An Apple A Day

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.

This video talk is exceptional. You will find it interesting and surprising. The presentation style is very cool and the information is accurate, overlooked and extremely important.

Pooh-poohing Mind-Body Interaction

I surprise patients some times when I tell them that I do not believe in what is often called “mind-body interaction”. My explanation, though, convinces them not to run away and look for a different doctor. The idea that thoughts affect the body and physical disease alters emotions is right, but also very wrong. This concept falsely splits us apart.

The truth is that the brain is in the body. Every time I look at my books, there it is. The same was always true in anatomy lab, as well as looking at MRIs and CT scans. Despite this incontestable fact, there are those who view habits of thought as entirely divorced from biochemistry and physical health.

The problem starts on the medical side. A doctor tells a patient that the tests are normal. Therefore, there is no problem or the problem is 100% emotional. Go away and fix yourself. This ignores the limitations of our testing and allows us to abdicate our response to provide help. We fall into this trap out of ignorance at times, deluding ourselves into believing that thoughts are not biochemical, produced by and creating our physiology. We know better. MRIs show that the physical structure of our brains change after going through psychological counseling. Proteins, hormones, immune factors, and alterations in the levels of a broad range of the compounds normally found in our blood, can all have subtle and lethally dramatic impacts on our brains’ ability to function, including thoughts and feelings.

On the patient side, recognizing the importance of right thinking tends to lead to blaming the victims of suffering, including themselves, for getting sick. Thoughts and feelings are supposed to be all powerful from this view point.

My experience is entirely at odds with both of these limited perspectives.

Regardless of whatever spiritual radiance/vitality we manifest, our bodies always break down. The Law of Entropy applies to everything in the material world. You can do a lot to make your life healthier and better, but not forever. Responding to an influenza infection, your body will work as hard as it can to create massive quantities of immune factors to save its/your life. Those immune factors make you feel tired and alter your brain and thinking.

Honestly, I can not figure out how to separate mind and brain enough to determine which is changing the other. In reality they are one, influencing and influenced by everything. Managing stress, thereby improving the quality of your life, is an excellent idea if you have cancer, heart trouble, depression, any other disease, or even if you are well. Meditating increases telomere length, and then probably how long you will live. Being angry cuts off the blood supply to your heart and kills far too many people every day.

This is not New Age, airy fairy, trivial or simply about living a beautiful life. It is quite predictably a matter of life and death. The only part that is unpredictable is the due date.

Building on that perspective -

Sudden cardiac death risk and emotion
Considering the effects of emotion on physical health, death is about as meaningful an outcome as one might imagine.

Swedish investigators recently determined to do something about what we know (BRAVO!). They took 362 patients who had been discharged from the hospital after a heart attack or a procedure to increase blood flow to the heart, and randomly assigned them to usual care with or without twenty sessions (2 hours) of small group cognitive therapy focusing on stress management. Patients in the counseling group were over 40% less likely to have any cardiovascular event (like a heart attack) and 28% less likely to die for any reason. It is notable that these effects were seen despite an absence of differences in the traditionally recognized risk factors (cholesterol levels, cigarettes, etc) between the groups.

Scientifically, this extremely impressive result should be confirmed but as far as those of us living in the real world, it is absolutely certain that if you do not want to die from heart disease or at least live as long as possible, you MUST become a master at stress management.

Preventing Sudden Cardiac Death

Women are less prone to heart attacks than men, but just barely. Unfortunately, the symptoms they suffer are often not as easily recognizable as caused by their hearts, and often they have fewer symptoms. We have much less research on women and heart disease than we have on men.

Sudden Cardiac Death (SCD) is much more common in men than in women. You probably know of someone “who just dropped dead” one day unexpectedly. Usually this is a surprise, coming out of the blue in the sense that most victims of SCD have not been diagnosed with coronary heart disease. However, it turns out that a lack of diagnosis does not mean absence of disease. At autopsy, the hearts of SCD victims usually show evidence of previously unrecognized coronary heart disease, suggesting that some of them ignored or did not recognize symptoms caused by their heart trouble. Others, especially women and diabetics, are prone to unusual symptoms and might not even have any pain.

What are the usual symptoms? Crushing left sided chest pain “like an elephant sitting on my chest”. The pain can extend to the left arm or jaw. Physical activity, emotional upset and eating can worsen the pain. The heart will often beat rapidly or irregularly. Shortness of breath, sweating and dizziness are also common symptoms. Of course, each of these can have other causes, but you should not assume that the cause is minor.

Prevention is always the best idea, and studies of SCD are giving us useful ideas. Fortunately, the major risk factors for SCD are the same in women as in men. Harvard investigators dug into data collected from 1984 - 2010 in the Nurse’s Health Study to learn what factors might lead to SCD. What they found is really exciting, because it confirms that we are not so powerless against SCD as we had thought.

They found that following a healthy lifestyle dramatically reduced the risk of SCD. The factors they considered were avoiding smoking, keeping weight down, averaging more than 30 minutes of exercise daily, and eating a Mediterranean type diet (lots of veggies, nuts, beans, fruit, fish, whole grains and moderate alcohol). Women who did one of these right cut their risk of SCD in half. Add another and the risk was down 60%. Following three of these four wise health practices lowered risk by two thirds and a clean sweep of all four lowered risk of SCD by a dramatic 92%. Looking at the data the other way around, they found that fully 81% of the Sudden Cardiac Deaths were attributable to lifestyle factors.