January 7, 2010

Dear Patients,

I hope you are passing through this time of reflection well. Traditionally this time of year connects us to both the past and the future. We take stock of our lives, considering all that has gone before and what is to come. With all of these reminders of the past, the likelihood of regrets and sadness is quite high, heightened further by the darkness outside. At the same time, this is a season of hope. Our active decisions about where to steer our lives in the coming year turn us toward what we can do to make things better for ourselves and those we love. Just as the sun comes back, we can and should build our own strength or maybe inner light in a manner of speaking.

With all of this in mind, this newsletter is an essay on making changes, hoping to give you some encouragement and useful tips as we start out on a new year.

Best
Michael Carlston, MD
www.carlstonmd.com

Making changes
The idea of making changes in the New Year is easy fodder for comedians. Everyone talks about it, but no one really accomplishes anything. That’s right and its also very wrong.

In the Northern Hemisphere, where most of us live, the New Year roughly marks the return of the sun. The days start to become longer and warming weather will follow. Greeting the New Year with hope and new ideas has been the tradition as far back as we can trace human cultural history in the north. I think this tradition would have died out long ago if every attempt were met by failure. On the contrary, every day I see patients successfully change their lives for the better, not just at the New Year. You should be optimistic about making changes.

Change doesn’t happen simply by rolling out of bed on New Year’s Day, although that IS a necessary first step. To ensure success, you need to develop a plan.

Self-Assessment
The dark, cold months of the year are traditionally a time of reflection, a time of the inner life. Figuring out where you are is essential in creating a map to get you where you want to be.

I cannot emphasize enough how important an honest and thorough self-assessment is when you are trying to make changes. Your self-assessment must be as objective as you can make it. An inaccurate assessment inevitably carries the seeds of failure. If you think you are in better shape than you really are, the training for that April marathon WILL injure you. You might think you aren’t eating well enough, when your lack of exercise or poor stress-management is holding you back even more.

We usually perceive some problems clearly, others we think are bigger than they really are, while still others are invisible to our own eyes. Trying to sort things out by yourself can be a lot like painting a self-portrait without a mirror, or maybe having only a distorted, funhouse mirror to look at. This is the reason why so many people find the help of a professional useful. A professional can identify problems and solutions you might not recognize or know about. A professional should have learned from the experience of many patients, and can use that accumulated wisdom to guide you. Seeking the advice of family and friends can also be helpful at times.

Reflection is an inward, ideally a meditative, process. In keeping with that inwardness we should start from the inside, meditating on who we are and who we want to become. Following is a list of some areas to consider:

• Spirituality/life purpose
  
• Attitudes and mood
  
• Stress
  
• Relationships
  
• Sexual health
  
• Injuries/weaknesses/illnesses
  
• Ones you currently have
  
• Tendencies
  
• Exercise habits
  
• Aerobics, weight training, flexibility, balance training, interval work, how much, intensity level, variability, proper recovery
  
• Diet
  
• Water intake
  
• Eating habits - how not just what
  
• Types of foods – veggies, sweets, protein (veggie and animal), processed vs. unprocessed, organic, local
  
• Avoiding poisons
  
• Alcohol, street drugs, tobacco, foods, environmental exposures, medication overuse
  
• Body weight and composition
  
• Sun/vitamin D
  
• Sleep
  

In a more subtle way, just deciding that you want to be stronger or thinner or calmer won’t work either. You need a plan. There is an art to creating goals that will help you achieve success.

Second Step - Goals must be specific
If you set a goal but don’t have a pathway to follow to achieve it or don’t know when you have achieved it, you won’t achieve it. For example, you decide that you want to lose weight. You then must sort out how you are going to achieve that goal and how you are going to measure it. Let’s say that you decided that the keys for you are to increase your activity and change your diet by eating more vegetables and cutting out soda and alcohol.

You could start by tracking your activity level for a week, either by timing yourself or, better still, wearing a pedometer. Then as you set about implementing the changes, you have clear evidence and incentive by simply reading the numbers.

The same applies to your diet. You could decide that you will eat some vegetables at every meal, including two servings at lunch and dinner with a leafy green salad every night. You also decide to limit yourself to no more than one alcoholic drink and one soda a week. All you have to do is look at your plate and into your drinking glass to learn whether you are reaching your goals.

I have a couple of comments about weight loss as a goal. First, it is not a very health-oriented goal, so I don’t like it much. As long as you are sort of close to “normal”, other factors, especially physical fitness, are much more important than the reading on the scale. The scale also does not tell you what you are made of, in other words, your body composition. Most people who weight train are overweight by tables that simply compare weight and height. However they actually have low body fat and are healthier because increased levels of body fat are more risky than similar increases in body weight. Many people find that improving their diet an exercise pattern does not change their weight as much as it changes how they feel, their physical capacity and how their clothes fit. Muscle is denser than fat, so patients often tell me their clothes are fitting looser even though their weight has not changed significantly.

Third Step - Early Success
To maintain and build on a change we need positive feedback. If you try to do too much, feel horrible while doing it and feel worse the next day, how likely are you to try it again?

Creating those specific, achievable goals helps you set in motion a positive feedback cycle. You met your goal. What you did made you feel better. You felt good because you met your goal. You then want to keep it going. It is vital to let yourself feel good about your accomplishment. CELEBRATE YOUR SUCCESSES!

Short-term vs. long-term goals
Tied closely to the concept of early success is the distinction between short and long-term goals. If you are only going to be satisfied when you have gone all the way from couch potato to triathlete, you are going to be unhappy for a long time, and probably never going to become a triathlete.

Short-term goals are the steps on your path. Long-term goals are the destinations to where the path leads you. If you think only about the beach, you are going to get lost on the path through the jungle.

Taking Action
Implementing your strategy requires determination, but it also demands gentleness. For some patients I need to be a cheerleader, doing everything I can to convince them of the need for change and applauding their positive steps. For many others, particularly those who are less healthy than they used to be because of age or because they just really let themselves go, I have to work hard to reign in their enthusiasm.

Particularly with exercise, it is very easy to do too much too fast. The consequence is often an injury, and the time needed for recovery often sets the patient further back. You will make the fastest progress by going slow. When increasing physical activity, I tell all but the youngest, strongest patients to increase either intensity or duration by 10% a week.

On the other hand, changing many problem areas in your life all at once can be very good and a highly successful approach. Diet changes in particular are often most successful when they are dramatic.

The greatest wisdom is in simply paying attention to how you feel and adjusting accordingly.

Failure
The road of excess leads to the palace of wisdom
William Blake

I think failure is good. It is good because we have to make mistakes to learn. When I see a patient who has not implemented my recommendations I always want to know why and, in fact, must understand why to help them further. Problem-solving is an inevitable part of doing anything new. If I recommend swimming for a patient with back trouble as the best exercise for her condition, but she can’t swim, what is the point? If a patient has not been using the breathing exercise I recommended because he did not understand it, I need to make it clearer.

The only real mistakes are those that we do not learn from. Mistakes teach us how to correct our course before we get way off track. If you haven’t made mistakes, you haven’t been trying.

Good Gadgets for Exercise
Most positive lifestyle change is not high tech. “Just Do It” as Nike says, forgetting perhaps that the slogan should remind us that we also don’t need Nike. While it is important not to let consumerism clutter our lives or obstruct the pathway to better health, there are a few simple bits of exercise equipment that can be very helpful.

Pedometer – You can pick up a pedometer for $5-$10 which can become the most useful piece of exercise equipment you own. If you wear it every day you will learn how much you are moving around (almost always less than you think). Remember 10,000 steps a day is a reasonable long-term goal for almost everyone.

Heart rate monitor – These gadgets have become quite inexpensive. While a pedometer tells you how much you move, heart rate monitors are the best way of learning how mush effort you are putting into your exercise. They can be very helpful on recovery days when you should be working significantly less than intensive training days. That monitor will scold you to slow down with its beeping. If you really want to maximize your use of a heart rate monitor get in a habit of checking your morning resting heart rate and learn to use the Karvonen (Heart Rate Reserve) formula to establish your training zones. There are a variety of formulas scattered across the internet http://www.brianmac.co.uk/maxhr.htm http://www.racedaynutrition.com/HeartRate.aspx http://www.sarkproducts.com/targetzonecalculator.htm

MP3 player – Yes, I love my ipod, but I use it selectively for exercise. I never wear it when I run or walk, much preferring to enjoy the sounds of the outdoor world (and hoping not to miss hearing that car coming up behind me!). When I lift weights at the gym, my ipod keeps me going. Many people do love their MP3 players for exercise. It helps them work harder and enjoy their exercise time or make it pass more quickly.

Good shoes – Okay, maybe Nike knows this one is inevitable. We wear shoes all the time. Athletic shoes have become quite specialized and very expensive. As athletic shoes have become more sophisticated, they are tailored more and more to individual needs. I think this individualization of shoes has created a situation where you can easily buy a high-quality shoe which is really bad for you. Ironically, the more expensive and well-cushioned the shoe, the more likely this is. There are websites that help you get an idea about which shoes might be better for you, and many good running shoes stores will let you try out their shoes. Better still, start exploring barefoot running. Well, not actually barefoot, but nearly barefoot. I am convinced that the athletic shoe manufacturers have been creating more problems than they have been solving with “the latest and greatest” shoes.

Final point - Avoid equipment that can hurt you or set you back. Everyone is different. The “best” shoes or “best” weight lifting book might be bad for you. Learn from your mistakes.

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