An Apple A Day

Newly released data, collected over nearly 40 years, indicate that runners live 5-6 years longer than other people.  I like this but also have some doubts. 

I began running as a 12 year old, and after a few more months of surgical recovery, hope to resume this life-long habit. I love it.  My work as medical staff at marathons and as Medical Director of the Santa Rosa Marathon are the confluence of my interests.  Just like this study shows, I am certain that running, and more broadly, being physically active, are crucially important to any person’s health and wellbeing.

Now for the doubts.  Five to six years is a huge difference.  The study has a number of flaws, unfairly visible with close to two generations of hindsight.  Why “unfairly”?  Well, any long-term study will have significant problems.  There is too much we don’t know, including unknown and then unobserved variables.  So, weakness are inevitable.  Too much criticism is also unfair, because of course the reason to do research is to learn what we don’t know. We can’t expect researchers to know what no one knew when they began.  So, my advice is to take these findings with a grain of salt.  Running is great.  However, exercise in any form is great and there are excellent reasons, theoretically, scientifically and understood by those with experience, why other forms of exercise are also essential and sometimes preferable.

As my father died of a heart attack at age 47, can I attribute my 10 additional years (SO FAR) to my running?  Sure, but only in part.  My diet has been excellent, way better than his was, for the last 40 years.  That influence, other elements of my exercise regimen and many other factors for sure play their parts.

 

So, run if you want to run, but exercise, you must.  While you are at it, adding in the other good stuff will help you live better, not just longer.

 

If you read about vitamin supplements you must be confused.  Actually, it would be hard not to be. Vitamins are, by definition, essential to health.  Studies of hundreds of millions of people confirm that truth. However, a rash of recent studies have linked taking vitamin supplements to higher rates of a variety of diseases, especially cancer.  What’s up?

 

The fundamental problem is bad research.  This bad research is the consequence of poor understanding, plus the difficulties inherent in designing and conduct nutritional studies that apply to the real world.  The best examples of the faults in these nutritional studies are probably those dealing with folic acid and vitamin E.  

 

Many studies show that dietary folic acid reduces the risk of many diseases, particularly cancer.  The prevention of congenital spinal malformations is the main reason our food supply has been fortified with folic acid for decades.  Surveys of the American population show that this approach works.  That is the simple part.  The confusing part is that some studies have shown an increased risk of cancer with folic acid supplementation, while others have shown that folic acid lowers the risk of the very same cancers.

 

As many of you have heard me explain following your own blood testing, nearly 20% of us have a genetic inability to convert folic acid to its metabolically active form.  Those individuals among us need to take a special form of folate.  If they take the common, most widely available kind of folic acid, not only does it not help, it seems to cause problems consistent with the unhappy research findings. After MERCK, which holds a patent on this form of folic acid, allowed others to use it, I had it added to my multiple vitamin.  Very few multiple vitamins contain this form of folic acid, as it is more expensive.  Two months ago I read an editorial in a major medical journal wherein a couple of prominent experts pointed out that negative studies on folic acid in diabetics had neglected to address this issue.  Their opinion, with which I am in complete agreement, was that these studies were fundamentally flawed and almost certainly drawing incorrect conclusions as a consequence.

 

Vitamin E has also taken a lot of heat due, to a similar lack of understanding.  Most of the vitamin E you can buy in supplements comes as alpha tocopherol.  Unless you are a chemist, your brain won’t want to swallow that word or distinguish it from beta, gamma, delta or any other tocopherols.  It is not even that simple, because even with all of those tocopherols, an additional class of compounds called tocotrienols are part of the Vitamin E family and seem to be important.  Food contains all of these compounds, and it appears that alpha tocopherol might be the least important of all.  As one vitamin E researcher wrote, “taking a mixture of vitamin E that resembles what is in our diet would be the most prudent supplement to take”.  I would amend that statement to read, “taking a mixture of vitamin E that resembles what would be in an ideal diet and considers your individual needs, would be the most prudent supplement to take”.

 

A recent survey concluded that very few Americans were low on any vitamins or minerals.  While that got significant media attention, the fact that hundreds of studies have shown the opposite, did not.  Many of those studies actually measured body levels.  That is especially important as estimates from dietary records are woefully misleading.  Dietary records are infamously different from the truth of what people really do eat.  On top of that, absorption varies tremendously from person to person and even time to time for the same person.

 

Thankfully, there is evidence that some who write about and study nutrition are thinking more clearly.  The “experts” are becoming more expert.  Also, those with a better understanding are getting at least some attention for their criticisms.

 

Positive evidence of the benefits of dietary supplementation continues to accumulate (of course).  Recent studies have shown that the brains of people of all ages, from young children to elderly adults, function better beginning just days after starting to take a multiple vitamin.  The same holds true of omega-3 supplements. In an example of the complexity of nutrient interaction, vitamin E lowers the rate of prostate cancer but only when taken along with selenium.

 

Bottom line-

Think critically -  If something is vital, many of us need it.

Don’t forget the food – A vitamin pill cannot entirely replace good food.  

Don’t go crazy -  Take moderate amounts of nutrients as a safety net.

Go crazy if YOU need to -  Some people, especially when ill, need much more.

Vitamins vary – Cheap forms of nutrients cost less, but they are usually a waste of money and can be harmful

 

 

As you probably know, exercise may well be the single most important health habit.  Drinking water, eating well, using supplements properly, avoiding toxins, sleeping, working on your attitude and relationships are all also vitally important.  However, even beyond its power to prevent and treat disease, exercise may well provide the greatest wellbeing boost of any of the essential health habits.

Whether exercise is “number one” or not, it is huge though, and getting people to exercise can be an equally huge problem.  The number one obstacle for most people is time.  Sure, our heritage is to be physically active all day long, sometimes vigorously so.  Just as we are omnivorous eaters, consuming just about anything, our bodies need all kinds of physical activity and thrive on the greatest diversity.  We need to work on our muscular strength (especially as we get old).  We need aerobic activity to strengthen our heart and lungs.  Flexibility and balance are also necessary.  Our bodies, including our brains, need all of this physical activity, but where can one find the time?

Like many in sports medicine, I am very excited about recent discoveries about one form of exercise that can shorten your time commitment, while simultaneously providing you with even greater benefits than those long, slow, time-consuming physical activities pursued by so many.

This magical form of exercise is called High Intensity Intermittent/Interval Training (HIIT).  Many of you will recall the crushingly intense sprint work your coach or PE teacher used to train/punish you with long ago.  HIIT is a bit like that, but NOT torturous.  In fact, when patients in intensive care with heart disease where given a choice of walking on a treadmill or a HIIT workout, the great majority preferred HIIT.

That’s right, ICU patients encouraged to engage in a workout that would seem to be a good way to kill them off.  I am almost as impressed by the fact that these latest studies using very sick hospitalized patients were approved by human subjects committees, as I am with the remarkable impact of the HIIT regimens.

When the first studies came out on this approach less than 10 years ago, they were small but impressive, conducted on young, often already well-conditioned athletes.  HIIT seemed like it might prove to be a way for these athletes to kick up their fitness after a layoff, or in the lead up to a big competition.  After more and more results came in, showing how efficacious this approach could be, researchers decided to try it out on other populations.

Amazingly, we have now built up research evidence ranging from the basic sciences (cellular and physiological changes) to clinical trials of old and young, fat and thin, trained and out of conditioned individuals.  The bottom line: It’s all good.

In only two to three weeks of 2-4 short sessions of HIIT each week, just about every measure we have of fitness improves, often markedly so. It also improves blood tests associated with long-term risk of heart disease, diabetes, cancer and Alzheimer’s.  Also, forget the long, slow activity and the “fat burning” heart rate zones you see posted on exercise equipment.  HIIT gets fat burning better than low intensity exercise, and keeps it going for hours after your workout ends.

One of the incontestable failings of age is that our maximal oxygen uptake drops year after year, beginning in our late 20s.  We just don’t have the aerobic capacity we used to. HIIT has been shown now to improve oxygen uptake, the most essential fuel for our cells, regardless of age, gender or previous fitness.

This is all great news, but it gets better. HIIT, with the rest intervals between the intense exertion intervals, is unlike the sprint training you might have endured long ago, and not just because it is less unpleasant.  The only research comparing HIIT to that sprint-sprint-sprint-till-you-drop torment, shows that HIIT actually works better.  Yay!

With one exception, I cannot remember any similar wave of research on a specific treatment.  That one exception, vitamin D, is an almost perfect comparison.  The evidence suggests vitamin D levels are linked to improvements in nearly every human health trouble.  Similarly, HIIT does almost everything we have learned that exercise can do.  Although there are fewer studies of HIIT than vitamin D, the quality of evidence might actually be even stronger than the vitamin D studies to date, because the of the way HIIT studies can be designed (intervention versus observation).

Okay, so how do you do it?  Very simple.  Warm up a few minutes (5-10).  Then alternate working hard and easy.  How long?  The easiest way is probably to go hard for a minute and then easy for one minute, repeating that cycle a total of 10 times.  Some studies used a four minute hard interval followed by three minutes of easy, for a total of four cycles.  We do not know if some duration will prove to be better than another.  All the studies, using whatever interval, show that it works.  Consequently, I’d say it is up to you.

My son, for example, lives in a high rise building in a big city.  He wanted to work out climbing stairs as he does not have any cardio equipment and gyms are extremely expensive where he lives.  The plan we worked out was for him to climb up for 4 minutes, which gets him near the top of the 30 stories, take the elevator back down then do it three more times.

You can walk, going faster and then slower.  You can do the same with swimming cycling or whatever activity you prefer.

How hard is hard?  90% of your maximal heart rate.  Maximal heart rates are very scientific but they can be annoying to use as a measure, because you have to monitor your heart rate and figure out what 90% of MHR is for you.  Maximal heart rate is different for different people, men versus women and it changes with age.  It also differs by what you are doing.

My advice is to do this by how hard it feels to you.  90% = panting.  Go hard enough so that you are breathing heavily and then go easy.  As you go through the cycles, you will probably learn that, keeping your effort at the same level of intensity, you are going at a slower pace.  That is fine.  Do not try to maintain the same pace unless you feel about the same level of exertion.  The point is your effort, how it feels to you. Do not thrash yourself.  Start out being careful not to push yourself too much, and as you do it for a while you can get a better sense of what your limits are.  You do need to approach those limits, to push yourself, to get the maximum benefit from this.  If you have any questions about this, please come in to talk about your individual circumstance.

I will add that there are some HIIT regimens that make the hard exertion interval much longer than the easy, recovery interval.  I do not like that for anyone who is not already quite fit.

My own experience with HIIT may be of interest.  In years past I trained in this way to build fitness, partly because it was closer to the most demanding physical work I did.  Refereeing semipro men’s soccer games, at times sprinting to keep up with athletes 20 years younger than I, was not at all like jogging for an hour or two.  More recently, as problems leading to my knee surgery became increasingly troublesome, I dropped all of my longer aerobic sessions.  My knee just would not tolerate them.  I experienced much of the same energized but relaxed sensations of the longer aerobic work, but with considerably less pain in my knee.  One conclusion from this is that HIIT can have an important role to play when a person has a chronic or acute joint problem, limiting the stress his/her body can endure.

Many medications are available only by prescription (unless you own a computer or travel to another country).  That is because of the risks that accompany their use. When drugs become available we tend to believe that availability is some sort of certification that they are safe, and weak compared to prescription meds. Not true.

Recent news that daily use of aspirin lowers the risk of a number of cancers (especially esophagus, colon, rectum and lung) is another example of apparently wonderful information that is not, if you know enough.  Seems great, doesn’t it?  Take a safe drug and prevent some very nasty diseases.  Shouldn’t I be taking it anyway, because it prevents heart attacks and strokes?

Here comes the buzz kill.  Other studies, larger and more carefully designed, have not found this effect.  Also, studies have found that taking aspirin does not prevent a first heart attack or stroke, as we had thought it would.  It might be a good idea for that purpose in some middle-aged individuals, and probably is for those who have already had a heart attack or stroke. Finally, recent data shows that daily aspirin doubles the risk of macular degeneration, already one of the most common causes of age-related blindness.

Aspirin used to be routinely given to infants with fever.  Then we learned that this could lead to (potentially fatal) Reyes Syndrome.  I have never liked using it in this circumstance, because fever is generated by the body in its effort to make itself an unpleasant place for bacteria and viruses to live.  Squashing the fever squashes the immune response and, as research shows, prolongs illness.

Ibuprofen, (aka ADVIL, MOTRIN, MUPRIN, RUFEN) seems like a good choice to so many.  Inflammation is “bad”, so anti-inflammatory is then good.

Ibuprofen is the leading cause of impaired kidney function in the US.  Years ago a kidney specialist told me she would not see a new patient for kidney trouble until the patient had been off ibuprofen entirely for at least a month, because dropping the kidney-imparing ibuprofen fixed 75% of the patients sent to her.

Ibuprofen markedly increases the risk of the most serious problem commonly seen in marathon runners.  Their kidneys slow down from the exertion.  Taking ibuprofen makes it worse. Their sodium drops and they can die.  Not good.

Many athletes take ibuprofen before engaging in their sport.  Ironically, ibuprofen increases damage to muscles and soft tissue because “inflammation” is one aspect of the healing process.  At the medical meeting of physicians working with endurance athletes before the Marine Corps Marathon last fall, I was delighted to find myself in the company of others who shared my dislike for ibuprofen.  We discussed its harms at length, as well as the muscle damaging effects of statin drugs.  I loved it.

Is Tylenol, the “safer choice”.  Not really.  Starting from the very beginning of my medical training I spent a great deal of time working as an Emergency Room Physician.  One of my first ER shifts I took care of a teenaged girl who was upset and, crying out for help, took an overdose of Tylenol, believing it was safer than aspirin.  By the time she arrived in the ER, she had changed her mind and was feeling fine. She did not realize that, although , in the coming days her life was at risk due to the delayed, liver toxicity of acetaminophen/tylenol.

Following the recognition of the link between aspirin and Reye’s Syndrome, everyone switched to Tylenol.  Now many think that the rise in childhood asthma, which began at the same time, is not a coincidence.

Remember, there is no “free lunch” biologically or otherwise.  The best medication is no medication.  Taking care of yourself, minding the essential health habits, will do far more to help you live well and happily than any medication.  There is a place for drugs but they are only pharmacological band aids.

 

I hope that, respecting tradition, you have dedicated yourselves to creating some better health habits in this New Year.  I also hope that you are going about that in a joyful way, understanding that doing the right things will help you enjoy your life more.  Also, pursuing good health habits should be fun, not tedious and just “good for you”.  Sure, sometimes it takes a little while before you start noticing the benefits, so a little discipline is needed to establish your new habits.  Other times, you feel better right away.  Instantaneously or gradually, disease-reducing, longevity-promoting or not, do it because you will feel better. This newsletter is a map, guiding you along the most direct path towards a better life. Change is not just a matter of will-power. Going about it the right way makes it much easier, and markedly increases your chances of success.

I am in an exercise focus right now.  Admittedly, some of that is because of the time I spent during the last month working at the Olympic Marathon Trials and attending a sports nutrition conference, but more importantly, a lot of new data is coming out that is very interesting and will be useful to you. In this blog I will soon post some thoughts about some physical training specifics.  The purpose will be to make your exercise more efficient and more effective.

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 it’s 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.  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 to creating a map to get you where you want to be.

I cannot overemphasize 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 the bigger issue.

We usually perceive some problems clearly, but 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 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:

Essential health habits

Drink Enough Water

Exercise Almost Every Day

Eat Well

Take Your Supplements

Avoid The Things That Make You Sick

Get Enough Sleep

Be Involved in Your Community

Have A Healthy Sex Life

Remember That Attitude Is Important

Spirituality/Life purpose

Goal Setting

After you sort out where you are, you can create an image of where you want to be and construct a map to get you there. Deciding that you want to be younger is not going to work anymore than deciding you want to be taller or win the lottery.  Make your goals achievable!  That is the first step in goal setting.

In a more subtle way, deciding that you want to be stronger or thinner or calmer won’t work either.  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 path to follow towards the goal, or you don’t know when you are there, you won’t ever get there.  For example, you decide that you want to lose weight. You then must sort out how you are going to do that and how you are going to measure it.  Let’s say you determined that, for you, the keys to improved health are to increase your activity and change your diet by eating more vegetables and cutting out soda and alcohol.

You could begin 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 determine 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 particularly 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.  There is some evidence that, as long as you are physically fit (i.e., good aerobic capacity and strength), obesity might not be a risk factor for death, disease or feeling poorly.  The scale does not tell you what you are made of, your body composition.  Most people who do a lot of strength training are overweight on the charts, but have low body fat.  Increased levels of body fat are more risky than similar increases in body weight. Many people find that improving their diet and 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 usually tell me their clothes are fitting looser even when 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.  Living with a drill sergeant is not going to work, especially if YOU are the drill sergeant. 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, illness or they just let themselves go, I have to work hard to reign in their over-enthusiasm.

Particularly with exercise, it is very easy to do too much too fast.  The consequence is often an injury, and the time then needed for recovery often sets the patient further back than she/he was to begin with.  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.

The other side of it is that changing several problem areas in your life at the same time can be very good and a highly successful approach.  Diet changes in particular are often most successful when they are dramatic.  You feel better quickly and that experience helps you do more.  As you feel the benefit, your commitment will be stronger and you will have more energy to do more to feel better still.

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

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.  Actually I have to understand why they failed, in order to help them go 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.