Advanced Mediterranean Diet

I  recently read The Smarter Science of Slim, by Jonathan Bailor and published in 2012.   Per Amazon.com’s rating system, I give it four stars (”I like it”).

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Mr. Bailor’s weight-management diet avoids grains, most dairy, oils, refined starches, added sugars, starchy veggies, corn, white potatoes.  You eat meat, chicken, eggs, some fruit, nuts, seeds, and copious low-starch vegetables.  No limit on food if you eat the right items.   

It’s high-fiber, high-protein, moderate-fat, moderate-carb (1/3 of calories from carbohydrate,  1/3 from protein, 1/3 from fat).  He considers it Paleo (Stone Age) eating even though he allows moderate legumes and dairy (fat-free or low-fat cottage cheese and plain Greek yogurt).

Will it lead to weight lose? Quite probably in a majority of followers, especially those eating the standard, low-quality American diet.  When it works, it’s because you’ve cut out the fattening carbohydrates so ubiquitous in Western societies.  The protein and fiber will help with satiety.  Is it a safe eating plan?  Yes.

(For those with diabetes needing to lose weight, I prefer a lower carbohydrate content in the diet, something like Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.  For non-diabetics, is Smarter Science better than my Advanced Mediterranean Diet 2nd Edition?  Of course not, silly!)

I don’t recall any recipes or specific meal plans.  You put your own meals together following his guidelines.

Our major points of agreement:
 - Exercise isn’t terribly helpful as a weight-loss technique for most folks.
 - We’re overweight because we eat too many starches and sweets.
 - Natural, minimally processed foods are healthier than man-made highly refined items.
 - No need to emphasize “organic” /grass-fed beef/free-range chicken.
 - We don’t do enough high-quality exercise.

I have a few problems with the book:
  - It says we’re eating less.  U.S. caloric consumption over the last several decades has increased by about 150 cals (630 kJ) a day for men and 300 cals (1260 kJ) for women.  The author seems to contradict himself at one point by favorably quoting Hilda Bruch’s writing that “…overeating is observed with great regularity” in the obese. 
  - Scary graphs showing increasing instances of heart disease and diabetes over time aren’t helpful because they ignore population growth.  The population-adjusted diabetes rate is indeed increasing whereas heart disease rates are decreasing.
  - It says the Calories In/Calories Out theory of overweight has been proven wrong.  This is by no means true.  It just hasn’t helped us much to reverse the overweight epidemic.  Sure, it’s often said that if you just cut a daily tablespoon of butter out of your diet, you’d lose 11 lb (5 kg) in a year, all other things being equal.  Problem is, all other things are never equal.  In reality, we replace the butter with something else, or we’re slightly less active.  So weight doesn’t change or we gain a little.
  - It says the “eat less, exercise more” mantra has been proven wrong as a weight loss method.  Not really.  See above.  And watch an episode of TV’s “The Biggest Loser.”  Exercise can burn off fat tissue.  The problem is that we tend to overeat within the next 12 hours, replacing the fat we just burned. I agree with the author that “eat less, exercise more” is extremely hard to do, which is the reason it so often fails over the long run.  As Mr. Bailor writes elsewhere: “Hard to do” plus “do not want to do” generally equals “it’s not happening.”  Mr. Bailor would say the reason it ultimately fails is because of a metabolic clog or dysregulation. 
  - He says there’s no relationship between energy (calorie) consumption and overweight.  Not true.  Need references?  Google these: PMID 15516193, PMID 17878287, PMID 14762332.  The author puts too much faith in self-reports of food intake, which are notoriously inaccurate.  And obese folks under-report consumption more than others (this is not to say they’re lying). 
  - Mr. Bailor’s assessments too often rely on rat and mice studies.
  - By page 59, I had found five text sentences that didn’t match up well with the numeric bibiographic references (e.g., pages 48, 50, 59).
  - S. Boyd Eaton is thrice referred to as S. Boyd.
  - How did he miss the research on high intensity interval training by Tabata and colleagues in 1996?  Gibala is mentioned often but he wasn’t the pioneer.
  - Several diagrams throughout the book didn’t print well (not the author’s fault, of course).
  - In several spots, the author implies that HIS specific eating and exercise program has been tested in research settings.  It hasn’t.

Mr. Bailor’s exercise prescription is the most exciting part of the book for me.  His review of the literature indicates you can gain the weight-management and health benefits of exercise with just 10 or 20 minutes a week.  NOT the hour a day recommended by so many public heath authorities.  And he tells you how to do the exercises without a gym membership or expensive equipment.  That 20 minutes is exhausting and not fun.  You have fun in all the hours you saved.  If this pans out, we’re on the cusp of a fitness revolution.  Gym owners won’t be happy.  Sounds too good to be true, doesn’t it?

One component of the exercise program is high intensity interval training (HIIT), which I’m recently convinced is better than hours per week of low-intensity “cardio” like jogging. Better in terms of both fitness and weight management.

The resistance training part of the program focuses on low repetitions with high resistance, especially eccentric slow muscle contraction.  This is probably similar to programs recommended by Doug McGuff. John Little, Chris Highcock, and Skyler Tanner.  I’m no authority on this but I’m trying to learn.  By this point in the book, I was tired of looking up his cited references (76 pages!).  I just don’t know if this resistance training style is the way to go or not.  I’ll probably have to just try it on myself. 

I admire Mr. Bailor’s effort to digest and condense decades of nutrition and exercise research.  He succeeds to a large degree.

Steve Parker, M.D.
 

Exercise is not supposed to be fun.  If it is, then you should suspect that something is wrong.

That quote is from an essay by Ken Hutchins posted at the Efficient Exercise website.

When I was a young man in my 30s, I was jogging 20 miles a week and ran a couple marathons (26.2 miles).  I enjoyed it and didn’t do much else for exercise or overall fitness. I thought I was in pretty good shape.  You can get away with that when you’re 35, but not when you’re 50.  At 57 now, I can’t think of any single recreational activity that can help me maintain the overall strength, functionality, and injury resistance I want and need as I age. 

I’ve come to view exercise as a chore, like flossing/brushing teeth, changing the oil in my car, and sleeping when I’d rather not.  I’ve got my current exercise chore whittled down to an hour three times a week.  OK, sometimes just twice a week.

Skyler Tanner takes a thoughtful and in-depth look at the exercise versus recreation dichotomy at his blog.  If you have comments, more people will see them at his site than here.

Steve Parker, M.D.

To get the full health benefits of regular physical activity, you need to put some effort into it.  A leisurely hour-long stroll in the mall while window-shopping doesn’t pass muster, although that’s better than nothing.

One rough way to gauge whether you are working hard enough during aerobic exercise is to monitor your heart rate, also known as pulse.  Subtract your age from 220.  The result is your theoretical maximum heart rate in beats per minute.  Your heart rate goal, or target, during sustained aerobic exercise is a pulse that is 60 to 80 percent of your theoretical maximum pulse.  For example: maximum heart rate for a 40-year-old is 180 (220 - 40 = 180), so the target heart rate zone during exercise is between 108 and 144 (60 to 80 percent of 180).  Exceeding the upper end of the target zone is usually too uncomfortable to be sustainable.  Exercise heart rates below the target zone suggest you’re not working hard enough to reap the full long-term benefits of aerobic exercise.

Here’s how to determine your pulse.  After five or 10 minutes of exercise, stop moving and place the tips of your first two fingers lightly over the pulse spot inside your wrist just below the base of your thumb.  Count the pulsations for 15 seconds and multiply the number by four.  The result is your pulse or heart rate.  It will take some practice to find those pulsations coming from your radial artery.  If you can’t find it, ask a nurse or doctor for help.

Like all rules-of-thumb, this target heart rate zone isn’t always an accurate gauge of cardiovascular workout intensity.  For instance, it is of very little use in people taking drugs called beta blockers, which keep a lid on heart rate.

As you become more fit, you’ll notice that you have to work harder to get your heart rate up to a certain level.  This is a sure sign that your heart and muscles are responding to your challenge.  You may also want to monitor your resting heart rate taken in the morning before you get out of bed. Unfit, sedentary people have resting pulses of 60 to 90.  Athletes are more often in the 40s or low 50s.  Their hearts have become more efficient and just don’t need to beat as often to get the job done.

As you become more fit, you’ll also notice that you have more energy overall and it’s easier to move about and handle physical workloads. You’ll feel more relaxed and have a sense of accomplishment. Expect these benefits eight to 12 weeks after starting a regular exercise program.

Steve Parker, M.D.

Exercise is not supposed to be fun.  If it is fun, then you should suspect that something is wrong.

The quote above is from an essay entitled “Exercise vs Recreation” by Ken Hutchins, posted at the Efficient Exercise website.  Skyler Tanner works at Efficient Exercise and his blog is one that I follow.  We have a strange connection.  He grew up in Fountain Hills, AZ; I live about 20 miles from there.  He lives in Austin, TX, now; I lived there for eight years.

Here’s another quote from that essay:

One pound of human fat can support the energy demands of running 35-45 miles, probably more.  This would require the average man to run for 6-8 hours.  He would burn the calories he could easily ingest in as many minutes.

On the way to the hospital today, I heard a radio advertisement for a nationally known weight-loss program  that starts with “M”.  Respected local radio personalities touted weight loss of ”up to three to five pounds a week.”  Not just the first week (mostly water and intestinal content loss).  No doubt, a tenth of a pound per week would still be considered up to three to five pounds a week.       

Hutchins’ essay is thought-provoking.  It may change the way you think about exercise.

Steve Parker, M.D.

I just read Which Comes First, Cardio or Weights?: Fitness Myths, Training Truths, and Other Surprising Discoveries from the Science of Exercise by Alex Hutchinson, published in 2011.  Per Amazon.com’s rating system, I give it five stars (I love it).

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Since starting Mark Verstegen’s Core Performance workout program four months ago, I’ve developed a serious interest in exercise.  I stumbled across one of Alex Hutchinson’s helpful (and recommended) blogs: Sweat Science.  That’s where I heard about this book.

Mr. Hutchinson uses a Q & A format to address 113 debatable issues facing people who exercise regularly.   The questions are independent although grouped according to subject matter, such as “Nutrition and Hydration.”  This is great for those who have time only for snippets of reading (bathroom reading, for example).

High-intensity interval training (HIIT) is a particular interest of mine lately.  I see it as way to replace five hours a week of traditional cardio (aerobic) training with just one hour.  The author gives a nice description of HIIT and succinctly and accurately summarizes the science in support of it, along with the risks.

Mr. Hutchinson typically answers controversial questions with the best available evidence from current scientific research.  Rarely, he has to depend simply on expert concensus, which is less reliable.  I envision a new edition every five years or so.

The book is easy to read.  The style is congenial and witty.  Contrary to a recent publishing trend, the font size is reasonably large. 

The audience for this is folks who have made a commitment to make regular physical activity part of their lifestyle.    Trust me, I’m a doctor: the guys at the gym and Internet sources are quite often wrong on these issues. 

If you refuse to do more than just stroll in the neighborhood for 30 minutes a day, you don’t need the book.  But I urge you to consider challenging yourself to do more.   

Steve Parker, M.D.

I just finished week 11 of the Core Performance physical training program.  It’s actually week 14 for me since I had to do the preliminary work for three weeks in view of my age and relatively sedentary lifestyle.

Injury Report

• Left sided musculoskeletal chest pain is almost entirely gone.
• No new injuries.

General Comments 

The most notable changes over the last couple weeks have been:

• More heavy metal - weight-lifting in other words - four days a week.  I like this.
• Intense  interval training in the part of the program Verstegen calls Energy System Development.  I’m doing  this on a treadmill.  An example is a three-minute warm-up (jogging 5.3 mph, 1% incline), then 90 seconds running fast (7-8 mpg, 1% incline), then 90 seconds slow running (5.3 mph, 1% incline).  By the end of warm-up, my heart rate is 120-125 bpm.  By the end of fast running, my heart rate is 160.  During the 90-second recovery from fast running, my heart rate drops to 130-140.  I do the fast/slow cycle four times, for a total work-out of 15 minutes.  Eight miles per hour for 90 seconds is probably a little dangerous: I get dizzy right at the end of it. 

As the weeks have passed, I’ve notice less creaking in my knees when I do lunges.  It was never painful, but it reminded me to take it easy so I don’t injure myself.  Even with push-ups I’d feel weird creaking between my shoulderblades, where there’s no joint.  None of the creaking has been painful: it’s a marker of my age (56) and sedentary lifestyle.

I thought that treadmill running might be hard on my knees.  It’s not been.  The treadmill sits on a quarter-inch thick rubber pad on a carpeted floor with a half-inch thick pad under the carpet.  And the treadmill has some built-in shock absorbers, too.  Verstegen doesn’t require running for cardio; you could bicycle, use an elliptical trainer or stairclimber, etc.

A good treadmill cruising speed for me is 5.3 or 5.4 mph (8.6 kph) on a 1% grade (incline).  I can easily do this for 30 minutes, keeping my heart rate at 120 to 140 (higher towards the end of the work out).  That heart rate is Verstegen’s Zone 1 (the easiest of three).     

I must admit there are days I’d rather not work out.  But I do it anyway.  More on this in a future post.

The basic Core Performance routine is for 12 weeks, not counting the three preliminary weeks I did.  It’s taking 50-60 minutes a day, six days a week.  After this coming week, I’m hoping to cut back to three work-outs a week, for about an hour each.  Verstegen wouldn’t necessarily endorse that reduction, but I think the science is there to support it. 

Steve Parker, M.D.

The more overweight you are, the harder it will be to exercise. At some point even light exercise becomes impossible. Average-height women tipping the scales at about 280 pounds (127 kg) and men at 360 pounds (164 kg) aren’t going to be able to jog around the block, much less run a marathon. These weights are 100 percent over ideal or healthy levels. An actual “exercise program” probably won’t be possible until some weight is lost simply through very-low-carb eating, calorie restriction, or bariatric surgery. The initial exercise goal for you may just be to get moving through activities of daily living and perhaps brief walks and calisthenics while sitting in a chair.

“I’ll get started after I finish this cigarette.”

Markedly obese people who aren’t up to the aforementioned extreme weights can usually tolerate a low-intensity physical activity program. At 50 percent over ideal weight, an average-height woman of 210 pounds (95 kg) is carrying 70 excess pounds (32 kg) of fat. Her male counter-part lugs around 90 pounds (41 kg) of unnecessary fat. This weight burden causes dramatic breathlessness and fatigue upon exertion, and makes the joints and muscles more susceptible to aching and injury. If you’re skinny, just imagine trying to walk or run a mile carrying a standard five-gallon (19 liter) water cooler bottle, which weighs only 43 pounds (19.5 kg) when full. The burden of excess fat makes it quite difficult to exercise.    

If you’re markedly obese, several tricks will enhance your exercise success. I want you to avoid injury, frustration, and burn out. Start with light activity for only 10 or 15 minutes, gradually increase session length (e.g., by two to four minutes every two to four weeks) and increase exercise intensity only after several months. Your joints and muscles may appreciate easy, low-impact exercises such as stationary cycling, walking, swimming, and pool calisthenics/water aerobics. You may also benefit from the advice of a personal fitness trainer arranged through a health club, gym, or YMCA/YWCA. Check out several health clubs before you join. Some of them are primarily meat markets for beautiful slender yuppies. You may feel more comfortable in a gym that welcomes and caters to overweight people. Hospitals are increasingly developing fitness centers with obese orthopedic, heart, and diabetic patients in mind.

Steve Parker, M.D.

Physically active lifestyles are often credited with at least some of the health benefits of the mid-20th century Mediterranean diet.  We in the 21st century don’t necessarily have to be so active, thanks to technologic and scientific advances.  Some choose to make up the deficit by exercising, which isn’t alwaysafe.

To protect you from injury, I recommend that you obtain “medical clearance” from a personal physician before starting an exercise program, especially vigorous physical activity.  A physician is in the best position to determine if your plans are safe for you, thereby avoiding complications such as injury and death.  Nevertheless, most adults can start a moderate-intensity exercise program with little risk.  An example of moderate intensity would be walking briskly (3–4 mph or 4.8–6.4 km/h) for 30 minutes daily. 

Note the metric units; I use both U.S. customary and metric units throughout Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.  Unfortunately, I used only U.S. customary measurements in The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer.

Men over 40 and women over 50 who anticipate a more vigorous program should consult a physician to ensure safety.  The physician may well recommend diagnostic blood work, an electrocardiogram (heart electrical tracing), and an exercise stress test (often on a treadmill).  The goal is not to generate fees for the doctor, but to find the occasional person for whom exercise will be dangerous, if not fatal.  Those who drop dead at the start of a vigorous exercise program often have an undiagnosed heart condition, such as blockages in the arteries that supply the heart muscle.  The doctor will also look for other dangerous undiagnosed “silent” conditions, such as leaky heart valves, hereditary heart conditions, aneurysms, extremely high blood pressure, and severe diabetes.

But, Doc, what if I have diabetes?

The American Diabetes Association’s Standards of Care—2011 states that routine testing of all diabetics for heart artery blockages before an exercise program is not recommended; the doctor should use judgment case-by-case.  Many diabetics (and their doctors) are unaware that they already have “silent” coronary artery disease (CAD).  CAD is defined by blocked or clogged heart arteries, which reduced the blood flow to the hard-working heart muscle.  Your heart pumps 100,000 times a day, every day, for years without rest.  CAD raises the odds of fainting, heart attack, or sudden death during strenuous exercise.  I recommend a cardiac stress test (or the equivalent) to all diabetics prior to moderate or vigorous exercise programs, particularly if over 40 years old. CAD can thus be diagnosed and treated before complications arise.  Ask your personal physician for her opinion.

But, Doc, I’ve got bad arthritis and poor circulation!

Regardless of age and diabetes, other folks who may benefit from a medical consultation before starting an exercise program include those with known high blood pressure, high cholesterol, joint problems (e.g., arthritis, degenerated discs), neurologic problems, poor circulation, lung disease, or any other significant chronic medical condition.  Also be sure to check with a doctor first if you’ve been experiencing chest pains, palpitations, dizziness, fainting spells, headaches, frequent urination, or any unusual symptoms (particularly during exertion).

Physicians, physiatrists, physical therapists, and exercise physiologists can also be helpful in design of a safe, effective exercise program for those with established chronic medical conditions. 

Steve Parker, M.D.

What’s “strength training”? It’s also called muscle-strengthening activity, resistance training, weight training, and resistance exercise.  Examples include lifting weights, work with resistance bands, digging, shoveling, yoga, push-ups, chin-ups, and other exercises that use your body weight or other loads for resistance.

Strength training three times a week increases your strength and endurance, allows you to sculpt your body to an extent, and counteracts the loss of lean body mass (muscle) so often seen during efforts to lose excess weight.  It also helps maintain your functional abilities as you age.  For example, it’s a major chore for many 80-year-olds to climb a flight of stairs, carry in a bag of groceries from the car, or vacuum a house.  Strength training helps maintain these abilities that youngsters take for granted.

According to the U.S. Centers for Disease Control and Prevention: “To gain health benefits, muscle-strengthening activities need to be done to the point where it’s hard for you to do another repetition without help.  A repetition is one complete movement of an activity, like lifting a weight or doing a sit-up.  Try to do 8–12 repetitions per activity that count as 1 set.  Try to do at least 1 set of muscle-strengthening activities, but to gain even more benefits, do 2 or 3 sets.”

If this is starting to sound like Greek to you, consider instruction by a personal trainer at a local gym or health club.  That’s a good investment for anyone unfamiliar with strength training, in view of its great benefits and the potential harm or waste of time from doing it wrong.  Alternatives to a personal trainer would be help from an experienced friend or instructional DVD.  If you’re determined to go it alone, Internet resources may help, but be careful.  Consider “Growing Stronger: Strength Training for Older Adults” (http://www.cdc.gov/physicalactivity/downloads/growing_stronger.pdf).  Don’t let the title turn you off if you’re young—its a good introduction to strength training for folks of any age.  Doug Robb’s blog, HealthHabits, is a wonderful source of strength training advice (http://www.healthhabits.ca/). 

People with diabetes must be particularly cautious before starting a fitness program.

Current strength training techniques are much different than what you remember from high school 30 years ago—modern methods are better.  Some of the latest research suggests that strength training may be even more beneficial than aerobic exercise.

Steve Parker, M.D.

What’s “aerobic activity”? Just about anything that mostly makes you huff and puff. In other words, get short of breath to some degree. Examples are brisk walking, swimming, golf (pulling a cart or carrying clubs), lawn work, painting, home repair, racket sports and table tennis, house cleaning, leisurely canoeing, jogging, bicycling, jumping rope, and skiing. The possibilities are endless. A leisurely stroll in the shopping mall doesn’t qualify, unless that makes you short of breath. Don’t laugh: that is a workout for many who are obese.

But which aerobic physical activity is best? Glad you asked!

The most important criterion is that it be pleasant for you. If not outright fun, it should be often enjoyable and always tolerable.

Your exercise of choice should also be available year-round, affordable, safe, and utilize large muscle groups. The greater mass and number of muscles used, the more calories you will burn, which is important if you’re trying to lose weight or prevent gain. Compare tennis playing with sitting in a chair squeezing a tennis ball repetitively. The tennis player burns calories much faster. Your largest muscles are in your legs, so consider walking, biking, many team sports, ski machines, jogging, treadmill, swimming, water aerobics, stationary cycling, stair-steppers, tennis, volleyball, roller-skating, rowing, jumping rope, and yard work.

Walking is “just what the doctor ordered” for many people. It’s readily available, affordable, usually safe, and requires little instruction. If it’s too hot, too cold, or rainy outside, you can do it in a mall, gymnasium, or health club.

Another option is instructional exercise DVDs, often featuring either a celebrity or prominent fitness trainer. Many of these programs require only a pair of sneakers and loose clothing. Others include the option of using inexpensive equipment, such as light hand-held weights.

If exercise videos sound appealing, consider one of these: Walk Away the Pounds—Walk Strong, by Leslie Sansone; Tighter Assets With Tamilee: Weight Loss & Cardio, by Tamilee Webb; Burn & Firm—Circuit Training, by Karen Voight; Minna Optimizer—Balanced Blend, by Minna Lessig; Personal Training System, by Denise Austin; Timesaver—Lift Weights to Lose Weight (volumes 1 & 2), Super Slimdown Circuit, and Functionally Fit—Peak Fat Burning, by Kathy Smith. Search for these titles at Amazon.com, where you can read reviews of them by actual users. Although many of these are designed for weight loss, you’ll get a good workout even if you’re at a healthy weight. Several of them also feature strength training.

Another fun option for indoor aerobic exercise is Dance Dance Revolution by Konami. Perhaps you’ve seen a version of this video game in an arcade. You must use a video game console, such as a PlayStation or Xbox, and the Dance Dance Revolution Controller along with your TV screen. The controller is a 32 inch by 36 inch (81 x 91 cm) floor pad partitioned into several large squares. The TV screen shows you which squares to step on in sequence as the music plays, and you rack up points for accurate timing and foot placement. If you enjoy moving to music, it’s more fun than I can describe

The latest indoor computerized exercise gadgets are the Kinect for Microsoft’s Xbox 360, the PlayStation Move, and Wii Fit. Check’em out.

Steve Parker, M.D.