher exercise groups then had roughly 18 minutes of exercise added to their weekly exercise time until they reached the maximum exercise duration for each group. So the 8 KKW and 12 KKW groups would have been increasing their exercise durations at the same pace for weeks 2 through 4 (where the 8 KKW group would stay at the 134 minutes and the 12 KKW group would continue to add time each week until they reached the 194 minutes of weekly exercise at week 8 of the study.

To their credit, the researchers acknowledge that the point of their study was to determine whether or not there was a linear dose (or time)-dependent relationship between the amount of weekly exercise and the amount of weight loss by their test subjects. They also clearly state during their discussion of their findings that:

Our findings should not be interpreted as suggesting that lower doses of exercise are more effective in producing weight loss than higher doses. We emphasize that DREW was not a weight loss study and it was not designed to examine the nuances of exercise induced weight loss.

The authors of the research paper also note the a good portion of the 12 KKW (higher duration exercise group) continued to loss weight at the predicted rate (27% of the 12 KKW participants according the the data). So the reality is that while a subgroup of the higher amount of weekly exercise group didn’t lose weight at the predicted rate, another group did match the predicted weight loss.

One reason suggested for the lack of weight loss in the higher time-duration exercisers from the Time article was the possibility that the high exercise-time group were less activity during their non-exercise time away from the research lab. A credible reason, except that the researchers controlled for this variable by having all groups wear pedometers, including the control group that did not exercise at all. What kind of difference did they find in the outside activity levels between all groups?

None. That’s right. All four groups (the non-exercising control group and the three exercise groups) had roughly the same activity levels outside of the research lab when they were performing their exercises for the study. So the high exercise group didn’t go home and lay around on the couch after their workouts, or limit their walking or other activities any more that the other groups.

Further studies have also demonstrated that people that have lost a substantial amount of weight (think the Biggest Loser) usually exercise 45 minutes a day in order to maintain their weight loss. Exercising 45 minutes a day for 4 days a week would put that prior weight loss group at roughly the 8 KKW group exercise duration.

Its an interesting concern as more people try to improve their diet and nutrition and increase their fish consumption for the benefits of the omega-3 fatty acids. While I think the risk is small, especially with other issues such as mercury content in larger fish, the risk of developing “Mad Cow” disease could be an evolving concern. One more reason to look closely at the type of fish that we eat – farm-raised salmon should be labeled either as “farm raised” or “color-added”. Fish caught in the wild is also usually labelled as such.

Local, and state health care providers and agencies as well as the U.S. government  and the Centers for Disease Control and Prevention have been treating the H1N1 influenza virus outbreak as if it was a pandemic since initial reports of the viral infection in late April.

The good news is that while we’ve now seen the virus spread world-wide, we haven’t seen the H1N1 influenza virus undergo any significant mutations that make it a more severe or fatal influenza virus strain. Thus far, most of the cases repored in the U.S. have been mild and infected people have had a full recovery. In the San Deigo region, we have not seen a significant increase in hospitalization rates of patients infected with the H1N1 influenza virus.

It is, however, important to acknowledge that H1N1 influenza has resulted in severe cases and even the deaths of some patients in the United States, similar to what occurs with the typical, seasonal influenza. That fact, coupled with today’s elevated designation by the WHO of the H1N1 virus as a pandemic, However, the recent designation of the H1N1 influenza virus as a pandemic should be an important and sobering reminder that all strains of the influenza virus can cause serious and life-threating problems for some parts of the population and its important to be vigilant and practice good hygeine to prevent unnessecary spread of the influenza virus.

Some quick health tips from the CDC include:

• Keep up to date The CDC Web site has regular updates about the H1N1 influenza outbreak.
• Take these common sense actions to prevent spreading the virus.
  • Cover your mouth and nose when sneezing or coughing. Use a tissue and throw away, or be sure to wash your hands.
  • Keep your hands clean – Use either soap and warm water or an alcohol-based hand cleaner.
  • Avoid spreading the virus by not touching your eyes, nose or mouth.
  • If you are sick,  stay home from work or school.The current CDC recommendation is to stay home from work or school and limit contact with others.
• Follow public health recommendations about school closures, avoiding crowds and large gatherings if there is a significant influenza outbreak in your area.

More info on the Velonews website 

Steve Larsen’s athletic career crossed from road cycling, into mountain biking and then into triathlons. He managed to win two NORBA National Mountain Biking Championships as well as taking the 2001 Ironman USA Triathon title in Lake Placid, New York and a 9th place in the Ironman Triathlon World Championships.

His road cycling career include time on the US-based Motorola cyling team with appearances in the Giro d’Italia and other top European cycling races.

Recently he was living in Bend, Oregon with his wife and 5 children and working in the real estate field.

I had the opportunity to meet Steve several times through out his career(s). First was way back in the 1990′s when he was competing on the pro mountain bike circuit and the last time out in Kona at the Ironman triathlon. Very gracious both times, one when he wasn’t feeling too well after Ironman. Also watched him completely destroy the field at Ironman Lake Placid in 2001 where he shattered the bike course record (and my first Ironman triathlon)

A very talented athlete and person – our hearts, thoughts and prayers go out to his family and friends.

The original topic was supposed to be about the recent 50 game suspension of Los Angeles Dodgers outfielder Manny Ramirez, but sports anchor Rick Willis is a big marathon fan and decided to focus more on the healthy aspects of running and training for running races from the local 5 km fun runs to the San Diego Rock and Roll Marathon.

Note that Dr Martinez had to slouch down to fit in the camera shot, and if the beginning seems a little disjointed – apparently the wireless microphone box kept unclipping and falling to to ground as they were about to come back from the commerical break!

Unfortunately for Manny Ramirez, HCG was added to Major League Baseball’s banned substance list in May 2008 and Ramirez received a 50 game suspension as a first-time offender of MLB drug-testing program. Further reporting by Sports Illustrated and the Los Angeles Times now suggest that Ramirez’s urine sample tested positive for synthetic forms of testosterone and no presence of HCG was found. This latest finding of  synthetic testosterone would be suggestive of someone that was taking or recently taking anabolic steroids, which are also on MLB banned substance list.

What is HCG and why take a fertility drug?

The obvious question most people are asking is why would Ramirez take a fertility drug and what benefit would he gain?

When anabolic steroids are used to increase muscle mass, the pituitary gland often shuts down production of luteinizing hormone (LH) which controls testosterone production by the testis. When an anabolic steroid user comes off a cycle of steroid use, there is a need to quickly restart the body’s natural testosterone production. Since there can be a significant delay in the pituitary gland’s response to restarting luteinizing hormone (LH) release and therefore, testosterone production by the testes, often times HCG is used instead to increase natural testosterone production.

The benefit to an athlete would be an increase in testosterone production which would increase muscle mass,  drop healing time from muscle damage and decrease body fat.

Did he test positive for steroids?

Current reports on the case only mention Ramirez testing positive for an elevated level or ratio of testosterone to epitestosterone in his urine. The typical male will have aprroximately a 1:1 ratio, with Major League Baseball using a cut-off of a 4:1 ratio of testosterone to epistesterone as an abnormal test. Ramirez’s urine sample from March allegedly tested higher than the 4:1 ratio and repeat testing reportedly has found the presense of synthetic testosterone, which would indicate Manny Ramirez was taking some type of performance-enhancing drug that is banned by MLB.

Additionally, since no HCG was found in the urine sample, Ramirez’ original arguement that the elevated levels of testosterone where due to his use of HCG for a medical condition is moot. No HCG present in the urine would suggest that the elevated testosterone levels were not due to his HCG prescription.

Furthermore, even if Manny Ramirez’ elevated testosterone levels were due to his HCG prescription, he and his doctor did not file a therapuetic exemption form with Major League Baseball outlining his need to take a substance on the MLB’s banned substance list for a medical condition currently under treatment by a physician.

The next question that arises is if Manny Ramirez is guilty of using testosterone or other performance enhancing drugs – then for how long? Should there be an asterix next to the 2004 and 2007 World Series Championships by the Boston Red Sox that Ramirez was an integral part of?

Looking at Ramirez’s career batting statistics from his stints with the Cleveland Indians (from 1993 to 2000), the Boston Red Sox (2001-2008) and the Los Angeles Dodgers (2008-present), there has been a significant uptick in Ramirez’s batting average (.312 with Boston and .13 with Cleveland to an amazing .380 in 80 games with the Dodgers.) and slugging percentage (a superhuman .710 with the Dodgers compared to simply an All-Star level of .592 with Cleveland and .588 with Boston).

After spending the morning looking at other national news organizations, the WSJ appears to have the most current and factual information. I would strongly recommend ignoring FoxNews and FoxNews.com. Their reporting this morning has had many significant factual errors and is more sensationalism than true journalism.

The information in this update is accurate as of 5 am PST on Tuesday, April 28th.

The CDC has been a little slow on updating their web page. They currently have 20 recorded cases of documented swine flu in the the U.S. (last updated 5pm EST on Monday).

The California and San Diego County public health officials have announced another few cases in California bringing the reported total of documented swine flu cases up to 20 total in the state of California.

A new case in San Diego County was confirmed in a 7 year old child and the child’s school,  Christ the Cornerstone Academy in Mira Mesa has been closed today pending further testing of teachers, staff and other close contacts.

The state and county Health Departments have also updated guidelines for patients that have flu-like symptoms.

• The current recommendation is to remain at home (don’t go to work, school, etc) until the symptoms improve
• The cases we’ve seen thus far in the US all appear to be similar to the normal winter-time flu and should resolve in 7 to 10 days.
• Seek medical attention (call your doctor’s office first) IF you think you have the flu AND:
  

1. You have severe underlying heart or lung problems such as
2. Experience severe breathing problems
3. Feel dehydrated and unable to take in enough fluids

Right now there is a significant lag time between when these people were actually sick with symptoms and when the CDC was able to positively identify the swine flu virus. Up until today, only 2 labs in North America had the capability to test for swine flu; the CDC in Atlanta and a Canadian laboratory.

Most normal lab tests take several days to get the results of influenza of flu viral cultures. Any positive test that can’t be properly identified is then sent out to the CDC for further identification, so there can be a 5 to 7 day delay before the swine flu virus is identified.

My understanding is that most of the reported cases of swine flu were actually ill and symptomatic at the beginning and the middle of the month, but we’re now just getting the results back. From personal experience, this time frame would also fit with a brief uptick in clinic visits we saw in San Diego for “flu-like” illnesses.

This past week was actually less busy at several clinics I’ve spoken with.

This decrease this week doesn’t mean that we are out of the proverbial woods, but that we still should remain prepared and aware.

The basic concepts of good hygiene still apply. Wash your hands, wash your hands, wash your hands. Make sure to cover your mouth if you cover. If you are sick, avoid going to public places such as restaurants, movie theaters, etc, and stay home from work until the symptoms clear.