An Apple A Day

The results of a recent trial were disappointing to some but I think that disappointment is unwarranted. Subjects were given 1000 iu of D3 daily. This dose did not reduce their body weight. That would have been nice for those wanting to lose weight. However, the subjects did significantly lower body fat and abdominal fat, both of which are more meaningfully connected to your health. Also, as many of you I am sure recognize, 1000 iu/day is pathetic. Just to reach a normal blood level, most of my patients have to take a minimum of 3-5,000 iu/day. So, an adequate dose might well have done more. That would have been in keeping with numerous other studies linking elevated weight with low vitamin D status.

A recent study in DERMATO-ENDOCRINOLGY authored by vitamin D pioneer William Grant adds to the evidence linking low vitamin D with autism. Children living in sunnier states developed autism roughly half as often as children living in the cold, dark northern states. With their darker, less vitamin D efficient skin, African Americans in the northern states were 40% more likely to be diagnosed with autism than white children in the same states, which parallels their reduced blood levels of vitamin D.

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?

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.

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.