Health-and-Fitness online information.

Some soothsayers tell us that if the instance of obesity increases at its current level, almost every American will become overweight by the year 2050. But while many people tend to focus on the cosmetic aspects of their expanding waistlines, the real significance of obesity is the occurrence of many related diseases and associated, mounting death rates.

The prevention of obesity and related problems, such as Syndrome X and type 2 diabetes mellitus, constitutes a modern medical emergency. And there's no doubt that dietary intake of simple sugars--that is, simple carbohydrates--is a key miscreant. This makes carbohydrate restriction a logical approach to combat the rise of obesity, but even this basic approach can be facilitated to become more effective and healthful. Refined (simple) carbohydrates are pivotal in the cause of the modern epidemics of Syndrome X and type 2 diabetes, but they aren't the whole story.

Obesity Has Disease Companions

Taking obesity for granted can be a deadly habit. Table 1 (p. 38) highlights the risks and complications of obesity. Much research has attempted to predict the "forms" of obesity that create the greatest risks. In general, excess body fat located in and around the organs of the body presents an independent risk factor for cardiovascular disease and many other diseases.

Obesity, Syndrome X, Pre-Diabetes and Type 2 Diabetes

Currently, approximately 70 million Americans have a condition called the metabolic syndrome or Syndrome X. Syndrome X requires careful definition and description if the real advantages of a low-carb diet can be fully appreciated. First of all, Syndrome X is a combination of factors that are almost invariably associated with excess weight. The simplest definition of Syndrome X, then, is the variable combination of obesity, high blood pressure and high blood cholesterol, all linked by resistance to the hormone insulin. (Figure 1)

Insulin and Blood Glucose

While we all recognize the ability of insulin to help the body handle glucose, insulin resistance occurs when the body doesn't take proper command of insulin. As a result, the body reacts by making more insulin, so blood levels of the hormone begin to rise. Insulin gives prime signals to fat cells to store fat. Hence, obesity goes hand in hand with insulin resistance and its excess in many people. Indeed, insulin can tell the liver to make cholesterol, and it can tell tissues of the body to raise blood pressure. You can now see why obesity, high blood pressure and high blood cholesterol occur together under the umbrella term Syndrome X. Furthermore, insulin can tell the ovaries to secrete male-type hormones, tell the body to make inflammatory messenger molecules and even tell genetic material to express cancer growth. Thus, insulin resistance and its excess cause a diverse array of diseases. This extension of Syndrome X beyond its role in creating cardiovascular disease is what I have called Syndrome X, Y and Z.

The Concept of Syndrome X, Y and Z

As depicted in Figure 2 (p. 39), Syndrome X leads from primary obesity-related diseases, such as coronoary heart disease, to further complications that I characterize as Syndrome Y (immune impairment, blood clotting, etc.) and Syndrome Z (inflammation, cancer and liver disease).

Combating Insulin Resistance and Controlling Calories

Once we understand the role of insulin resistance in the development of obesity and related disease, we can begin to see how a low-carb diet is a step in the right direction--and how such diets may need to be modified or supplemented to become more effective in their desired outcomes of weight loss and health promotion. Many physicians are accepting the notion that there are carbohydrate-sensitive individuals who gain weight easily when sugar is a major component of their diets. This sensitivity has started to make physicians and scientists rethink the simple idea or equation of "energy in and energy out" of the body.

Energy is taken into the body in the form of calories delivered by food. This energy is utilized by the body for day-to-day living and to support physical activity. However, this equation of energy in and energy out doesn't fit perfectly with weight control tactics in humans.

There are some people who can consume large amounts of energy (calories in food) and not gain weight, even though their level of exercise isn't particularly high. That said, calorie control is generally a very important aspect of weight control, and anyone who proposes that calories do not count is seriously misguided.

An Overall Healthful Weight-Control Initiative

That's why "diets" cannot be eliminated as one of several important components of weight management. Excess dietary intake of simple sugars, together with a lack of physical exercise and poor lifestyle, contribute to poor function of insulin. This provides a powerful incentive to adopt a diet that is controlled in its simple carbohydrate content While low-carb diets have not been shown to correct insulin resistance, per se, they are a step in the right direction.

Newmark Retail has announced hat Equinox Fitness Clubs has signed a lease for its 14th Manhattan club at 568 Broadway on the corner of Prince Street in SoHo.

The upscale full-service health club and spa will be occupying approximately 40,000 square feet in the spectacular art-deco building. "If there was ever a market made for Equinox it would be SoHo," said Jeffrey D. Roseman, Executive Vice President of Newmark Retail, who represented the tenant.

"The vibrancy, density and sexiness of SoHo mesh perfectly with the Equinox brand."

How do you get motivated to eat healthfully and exercise regularly--and how do you ensure you'll stay that way? It's one of the toughest quandaries in the fitness business.

The best advice I've ever heard on the subject is this: Recognize that even when we make smart and necessary changes, we shouldn't expect them to feel good right away. Abandoning your usual habits and trying out new behaviors is often uncomfortable and disorienting, and it can take a while before the changes we make (e.g., eating fewer calories, exercising more) start to pay dividends.

Once you tell yourself it's OK to feel anxious or even temporarily discouraged about your new efforts, you'll be freed of the pressure of counting on instant success. You won't beat yourself up for not immediately loving a new exercise class or for wanting to indulge in chips rather than carrots. Most important, if you give yourself the lee-way to experiment to find what works best for you, you'll end up with better results (just keep the faith that you will succeed eventually!).

Likewise, it's tempting at this time of year--when we make lots of ambitious New Year's resolutions--to get a little too gung-ho. Although it may seem like a good idea to dive into a fitness and weight-loss program headfirst, it's really a road to burnout and disappointment. Anyone who is a regular gym-goer is familiar with the "January phenomenon": The first and second weeks of the new year, the gym is packed solid with new members. By the third and fourth weeks, however, few return, because they burned out or got injured by starting out too aggressively.

So how can you avoid being a January-resolution casualty? Take it easy. For straightforward ideas about easing into healthful eating and weight loss, see "The Post-Binge Diet" (page 138). It's a four-week eating plan designed to minimize the discomfort of building new habits and to avoid the torment of a crash diet. Then, to get started with an exercise program that's fun and simple to follow, check out "The Body-Sculpting, Fat-Blasting, No-Burnout Workout" (page 118).

Also see our two new columns: Get Energized (page 82) and ShapeOver (page 28) for inspiration on getting started--or back on track. As this month's ShapeOver astutely points out, one of the best strategies for getting yourself motivated is to just do something--anything--positive, and you'll find that your motivation follows as your confidence builds. As you see results--and you will, if you stick to our diet and exercise plans--you'll be even more committed to building on your success!

We are officially a new sport now. Everywhere that I go, someone is reading "I'm the Fittest Man in the World!" [December]. Joe Decker no longer matters. He was invited twice to the World Fitness Championships and never returned my call. Mr. Decker is now invited to the World Fitness Challenge (1/2 distance), where he can work his way up to the World Fitness Championships, which, by his boasting, he should easily win. First, however, he has to come through me. And that's not going to happen. I now have three World Records and three World Fitness Championships in a row. He can come and get them if he thinks he is as tough as his talk.

FIT WERE UP TO YOU, YOU'D NEVER STRAY FROM your favorite pair of beat-up jeans and college football T-shirt. But they won't always fly with your girlfriend, or the office dress code. And if you don't have some backup duds, you've got a problem. The solution: Get more options in your closet, without abandoning what feels comfortable.

To help you, we're presenting the second installment in our MF Overhaul series--a sequence of strategies designed to make you as successful in your life outside the gym as you've been inside it. Last February, we transformed one fit couple's basement into the ultimate home gym. This time we've focused on style and grooming. After getting to the bottom of the mountain of readers' letters we received asking for help, we settled on Seth Hill, a 24-year-old student at the University of Washington, Tacoma.

Hill wrote in telling us how he'd recently lost 85 pounds by working out and eating right. He'd been heavy most of his life, hiding behind baggy shirts and jeans, and now that he'd worked out and built the body, he needed some help finding the right clothes to fit it properly. "My weight loss has given me a boost of self-confidence;' Hill wrote, "and I think I need a new look to go along with it." After checking out his current wardrobe, we readily agreed, and a few months later, Hill was in our New York office meeting with our style experts.

Here, we'll show you how MF fashion director Kimberly Kelly mixed and matched a few key items to create three unique looks for Hill. Then, we'll divulge the techniques Kelly used to help Hill whiten his smile and modernize his hairstyle. All of which should help you achieve your own personal transformation.

IN THE BOARDROOM

Since he'll be job hunting soon, Seth needed a professional look he could wear on an interview. "Because I was so overweight, I always felt frumpy and disheveled in dressier clothes," Seth admits. "I'd never actually worn a suit before" (MF rule No. 1: Every man should own at least one well-fitting suit.) To remedy that, we chose a charcoal pinstripe suit by Perry Ellis and paired it with a shirt and silk knit tie by Robert Talbott. Pinstripes elongate your frame, making you look taller and leaner. At the same time, buying a suit with a versatile charcoal hue will allow you to make an easy transition from the office to dinner and drinks after work. Another perk of having a charcoal suit? It can be worn with either brown or black shoes. In Seth's case, we set him up with a chocolate-brown pair by Geox.

Contrary to popular belief, suit shopping doesn't have to set you back a couple of months' rent. The secret to a great-looking suit is having it tailored to fit your frame--a reputable tailor can make any off-the-rack suit look custom-made. Start with the cuffs: Your jacket sleeve should be approximately half an inch shorter than your shirt sleeve; exposing a line of your shirt breaks up the monochromatic look of a suit. Also, when buttoned, your jacket shouldn't look boxy. If it does, have it taken in at the waist to create a slight hourglass shape for your upper body. There's nothing worse than having a suit that fits in the shoulders and hips but leaves you looking thick in the middle. As for dress pants, a pair that fits well should sit at your waist, with the hem falling about a quarter of an inch above the bottom of your heel.

WEEKEND WARRIOR

For the ideal weekend look, we put Seth in a pair of jeans by Replay, a tee by Perry Ellis, a hooded cardigan by 7 For All Mankind, and a blazer by Lucky Jeans. Though it's a casual style, dress shoes and a quality leather bag (like the one at right by John Varvatos, and the Geox shoes from the boardroom look) add polish. Seth's verdict: "It's comfortable but still seems like I pulled it together without overthinking." To emulate this casual style, try a deconstructed blazer (no shoulder pads; unfinished edges) in a casual fabric, such as cotton. Combine that with a good, medium-rinse pair of jeans. "Opt for a pair that's a little snug in the hip and thigh area, since most jeans stretch over time; says Keily. The rinse is key--a darker color is too dressy, while a light one is too casual. Medium-rinse blues can be worn just as easily running weekend errands as they can on an evening date.

GOING OUT

Speaking of dates, every guy needs his own personal dating armor. So for Seth's third look, we wanted something a little edgier that would be perfect for a night on the town. You won't believe how easy it was: We put him in the suit jacket from his first look, the jeans from his second, and an untucked button-down by American Eagle Outfitters. After that, we added a skinny tie by Robert Talbott and a pair of Converse sneakers. Seth approved, calling it "very punk rock." The secret to making it work was mixing dressy pieces like the jacket and shirt with casual ones like the jeans and sneakers. Choice of neckwear is also essential. "Go for something a little funkier than what you'd wear to work," says Kelly. Try ties in a different fabric, pattern, or width.

1 MAKE TIME FOR MEDITATION.

Set aside 10 minutes a day (just 10 minutes!), and try to clear your mind of all thoughts and distractions. Counting your breaths can often help.

2 THROW OUT THE SCALE.

If your goal is to lose weight, skip the scale and pull out the tape measure instead. Often the number on the scale won't change but inches lost will. Chart your progress by measuring yourself once a month.

3 PICK AN ENERGY/PROTEIN BAR RATHER THAN A CANDY BAR.

Because there are so many different bars to choose from, pick one that suits your needs--and your taste buds--and grab it instead of sugary, candy bars laden with calories.

4 DRINK MORE WATER.

A healthy body is hydrated. If you're always thirsty or your skin or lips are always dry, chances are you're no drinking enough. Get the biggest glass you can find and fill it up at the water cooler in the morning. Set a goal: Have your first glass finished before noon.

5 REMEMBER TO TAKE YOUR SUPPLEMENTS.

Get one of those plastic pill holders separated by days of the week. Fill each compartment with your multivitamin, and any other supplements you take, and leave it at your workstation.

Home Humidifiers

Using a tabletop humidifier can help soothe nasal and respiratory passages when you of a family member have the flu or a sore throat. Portable units can also provide relief for adults and children with asthma and dry skin or dry eyes.

But don't let the remedy to one problem result in another. The U.S. Consumer Product Safety Commission offers these tips to keep your portable humidifier free of harmful mold, fungi and bacteria.

* Change the water in your room humidifier daily. Empty the tank, dry inside surfaces, and refill with clean water,

* Use distilled or demineralized water. Tap water contains minerals that may promote germ-friendly film and scale build-up.

* Clean the humidifier often. Unplug the humidifier before cleaning and follow manufacturer's instructions.

* Maintain the relative humidity in your home between 30 and 50 percent if possible. You can measure humidity with an instrument called a hygrometer, available at your local hardware store.

Foot Care For Life

Daily inspection of the feet is a critical component of a healthy lifestyle, especially for diabetics. When inspecting the feet, look for the following:

* Color changes. Pale or light-blue toes may indicate poor circulation. Black skin is a sign of dead tissue; redness with streaks often signal infection. Red spots are caused by friction or pressure and may also turn into blisters, corns or calluses.

* Swelling, tenderness, and an increase in foot size may be symptoms of decreased blood flow.

* Temperature changes. Warm areas may result from an infection. Cool or cold areas indicate circulation problems.

* Sensation changes. Early indications of problems or damage to nerves in the feet include numbness, tingling, burning or lack of feeling.

* Cracks, sores, and ulcers. Abnormal pressure is the most common cause of ulceration of the diabetic foot.

* Ingrown toenails. Too-tight shoes (that squeeze the toes) can contribute to deeper penetration of the skin by the nail, which results in swelling, redness and pain.

Stretching For Flexibility

Sitting for hours every day, day after day, can shorten the flexor muscles across the front of the hips and contribute to lower back pain by causing the pelvis to tilt forward. A daily exercise regimen can help stretch hip flexor muscles such as the iliopsoas, and increase one's ability to fully straighten the hip joints.

Fitness expert Kay Mikesky recommends the following exercises to work the hip flexors:

Hip flexor stretch:

* Bend your knees and place both hands on your left knee.

* Extend your right leg behind you as far as possible, resting on your toes.--As an alternative, extend the right leg behind you, onto a bed.

* Keep your left knee directly above your left heel.

* Lower the front of your pelvis toward the ground (don't expect it to move very far downward) and hold for 15 seconds.

* Stand and repeat stretch on your left side.

Full-body stretch (on floor or bed):

1. Lie on your stomach on the floor or bed with legs straight and arms extended to your sides.

2. Concentrate on extending (straightening) your hip joints as much as possible.

3. Hold for 15 seconds.

4. Relax, then repeat stretch. Increase repetitions as able.

Eat Out, Eat Right

Italian restaurants rate high on Americans' hit parade of ethnic favorites; along with Mexican and Chinese, they're one of the big three. In her book Eat Out, Eat Right! published by Surrey Books, dietician Hope Warshaw offers the following advice for selecting healthy Italian menu options.

Soy Many Choices

Soy is an inexpensive way to add protein to your diet, and it may help reduce calories, saturated fat and cholesterol when substituted for meat. Consuming soy foods as part of a healthful diet seems to pose no health risk. Mayo Clinic experts offer these ways to include soy in your diet:

Soy milk: use it with cereal or in a smoothie. Check that it's fortified with calcium and B vitamins.

Soy flour: Substitute this product for up to 20 percent of the total flour in baked goods.

Roasted soy nuts: These taste similar to peanuts and are available in a variety of flavors.

Soy burger: It looks and tastes similar to ground beef.

At right is a great-tasting smoothie using Silk Vanilla Soymilk.

Smoothie Colada

Serves 2

8 ounces Vanilla Silk Soymilk
6 ounces pineapple juice
2 tablespoons coconut cream
1/2 cup frozen pineapple, diced
6 ice cubes

Dice pineapple and freeze overnight. Combine ingredients in blender and cover. Blend until smooth. Pour into two glasses, Garnish with any fruit.

www.silkissoy.com

Green flag words:

Lightly sauteed

Tomato-based sauces--marinara, Bolognese, cacciatore

Tomato sauce and meatballs

White or red calm sauce

Light red sauce

Piccata

Red flag words:

Alfredo

Carbonara

Saltimbocca

Parmigiana

Lasagna

Cannelloni

Susie Curry lights up the Vegas sky with her three-peat win at the 2002 Fitness Olympia.

The Fitness Olympia is the pinnacle of fitness contests, where thc best of the best strive to prove themselves the top competitors in the world. The 2002 contest, held in Las Vegas at the Mandalay Bay Resort and Casino Oct. 17-18, crowned the only three-time winner since the contest's inception in 1995: Susie Curry. Her standout combination of muscular development, symmetry, strength, flexibility and gymnastics skill held the other girls at bay ... but they aren't content to live in Susie's shadow forever. Here's the recap of this year's show, along with photos of the 15 talented, dedicated women who gave it their all.

ROUND 1

Thursday afternoon's prejudging began with the two-piece physique comparisons, in which competitors stand in a long line and are then "called out," three at a time, for a closer look. Though call-outs don't necessarily equate to top placing, they often reveal the competitors who are catching the judges' eyes.

Not surprisingly, two-time champ Susie Curry. Adela Garcia-Friedmansky and Jenny Worth were called out first. Atlanta-based Susie, who displayed years of muscle maturity topped with stellar definition, easily took first in this round. Right on Susie's high heels was Adela, from Bloomington, Illinois, who showed strong improvements in her back and overall appearance. Miami resident Jenny took third in this round, with a pretty and proportioned physique highlighted by beautiful ab development.

The big surprise in this round was newcomer Tracy Greenwood, a PhD candidate from Claymont, Delaware, who garnered lots of attention from the judges and was called out with the likes of Jen Hendershott. Kelly Ryan and Jenny worth.

ROUND 2

Competitors must demonstrate strength and flexibility skills in the 45-second round, which features six mandatory moves (one-arm push-up, straddle hold, leg-extension hold, full split front, full split side and high kicks). Since all competitors must perform these moves, it gets pretty difficult to determine who had a better front split or high kick.

Las Vegas transplant Kelly Ryan easily won this round, with Susie right behind in second place. Kelly is basically unbeatable when it comes to routines; she loves to perform and the crowd gives the love right back, particularly when she flips her way across the stage without batting a false eyelash. Kelly has had a hard year: Her hips went out in February and she tore a calf muscle in early August, then injured it further a few days later. You wouldn't know it to watch her, though, as she performed each move with confidence and flair.

Another highlight was Susie's "crotch buster" move, in which she jumps high into the air then lands in a front split (it's painful just to watch). Adela performed very well here, with four very strong, slow and deep one-arm push-ups that made the crowd roar. Since Adela lacks the gymnastics background of other top competitors, she compensates with eye-popping strength moves.

Also impressive was newcomer Stacy Hylton, who performed a gymnastics-laden high-energy routine the audience loved. Stacy, who hails from Orlando, had never even attended an Olympia contest before but has plenty of experience competing - she started gymnastics at the age of 4, competed nationally and, like Kelly Ryan, trained with Olympic coach Bela Karolyi in Houston.

ROUND 3

An entire year of practice can go into the two-minute routine round. Not only do the athletes have to master different strength, flexibility, gymnastics and dance skills, but they have to do it with a smile.

"The hardest part is just getting through it," explains Susie. "Initially, I start doing different moves I'm thinking about. I'll start conditioning them and doing some plyometrics to get my endurance up, them I work the routing piece by piece until it comes together. Sometimes I envision moves in my head, them I'll get out on the floor and just play around and do different things."

Jenny Worth took an entire year to master her signature strength moves (seen below). "I had that one strength move in the Olympia last year but I didn't have it mastered. I only had my arm up for like one second. This time I turned and then went out sideways. It took me a whole year to master it, and I still get nervous because if there's any little shake or wobble, nervousness or sweat, you're gone' I was just hoping I didn't wobble."

Despite tough competition, Kelly earned first place in this round, performing a comical clown routine that featured a layout stepout, which she explains as "basically a backflip in a laid-out position that I step out of one leg at a time." Kelly's exciting routine got the award for greatest audience response; other audience favorites included Jen Hendershott and Stacy Hylton.

How can my community become a Fitness City?

That is the question each park and recreation director should ask him/herself. I asked myself that question after attending a fitness conference in Indianapolis in 1980.

The conference was hosted by the National Recreation and Park Association and the President's Council on Physical Fitness. The audience was comprised of health professionals, recreational personnel, and physical educators at the academic level. At the close of the conference, I was confident that Geneseo, Illinois, had the potential to become a Fitness City.

I reported my findings to the Park District Board. Robert Cherry, board president, instructed me to devise a Fitness Master Plan for the community. Cherry had a great deal of experience with sports and fitness, having served as both director and chairman of the board of the National Sporting Goods Association in 1982 and '83. He knew about the health and fitness movement, and he wanted our community to position itself as a front-runner.

I proceeded to develop the following master plan, which was comprised of five basic steps.

The first step was to compile a list of all related fitness and wellness programs our agency currently offered.

Next came investigating our agency's ability to incorporate health and fitness into direct services (i.e., Was our mission statement for the department, city, and agency, related to fitness principles and the health and well-being of the community, being served?)

The third step involved documenting our agency's support, collaboration, or facilitation with other community resources for the promotion of health and fitness (i.e., What was our agency's philosophy in partnerships within the community?)

Step four was observing our agency's performance as a community catalyst or facilitator for educating the public about community efforts and coalitions.

The final step was considering what means our agency had taken to network and outreach with others in our community (i.e., uniqueness of public information and how we established our partners in this process).

After developing these five steps, the plan was implemented by constructing year-round facilities, partnerships, and networking.

In 1983 the community recreation center was built; two years later an indoor aquatics facility was added. From that, we were able to offer year-round recreational programming. That piqued everyone's interest in health and fitness and the benefits of physical fitness.

We partnered with senior citizens who were working to develop their own center. We also convinced the nonprofit daycare/preschool facility to partner with us and operate under our roof. The daycare accommodates 200 children, all of whom are able to utilize the center's programs and facilities. The hospital was going to construct a new wing for health-related rehabilitation purposes but instead partnered with us, gaining accessibility to our indoor pool.

Finally, communicating messages regarding healthy lifestyles through a network of media outlets was a priority for the Geneseo Community Park District. The district provided messages to inform, educate, and build awareness regarding the benefits of healthy recreation.

Building a Fitness City takes time, determination, and dedication, but anything can happen with the right mixture of people and programs. Begin today to determine if your community can, indeed, become a Fitness City.

Whether you've been a parent for a month or decade, the demands of raising children can derail even the best of exercise programs. But here's how some moms and dads are staying fit even with their hectic schedules.

It can happen to the most dedicated of exercisers once they become parents. Fitness moves far down their priority list amid the whirlwind of diaper changes, pediatrician appointments, home improvement projects and, eventually, PTA meetings. Yet somehow there are parents who manage to work out. What's their secret?

It's a matter of planning and creativity--and determination. If you decide you're ready to fit exercise into your life, you can. Tricks that other parents have found to get in their workouts can help you map out your own plan and stick to it.

Before You Break a Sweat

Putting pen to paper about your exercise plan can be a big motivator. As Laurel Davis, a mother of three, says, "It has helped me to make a plan, write it down, and follow it." Start with a list of short- and long-term goals. Be realistic; looking like Cindy Crawford or Ben Affleck should not be one of your goals! A realistic short-term goal: I will walk three times this week for 30 minutes. A realistic long-term goal: I will lose 10 pounds by my high-school reunion next fall. In addition to goals, list the benefits you'll gain through regular exercise: better sleep, more energy, and being a healthy role model for your children, for example.

Consider potential stumbling blocks and what you will do if they arise. Having a backup plan will keep you from getting sidetracked or making excuses. What if the weather is so bad you can't get out for your usual run, or the baby-sitter cancels on you? Plan to pop an exercise video into the VCR or jump rope in the family room. Are you too rushed in the morning to remember to pack your workout clothes? Always keep a packed gym bag in the trunk of your car, suggests Ben Kwock, a health club program coordinator and certified personal trainer. You have no one to watch your children during a scheduled fitness activity? With a little planning, you can sometimes take the kids along. Teresa Garrett brings her two children to her indoor soccer games when her husband isn't available to take care of them. Her teammates watch them when she's playing.

Do some brainstorming to pick what type of exercise you'll do. Think back to the activities you enjoyed as a child. Ask yourself whether you would rather be inside or outdoors when you exercise, and whether you would rather be alone or with others. Choose activities that meet these needs. Do you want your exercise time to be a period of personal reflection? Walking or swimming would be good choices. Do you want to concentrate on the activity? Racquet sports or kick boxing might work. Do you want to socialize? Consider playing volleyball, soccer, or basketball with an adult league. Let your instincts guide you to fun and fulfilling activities.

Fitting It In

When you have picked your activities, figure out how you are going to squeeze them into your schedule. Many parents find that working out in the morning is optimal. "Make your exercise the very first thing you do in the morning," says Liz Owen-Brune, a part-time graphic designer and mother of two. When you exercise early you don't have to take the time for a second shower, and you avoid the possibility of other activities getting in the way. If morning doesn't work for you, how about during your baby's naptime, your lunch hour, or immediately after work?

Look for ways to sneak in exercise throughout your day. You should accumulate 30 minutes of moderately intense physical activity, but it's OK to do it in several mini-workouts, such as one brisk 15-minute walk on your lunch break and another after dinner. Angela Harrington, a stay-at-home mother of three children, who is back to her prepregnancy size, is on the lookout for exercise opportunities. "Walk to the store, to the library, to the school, to the park ... anywhere ... instead of taking the car," she says. Do sit-ups during television commercials. Get off the bus a few blocks early. Take the stairs. Whenever you can fit a miniworkout into your day, jump (literally!) at the chance.

If you can't set aside time solely for exercise, then combine activities. Walk around the track while your kids have soccer practice; read or watch TV while you work out on an exercise bike, or power-walk the mall between purchases.

What to Do With the Kids

Most parents exercise when their children are at school or day care or when their spouse can watch the children. Busy single mom Anne Dilenschneider--she's a pastor, a writer, and a teacher--walks a trail near her home when her children go to school. "I just head out after the school bus comes," she says. "It's my major reflection time as well as exercise time." Another option is to trade off baby-sitting with a neighborhood parent so each of you can get in a workout.

Another alternative is to combine workouts with family time (see "Great Workouts With Kids" at right for more ideas). If you have a baby, walk with her in a back- or front-pack or push her in a stroller. Run or skate while your children ride their bikes alongside. If you start exercising with your youngsters when they are little, you're not just being a good role model; you're also laying the groundwork for them to be your workout partners later on.

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.

Introduction

Clinical psychologist LCDR Steve Jones began a regimen of brief cognitive-behavior psychotherapy with a 19-year-old hospital corpsman who presented to the mental health clinic with complaints of depression and difficulty in relationships. A careful assessment confirmed the diagnoses of dysthymia (mild but chronic depression) and a dependent personality disorder (which had not interfered with performance to date). After 2 months of weekly therapy, the client showed moderate improvement in mood, although he had become increasingly dependent on the support of LCDR Jones. With little notice, both the psychologist and the patient were then deployed for a 3-month period aboard one of the Navy's hospital ships. As a department head, LCDR Jones was in his patient's direct chain of command. He attempted to have the corpsman transferred to a different area of the ship, but his superior officer downplayed the issue of the preexisting therapy relationship. Although they continued with less-frequent sessions to address the patient's mild depression and difficulty with adjustment to the ship, both individuals felt uncomfortable about their new military roles with respect to one another and the more public nature of their occasional sessions. When the patient began to have serious performance problems, LCDR Jones was required to sign formal performance counseling forms. The patient terminated therapy at that point, and his performance further declined. Eventually, the executive officer ordered a fitness-for-duty evaluation. As the only mental health professional onboard, LCDR Jones, despite strong protests concerning his preexisting clinical relationship with the corpsman, was required to perform the evaluation and ultimately to find his patient unfit for duty on the basis of his personality disorder. The patient was administratively separated from the Navy. He later filed an ethics complaint against ICOR Jones for abandoning his clinical role and moving from provider to supervisor without warning.

Active duty military psychologists and psychiatrists are often faced with ethical quandaries regarding the blending of clinical and military roles with respect to mental health patients. As commissioned military officers bound to place the military mission foremost, these providers often report difficulty avoiding blurred boundaries and maintaining clear professional roles with patients. In addition, an increasing number of military psychologists and psychiatrists are being deployed as members of sea-going medical teams (e.g., on aircraft carriers and amphibious assault ships) and ground combat forces (in Army and Marine assault units). Mental health providers, as embedded members of deployed units, must view every member of the unit as a potential patient, and traditional ethical models of avoiding multiple roles are often rendered irrelevant or unhelpful by the frequent necessity of blurring role boundaries with current patients.1 In this brief article, we highlight the significance of ethical proscriptions against multiple relationships with psychotherapy patients and describe why such multiple roles can be especially problematic in military environments. We present several brief case examples of difficult multiple-role situations in military environments, and we offer some clear recommendations for military mental health care providers. We also hope to increase sensitivity to multiple-role dilemmas among nonpsychiatric colleagues and medical unit leaders.

What Are Multiple Relationships?

Multiple relationships occur when a provider participates simultaneously or sequentially in two or more relationships with a patient, and potential harm to the patient is exacerbated when there are substantial differences or conflicts between the two roles.2 Multiple relationships are also common when a mental health provider is treating a patient and is simultaneously in a relationship (professional or personal) with a person closely associated with the patient or when a provider promises to enter into a different kind of relationship (e.g., business or romantic) with a patient at some future time.3 Kitchener2 pointed out that multiple relationships are prone to become harmful when one or more of four conditions are met, i.e., (a) multiple roles cause the patient's expectations about one of these roles to go unmet, leading to surprise or anger; (b) the behaviors or obligations associated with one role are incompatible with the behaviors expected of another role; (c) conflicts of interest arise between the provider's professional obligations and his or her own personal, social, or political interests; or (d) substantial relational power asymmetry makes the patient vulnerable to exploitation. One can easily see how any of these conditions may cause a mental health patient to feel shocked, angered, or manipulated.

YOU SHOULD GET A complete cholesterol check every five years, according to a new set of national guidelines governing cholesterol measurement and treatment. And make sure to ask for a "full lipid profile," which measures LDL ("bad") cholesterol, HDL ("good") cholesterol and triglycerides.

The new guidelines use a sliding scale for LDL, meaning that the higher your risk for heart attack, the lower the LDL measure should be. While earlier guidelines deemed HDL levels under 35 to be "low," the updated standards give 40 as the minimum; below this number is considered unhealthy. An HDL count of 60 or more is regarded as protective against heart disease. The new guidelines lower the upper limit for triglycerides from 200 to 150.

"Once you find out what your levels are, then discuss with your doctor where they need to be, given other health risks [such as any cardiovascular disease], and what you can do to get them there," says Lynne Kirk, M.D., F.A.C.P., of the American College of Physicians-American Society of Internal Medicine. Lifestyle plays a big role in controlling your cholesterol, she adds, so in addition to maintaining a healthy weight and exercising, aim to:

* Reduce saturated fats in your diet to less than 7 percent of total calories, and lower dietary cholesterol to less than 200 milligrams per day.

* Consume foods with plant stanols/sterols (two grams per day)--these are present in certain margarines and salad dressings.

* Eat 10 to 25 grams per day of soluble fiber, which is found in apples, peas, beans, oats and nuts (you should eat approximately 25 to 30 grams of total fiber per day).

Myotonias are rare disorders characterized by difficulties in skeletal muscle relaxation. Either dominant or recessive modes of inheritance are possible. Underlying gene mutations cause defects in the ion channels of the muscle membranes. Previously undiagnosed myotonias may occur among military conscripts. We report here eight such patients with enhanced symptoms of myotonia during their military service. Six patients had myotonia congenita, one had myotonic dystrophy, and one paramyotonia congenita. In myotonia congenita, serum creatine kinase and aldolase levels correlated with the recommended service fitness classification. Because some anesthetic agents may have unfavorable side effects in myotonia, both patients and anesthesiologists need to be aware of the diagnosis. The awareness of military surgeons regarding the possibility of myotonia is necessary to provide a correct diagnosis and to establish the service fitness of these patients.

Introduction

Myotonia means difficulty in the relaxation of skeletal muscle after voluntary contraction. It is present with initial activation and usually abates after repeated muscle activity (warm-up phenomenon). The diagnosis is based on a careful neurological examination demonstrating myotonic features of muscles and, usually, skeletal muscle hypertrophy. Electroneuronomyography (ENMG) reveals typical repetitive discharges of varying amplitude and frequency.1 There is considerable overlap between the various clinical subtypes, and the severity of the clinical findings varies considerably.2 Muscle biopsy findings are nonspecific in differential diagnoses of myotonias.1 Several gene defects affecting ion channels in muscle membranes may lead to myotonia. Direct identifications of gene mutations causing the disorder are frequently available for further classification.3 Myotonia occurs in several specific disorders; three of them, pertinent to this study, are described below (for a more extensive description, see, for example, Online Mendelian Inheritance in Man, at http://www.ncbi.nlm.nih.gov/omim).

In myotonia congenita, myotonia is most clearly demonstrated by an inability or delay in release of the hand grip. Muscle strength is usually normal at rest, but myotonia may cause functional difficulties in proximal muscles, for example while climbing stairs. Myotonia may lead to muscular hypertrophy, particularly in the limbs and trunk. Percussion myotonia, a local postpercussion contraction followed by abnormally slow muscle relaxation, occurs in approximately one-half of the patients. The symptoms are usually not aggravated by exposure to cold. Myotonia congenita is caused by mutations of the gene on chromosome 7 coding the proteins of the chloride channel of the skeletal muscle membrane. Both dominant (Thomsen's myotonia) and recessive (Becker's myotonia) modes of inheritance are possible.3

Paramyotonia congenita is a dominantly inherited myotonia aggravated by exercise and exposure to cold. It is often associated with muscle weakness or flaccid paresis after myotonia1 and with lability of serum potassium levels.4 The disease is nonprogressive; no atrophy or hypertrophy of the muscles is observed. Paramyotonia congenita results from mutations of a gene on chromosome 17 coding proteins of a natrium channel.3

Myotonic dystrophy is an autosomal dominant disorder characterized by myotonia and muscular dystrophy starting from the distal muscles of the extremities and the face, head, and neck. Cataracts, hypogonadism, frontal balding, and electrocardiographic changes usually occur as well. The symptoms typically manifest in middle age but may start during the second decade of life.1 A gene mutation on either chromosome 19 (type 1) or chromosome 3 (type 2) results in sodium and chloride channel defects. Cognitive performance declines in proportion to increased size of the gene defect and decreased age of onset of symptoms.5 Amplification of the gene defect is frequently observed after parent-to-child transmission.6

The drills during basic military training include exercises requiring rapid onset of movement from rest, without any possibility for individual stretching or warm-up. This may make myotonia particularly distinct. Moreover, myotonia is frequently increased by cold, hunger, fatigue, and emotional upset. All of these may occur during military service. Augmentation of myotonic symptoms during conscript service has been described.7

The prevalence of myotonia congenita in Northern Finland has recently been estimated to be 7.3 cases per 100,000. The disease affects male subjects more often than female subjects. The mean age of onset of symptoms is 11 years, but the mean time needed for diagnosis after the onset of symptoms is 18 years.8 Therefore, military conscripts may have undiagnosed myotonias. To facilitate detection of these patients, this report describes the symptoms and signs of myotonias diagnosed among conscripts and military regulars at Central Military Hospital during 1996-2002.

Stress on staff when a colleague is unskilled or unprofessional in their practice was the third trend identified in a review conducted by the Practice Review Committee (PRC) of discipline decisions by the Professional Conduct Committee and Appeals Committee. In the May 2005 edition of Alberta RN, the first trend, a lack of professional responsibility and accountability, was discussed and the second trend, a lack of integrity and insight in a nurse's practice, was discussed in the July 2005 issue.

SCENARIO: Beatrice, a registered nurse (RN), is often five to ten minutes late for work. She arrives on the nursing unit out of breath and looking like she has just gotten out of bed. She often complains she is tired and just can't get a sound sleep like she used to when she first started out in her career.

Beatrice is always the first one to ask to go on a break and she is often the last one to return from break. On more than one occasion, her colleagues have observed that, when Beatrice comes back onto the nursing unit after her break, she seems very drowsy and inattentive to the nurse giving her report so the nurse usually has to repeat information several times. Staff members often answer call bells for Beatrice's patients as she either isn't around or doesn't seem to be aware that her patients are ringing their call bell.

The nursing staff is becoming increasingly concerned when they work with Beatrice that errors are just waiting to happen and they feel that they have a responsibility to check up on the care she provides. They are frustrated that she is always requesting to work extra shifts or to be on call when they know how tired she is when at work.

DISCUSSION: The Nursing Practice Standards provide guidance for RNs in addressing their concerns related to unsafe practice and support them in making sound decisions so that quality care can be provided.

STANDARD 1

Professional Responsibility

The registered nurse is personally responsible and accountable for ensuring that her/his nursing practice and conduct meet the standards of the profession and legislative requirements.

Indicators:

1.1 The RN is accountable at all times for his/her own actions.

1.6 The RN has a professional responsibility to practice competently.

1.7 The RN demonstrates competence by regularly evaluating his/her practice and taking necessary steps to improve personal competence.

1.8 The RN is responsible for ensuring her/his own fitness to practice.1

Beatrice has a responsibility to maintain her physical, psychological, emotional and spiritual well-being. Her behaviour suggests that she is experiencing a problem in one or more of these areas and that her thinking, decision-making, reaction time, judgment and ability to be flexible and handle stress may be negatively influenced. This problem can jeopardize client care.

When fatigue or other factors threaten an RN's fitness to practice safely, the RN has a right and a duty to withdraw from or refuse requests or requirements to work extra hours. In this scenario, Beatrice does not seem to be aware that her behaviour is placing her patients and co-workers at risk and she continues to request extra work hours. If staff members have concerns, they have a responsibility to address these concerns in a professional manner by first talking with Beatrice and then by bringing their concerns forward to their manager or clinical supervisor. RNs need to recognize the signs of stress that lead to self-exhaustion and identify strategies for dealing with stress for themselves and their colleagues.

RNs in direct care must balance a duty to care for patients with an equal duty to ensure that their fitness to practice competently does not threaten the safety of patients, co-workers or themselves. RNs in other roles (for example, clinical educators and managers) share this responsibility with RNs in direct care. Nurse managers are obliged to promote practice environments where fitness to practice and safe care can be maintained through ensuring appropriate staff mix, required resources and policies etc.