Advanced Mediterranean Diet

I’m near the end of Week 5 of the regular program but I had to do three weeks of preliminary work before I could start where younger, more athletic people start.  It’s going well and I have no regrets about choosing this plan.

The workouts are taking 30–45 minutes.  My least favorite part is “ESD”: Energy System Development.   Most others call it cardio or aerobics: steady work to get the heart rate up and keep it up for minutes on end.  I don’t like it because it just feels like uncomfortable work.  I’ve been jogging on dirt trails around my house.  In preparation for hot desert weather, I’m trying out my wife’s treadmill.  A speed of five miles per hour and 2% grade will get my heart rate up to 140.  I stayed between 128 and 140 for 30 minutes today. 

Verstegen gives you target heart rates to shoot for.  I’m still in such poor shape that it doesn’t take much exercise to get me up to 120.  You don’t have to run; you could use a bike, elliptical machine, stairclimber, swim, jump rope, etc.  

Doug McGuff disparages the benefits of cardio, but I disagree and think it helps in developing endurance and gaining the long-term benefits of exercise, such as longevity and reduced cardiovascular disease.  If I’m camping with a Boy Scout troop in the wilderness and a medical emergency develops, I suspect a person with strong cardio background will be better able to run for help.

Injury Update

• Left posterior chest pain (soft tissue strain) still there but almost gone, and not interfering with exercise or sleep.

I have some creaking in my knees (aka crepitus) during certain maneuvers, such as lunges, but no pain.  I’m anxious to avoid knee ligament and meniscus injuries.

Steve Parker, M.D.

At my Diabetic Mediterranean Diet blog, I recently noted that regular physical activity prevented or postponed death.  Onward now to other benefits.

Waist Management

Where does the fat go when you lose weight dieting?  Chemical reactions convert it to energy, water, and carbon dioxide, which weigh less than the fat.  Most of your energy supply is used to fuel basic life-maintaining physiologic processes at rest, referred to as resting or basal metabolism.  Basal metabolic rate (BMR) is expressed as calories per kilogram of body weight per hour.

The major determinants of BMR are age, sex, and the body’s relative proportions of muscle and fat.  Heredity plays a lesser role.  Energy not used for basal metabolism is either stored as fat or converted by the muscles to physical activity.  Most of us use about 70 percent of our energy supply for basal metabolism and 30 percent for physical activity.  Those who exercise regularly and vigorously may expend 40–60 percent of their calorie intake doing physical activity.  Excess energy not used in resting metabolism or physical activity is stored as fat.

Insulin, remember, is the main hormone converting that excess energy into fat; and carbohydrates are the major cause of insulin release by the pancreas.

To some extent, overweight and obesity result from an imbalance between energy intake (food) and expenditure (exercise and basal metabolism).  Excessive carbohydrate consumption in particular drives the imbalance towards overweight, via insulin’s fat-storing properties.

In terms of losing weight, the most important metabolic effect of exercise is that it turns fat into weightless energy.  We see that weekly on TV’s “Biggest Loser” show; participants exercise a huge amount.  Please be aware that conditions set up for the show are totally unrealistic for the vast majority of people.

Physical activity alone as a weight-loss method isn’t very effective.  But there are several other reasons to recommend exercise to those wishing to lose weight.  Exercise counteracts the decrease in basal metabolic rate seen with calorie-restricted diets.  In some folks, exercise temporarily reduces appetite (but others note the opposite effect).  While caloric restriction during dieting can diminish your sense of energy and vitality, exercise typically does the opposite.  Many dieters, especially those on low-calorie poorly designed diets, lose lean tissue (such as muscle and water) in addition to fat.  This isn’t desirable over the long run.  Exercise counteracts the tendency to lose muscle mass while nevertheless modestly facilitating fat loss.

How much does exercise contribute to most successful weight-loss efforts?  Only about 10 percent on average. The other 90 percent is from food restriction.

Fountain of Youth

Regular exercise is a demonstrable “fountain of youth.”  Peak aerobic power (or fitness) naturally diminishes by 50 percent between young adulthood and age 65.  In other words, as age advances even a light physical task becomes fatiguing if it is sustained over time.  By the age of 75 or 80, many of us depend on others for help with the ordinary tasks of daily living, such as housecleaning and grocery shopping.  Regular exercise increases fitness (aerobic power) by 15–20 percent in middle-aged and older men and women, the equivalent of a 10–20 year reduction in biological age!  This prolongation of self-sufficiency improves quality of life.

Heart Health

Exercise helps control multiple cardiac (heart attack) risk factors: obesity, high cholesterol, elevated blood pressure, high triglycerides, and diabetes.  Regular aerobic activity tends to lower LDL cholesterol, the “bad cholesterol.”  Jogging 10 or 12 miles per week, or the equivalent amount of other exercise, increases HDL cholesterol (“good cholesterol”) substantially.  Exercise increases heart muscle efficiency and blood flow to the heart.  For the person who has already had a heart attack, regular physical activity decreases the incidence of fatal recurrence by 20–30 percent and adds an extra two or three years of life, on average.

Effect on Diabetes

Eighty-five percent of type 2 diabetics are overweight or obese.  It’s not just a random association.  Obesity contributes heavily to most cases of type 2 diabetes, particularly in those predisposed by heredity.  Insulin is the key that allows bloodstream sugar (glucose) into cells for utilization as energy, thus keeping blood sugar from reaching dangerously high levels.  Overweight bodies produce plenty of insulin, often more than average.  The problem in overweight diabetics is that the cells are no longer sensitive to insulin’s effect.  Weight loss and exercise independently return insulin sensitivity towards normal.  Many diabetics can improve their condition through sensible exercise and weight management.

Miscellaneous Benefits

In case you need more reasons to start or keep exercising, consider the following additional benefits: 1) enhanced immune function, 2) stronger bones, 3) preservation and improvement of flexibility, 4) lower blood pressure by 8–10 points, 5) diminished premenstrual bloating, breast tenderness, and mood changes, 6) reduced incidence of dementia, 7) less trouble with constipation, 7) better ability to handle stress, less trouble with insomnia, 9) improved self-esteem, 10) enhanced sense of well-being, with less anxiety and depression, 11) higher perceived level of energy, and 12) prevention of weight regain.

People who lose fat weight but regain it cite lack of exercise as one explanation.  One scientific study by S. Kayman and associates looked at people who dropped 20 percent or more of their total weight, and the role of exercise in maintaining that loss.  Two years after the initial weight loss, 90 percent of the successful loss-maintainers reported exercising regularly.  Of those who regained their weight, only 34 percent were exercising.

Stay tuned for my specific exercise recommendations.

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’re 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.

I still like the program.  Exercises are similar to last week.  Time committment is only 25-40 minutes a day.  Yesterday I set a new personal record as a bowling score—175.  Can I credit Core Performance, or was I just having a good day?  Difficult to be sure, but I suspect the exercise is the reason.

Injury Update

• Left chest pain from soft tissue strain is slowly getting better.
• Right hip pain is gone.

Before this gets boring, I’ll reduce my Core Performance reports to less than weekly. 

Steve Parker, M.D.

January 1 this year, many folks made New Years’ resolutions to start exercising in conjunction with their other resolution to lose excess weight. I’ve got bad news for them.

Exercise is overrated as a pathway to major weight loss. Sure, a physically inactive young man with only five or 10 pounds (2 to 4 kg) to lose might be able to do it simply by starting an exercise program. That doesn’t work nearly as well for women. The problem is that exercise stimulates appetite, so any calories burned by exercise tend to be counteracted by increased food consumption.

“Should I go with aerobic or strength training….?”

On the other hand, exercise is particularly important for diabetics and prediabetics in two respects: 1) it helps in avoidance of overweight, especially after weight loss, and 2) it helps control blood sugar levels by improving insulin resistance, perhaps even bypassing it.

Even if it doesn’t help much with weight loss, regular physical activity has myriad general health benefits. First, let’s look at its effect on death rates.   

EXERCISE PREVENTS DEATH

As many as 250,000 deaths per year in the United States (approximately 12% of the total) are attributable to a lack of regular physical activity. We know now that regular physical activity can prevent a significant number of these deaths.

Exercise induces metabolic changes that lessen the impact of, or prevent altogether, several major illnesses, such as high blood pressure, coronary artery disease, diabetes, and obesity. There are also psychological benefits. Even if you’re just interested in looking better, awareness of exercise’s other advantages can be motivational.

The traditional Mediterranean diet of the mid-20th century may owe some of it’s healthfulness to a physically active lifestyle.

Exercise is defined as planned, structured, and repetitive bodily movement done to improve or maintain physical fitness.

Physical fitness is a set of attributes that relate to your ability to perform physical activity. These attributes include resting heart rate, blood pressure at rest and during exercise, lung capacity, body composition (weight in relation to height, percentage of body fat and muscle, bone structure), and aerobic power.

Aerobic power takes some explanation. Muscles perform their work by contracting, which shortens the muscles, pulling on attached tendons or bones. The resultant movement is physical activity. Muscle contraction requires energy, which is obtained from chemical reactions that use oxygen. Oxygen from the air we breathe is delivered to muscle tissue by the lungs, heart, and blood vessels. The ability of the cardiopulmonary system to transport oxygen from the atmosphere to the working muscles is called maximal oxygen uptake, or aerobic power. It’s the primary factor limiting performance of muscular activity.

Aerobic power is commonly measured by having a person perform progressively more difficult exercise on a treadmill or bicycle to the point of exhaustion. The treadmill test starts at a walking pace and gets faster and steeper every few minutes. The longer the subject can last on the treadmill, the greater his aerobic power. A large aerobic power is one of the most reliable indicators of good physical fitness. It’s cultivated through consistent, repetitive physical activity.

Physical Fitness Effect on Death Rates

Regular physical activity postpones death.

Higher levels of physical fitness are linked to lower rates of death primarily from cancer and cardiovascular disease (e.g., heart attacks and stroke). What’s more, moving from a lower to a higher level of fitness also prolongs life, even for people over 60.

Steve Parker, M.D.

Up to now, I’ve actually been doing Verstegen’s “Preliminary” Core Performance since I was too out of shape to do the real deal.  [”Can’t remember the last time you were able to bend at the waist and touch your toes?  Start with the preliminary program.”]  I give him credit for holding folks back until they’re ready for it.

Week 4 is easier than the previous weeks.  Completion takes only 30-45 minutes daily.  More focus on aerobic exercise than previously; Verstegen calls it ESD (energy systems development).  I’m now able to consistently do a slow jog for 12 minutes without stopping.  One day this week calls for 20 minutes of aerobics.  The aerobic exercise choice is yours.  You could run, skip rope, use a treadmill or bicycle, etc.  He give you a target heart rate.

Injury Update

• Right hip pain is gone.
• Left chest wall pain got worse before getting better.  Still there.  Interferes with sleep a little.  Don’t worry about my heart; it’s definitely musculoskeletal. 

So this is the first week of the classic 12-week program.  Intensity ramps up next week.

Steve Parker, M.D.

The program is getting easier now that I have many of the movements memorized.  On one of two occasions I was able to slow jog for 12 minutes without stopping, so this is progress.

Injury Report

• Right hip pain is fading and not a problem.  Doubt arthitis.  Probably a soft tissue thing.
• Two days of pain in the left side of my chest, worse with chest wall muscle movement.  I suspect I caused it by too much pressure on a muscle when using the hard foam roller.  This is a 5-inch wide cylinder that you put on the ground then roll various parts of your body against, to give yourself a massage.  It hurts if you allow too much of your body weight to be supported by the foam.  The pain came on gradually, so it shouldn’t be a cracked rib or torn muscle/ligament.

I’m glad to report I can finish some of the work outs in 30 minutes, in contrast to the two hours I spent on the very first day.

Steve Parker, M.D.

Disclosure: I don’t know Mark Verstegen.  I’m not being paid to write about his Core Performance program, nor do I earn a commision if you click the link to his book at Amazon.com.

I survived Mark Verstegen’s first week.  Yay!  I was pretty sore overall for the first 48 hours after the first day but not thereafter.  I must admit I sorta buy into the old saw, “No pain…no gain.”  But my muscular aching wasn’t much of a hindrance—”pain” seems too strong a word. 

I do have a bit of localized discomfort in my right hip.  Not sure if it’s a touch of greater trochanteric bursitis or just a strained muscle.  Not a deal killer by any means.

The program thus far is well-designed.  Light days follow heavy work out days; good variety.  The biggest hassle now is that I have to flip back and forth in the book since I can’t remember exactly what I need to do to perform “the scorpion,” “backward lunge with a twist,” “PB reach, roll, and lift,” “AIS 90/90 twist,” etc.  Talk about variety!  I count 40 or 50 maneuvers I’ve had to learn thus far.

I’m in such bad shape I couldn’t do a slow jog for 12 minutes, so I alternated running and fast walking.  Got my heart rate up and did some heavy breathing, however, which is the goal for now.  This is an embarrassing admission for someone who has run two marathons (26.2 miles).

Steve Parker, M.D.

I started Mark Verstegen’s “Core Performance” at-home work out program today.  He’s a local guy who trains lots of pro athletes.  The program was recommended to me by a physician colleague who had a good experience with it.

Why do it? 

I’d slacked off on exercise dramatically over the last six months while writing another book.  The family went bowling three months ago, and my right arm was sore after just three “lines” (games).  That’s just not right!  Five months ago I developed some left shoulder aching without a clear precipitant.  I was able to cure it recently with a rehab program involving weight training.

So I’m starting to feel like an injury-prone, old weakling.  I wish to stay in good enough shape to keep up with my active young teenage kids, even though I’m 56.  I’m also well aware of the myriad health benefits of regular physical activity, including postponement of death.

Does this have anything to do with the Mediterranean diet?  Yes, indirectly.  It’s possible that some of the healthful aspects of the traditional Mediterranean diet are instead attributable to an active lifestyle.

Core Performance is a serious, vigorous program.  At my age, I have to be very careful not to injure myself. 

I spent $350 (US) getting the necessary equipment, such as free weights (pre-owned, from Craigslist), physioball, exercise matt, elastic bands, and a weight bench.  That’s a lot of dough, but I consider it a long-term investment in myself and my family. 

I spent two hours doing my first session today, but should be able to get the time down to 45-60 minutes after I’m more familiar with the specific exercises.  Verstegen asks for exercise six days a week for the first 15 weeks.  After that, I’m not sure.  I hope that maintenance of fitness will only require three days a week.

My initial impression is that the program may be too hard-core for the average sedentary middle-aged person with little athletic background.  I’m not confident I’ll be able to do it.  I’m excited about it and see the potential for much good.  We’ll see. 

How could I recommend regular physical activity to my patients if I didn’t do it myself?

Steve Parker, M.D.

I’ve written elsewhere about the death-defying aspect of exercise and myriad other health benefits of regular physical activity. 

Very heavy folks potentially have more to gain in terms of health and longevity compared to skinny people. So it’s a cruel irony that the heavier you are, the harder it is 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.