An Apple A Day

A large new study of adolescents in the Minneapolis area surprised and excited the study authors and a writer for the New York Times. They found that many of the girls and over 1/3 of the boys were doing things (changing eating patterns, exercising, taking protein drinks or using steroids) to improve their body composition. The highest rates were seen among the boys on sports teams and girls who were obese. Just under 6% admitted using steroids, which is probably an underestimate because people often do not admit “bad” behaviors in surveys.

The researchers and the NYT writer interpreted their findings negatively– “cause for concern” the authors concluded. More careful consideration of the data leads to different conclusions. The article overemphasized the unhealthy potentials of these behaviors. Certainly individuals who are overweight or more serious athletically SHOULD be more serious about taking care of their bodies, including building muscle mass. The conclusions of this study were overblown, reflecting both a lack of understanding of proper diet and a hypersensitivity to body image issues.

The CDC estimates that over 1/3 of American teens are overweight or obese (significantly less than their parents). It is very clear that the most effective ways to reach a healthier weight is through physical activity and dietary improvement, especially by boosting protein intake. I would add that it is even more evident that weight is far, far less important than is body composition (ie, the ratio of muscle to fat). Athletes need strength training, both to enhance performance and to prevent injury. Strength training also builds muscle and speeds up metabolic rate, each improving body composition.

Considering the realities of American health in general and the health of adolescents, I am generally pleased by these findings. When I was 12 or 13 I was overweight. Ken Cooper’s book, AEROBICS, came out. I read it, changed my eating patterns, began a program of vigorous exercise, lost weight, learned the power of healthy lifestyle, grasped my ability to control my own life and eventually became the doctor I am today.

The use of steroids is very concerning and we need to do more about that. The researchers and NYT writer apparently had biases which led to their skewed interpretation of the study data. Although less extreme, I do share some of their concern, particularly the issue of male body image.

I have always supported the ideal of gender equality. This is not, however, the path I envisioned taking us towards that goal. Lowering perfectionistic expectations about female bodies was my expectation, not raising expectations about male bodies. We are moving towards an unhappy and disordered equality.

Columnist Richard Cohen, commenting on the latest Bond film, pointed out the irony that Daniel Craig’s Bond supposedly suffers weakness and disability of age, while the film simultaneously lingers on his hyper-perfect body. They are now marketing the “Daniel Craig” workout, so that we can ALL achieve a similarly imperfect body????? Thanks?

A recent article in the NY Times caught my eye. I couldn’t have agreed more, and also less. Titled “Let’s (Not) Get Physicals”, it was a reflection on the problems with conventional routine physical exams. http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all

The time-honored tradition has been for a thoughtful patient to see her/his doctor for an annual exam. The article discussed several of the screening tests that have been the foundation of the annual exam routine. Many of these have been shown to be ineffective. Ineffective screening tests are worse than just a waste of time and money, as they lead to other needless tests and procedures. The procedures, the next steps looking to identify or treat the “disease” that is not there or does not need to be treated, usually create their own problems. The end result is that the patient has been harmed by this well-intentioned effort. Bear in mind that dumping procedural screenings is nothing new. Annual chest Xrays, anyone? We used to do that not so terribly long ago.

That was the agreeing part. My disagreement is based on the definition of what is done. From my experience it is certain that an appropriately directed annual health assessment is wise. That is true, even excluding the simple technology of a couple of blood tests. I see people every day who are so vitamin deficient that it shows up in simple blood tests from a conventional lab. But forgetting that, dumping all the post 19th century technology, there is ample, easily accessed and useful evidence of what needs to be changed to better a person’s health.

Taking to patients about how they feel, what they eat, their exercise patterns, how they are managing the stress of their lives, etc., tells me a lot. With that information, I can help them improve the quality of their day to day lives and avoid developing the most common diseases in our society (e.g., heart disease and diabetes). The risks of talking to a patient, looking over a three day diet record, reviewing his/her use of supplements/medications and conducting a simple physical exam are close to nothing.

Another shadow, looming over this discussion, is that doctors know that patients don’t change their habits. You can never get them (you) to change their diet or exercise. They won’t work to learn how to manage stress better. Docs know that. As you know very well, docs are wrong.

A child can learn to read and write without any help. but it will take a long, long time and incredible determination. When a doctor tells a patient that they should get more exercise, eat better, stop smoking or whatever, without providing the specific steps to achieve those formidable goals, almost no one is successful. The patient feels like a failure and the doctor’s negative expectations are confirmed.

What my colleagues do not know and what perpetuates this vicious cycle of hopelessness is HOW to help patients make changes. Medical school lasts four years. After that we have to get at least one year more of training, with most of us taking three or more. In all of that, there is little emphasis on the benefits of changing lifestyle and none on how to help patients make changes. When I earned a national level soccer coaching license I received some of my most valuable medical education. That was how I learned the nuts and bolts of helping people make changes. That has made a huge difference for me, and more importantly, for my patients.

If my colleagues were taught more about healthy lifestyle, low-tech examination and how to actually help patients make changes, annual exams would be powerfully positive health and life-enhancing experiences.

Who is that in the photo? It is Joseph Bell, MD. He was the inspiration for Sherlock Holmes. One of Conan Doyle’s medical school professor’s, Bell was renowned for his remarkable insight into his patients, based purely on his skills of observation and thoughtful deduction. He might be an even better model for physicians today than in his own time.

The Foods You Choose Can Help You Lose, Or Not

Many people think that Americans are obsessed with celebrity, politics or some sport. Yes, we are, but our chief obsession is not on that list. Americans are truly obsessed with weight, especially losing it.

One reason exercise is so important for those losing weight and improving their body composition is that our body’s response, after losing weight by cutting dietary calories, is to slow down its metabolism. Faced with starvation, your body slows everything down. In that state, which some studies show persists for years, you will burn fewer calories than another person who weighs less than you, but never starved themselves. Exercise helps keep that from happening by forcing the body to keep running at a higher metabolic rate.

The really, really bad consequence of the metabolic slowdown is that many people who lose weight not only regain every pound they dropped, but they also end up with a higher percentage of body fat than they started out with. They bounce back up to the same weight, but now they are fatter at that weight. That outcome is cruelly disappointing.

A small but very interesting study shows that what you eat, specifically the balance of fat, protein and type of carbohydrates, might change the rules in this losing game. Researchers helped a group of overweight men and women lose 10-15% of their body weight, and then rigorously tested their individual responses to three different diets. One diet was the traditional low fat/high carb diet with 60% of calories from carbohydrates and 20% each from fat and protein sources. At the other end of the spectrum was a diet with 10% carbohydrates, 60% fat and 30% protein. The third diet had a middle range of carbohydrates (40%), with 40% of the calories coming from fat and 20% from protein. The carbohydrates in this diet were specifically selected to control blood sugar (low glycemic index and moderate glycemic load). Consistent with other studies, those in the low fat/high carb group dramatically lowered their metabolic rate, burning 300 calories a day less than those in the Atkins-like low carb group. In other words, those in the low carb/high fat group burned more calories. That caloric difference is like running 3 miles every day, without getting up off the couch. Piled up over a year, those additional 300 calories a day become 30 lbs of fat. The “old wives tale” about potatoes making you fat proves the wisdom of listening to old wives.

The middle diet had a middle-of-the-road effect, but could be the best choice for the long term. During that phase of the diet people had the least hunger and reported feeling the best. There are reasons not to jump to the conclusion that the Atkins model is certainly the best way to eat. One reason is that during that phase of the diet the subjects’ blood samples showed the highest levels of inflammation. The most important shadow of uncertainty is cast by the problem of protein disparities in this and other trials. Dietary protein makes bodies run hotter, raising the metabolic rate and burning calories. The low carb diet in the study had 50% more protein than the other two diets, and so was then not perfectly comparable.

Regardless of the scientific understanding of how and why, success is the best outcome measure. Without any doubt, my clinical experience teaches me that patients find it easier to lose weight on a high protein diet. For most individuals the simplest approach to making this change is to replace carbohydrate-rich foods with protein-rich ones. Although exercise, sleep, taking a supplement to get the right amount of vitamins and other elements are also required, the dietary essentials are as follows:

1. Target a specific amount of protein intake by taking your weight in pounds and multiplying by 0.7 - 1.0. That number is how many grams of protein you should get in a day.
2. Do not be afraid of fats.
3. Remember that sugars and other foods that make your blood sugar rise quickly (potatoes, processed grains, candy) are going to make it tough to keep your weight down. Although whole grain products like whole wheat bread are less bad, they still have a high glycemic index that will fight against your efforts to lose weight.
4. Alcohol, while it has a very low glycemic index, creates blood sugar instability, leading people to eat more for up to 24 hours, fighting the hypoglycemia alcohol creates.

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.

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.