An Apple A Day

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.

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.