Exercise, Part II: Getting Started

Perhaps you, like many patients I talk to, would like to begin an exercise program, but the idea seems overwhelming. It can be if you decide to start a program without a sound plan, because it will almost certainly not be something you can sustain for the long run. Patients often have no idea how long to exercise, how much to stress or strain their system, or how long it takes to "get in shape". All of this tends to lead to early errors, injury, or discouragement and giving up on the idea of becoming fit. It is important, and possible, to avoid this trap with the proper approach.

If you haven't been exercising regularly, it is important that you first consult with your doctor about whether it is safe. If you are 45 years of age or older, it is probably a good idea for you to obtain a treadmill exercise stress test. It is also important to have a good idea of your risk factors for cardiac disease, including your cholesterol and blood pressure level. You should also get a reading of your body mass index and set a target for your weight (more on weight loss later).

Assuming you get the green light, I recommend starting with about 15 or 20 minute sessions, three days a week. You should choose an aerobic activity, such as walking, jogging, biking, swimming, or an exercise machine like a treadmill or an elliptical machine. Aerobic activities are important to form the basis of your program because they are sustainable and lead to better cardiovascular fitness. We'll talk about the value of anaerobic activities, especially weight workouts, later.

If possible, either work out on a machine that has a heart rate monitor or else purchase a wireless continuous heart rate monitor. It is very difficult to exercise for fitness efficiently without one and they have become very affordable in recent years. As I noted earlier, it is important to exercise in the "aerobic" zone, which is about 60 to 80% of your maximum heart rate. You can obtain an estimate of your maximum heart rate by subracting your age from 220. For example, if you are 30, your estimated maximum heart rate is 220-30=190. So your exercise target is between 114 and 152. I usually recommend a midrange target of 70% or about 130 for this example.

It is important to be patient and persistent, remembering that each day builds on the last and that rest and exercise work together to stregthen the muscles and the cardiovascular system. By starting at 20 to 30 minutes three days a week, you minimize the risk of becoming too sore or fatigued to continue your program. A good rule of thumb is to increase your workouts by about 10% per week. So, if you start with 30 minutes, three times a week the first week, then you should increase one of your workouts by 10 minutes the second week. Then, the next week, increase one of your other workouts by 10 minutes. The next week, increase one of your workouts to 45 minutes and repeat the cycle. When you are up to 45 minutes three times a week, then add a 15 or 20 minute session on another day a week; then increase that session to 45 minutes, until you get to 5 days a week, 45 minutes a session. By the time you have reached this schedule, you will have completed at least 12 or 14 weeks and should have achieved a pretty good level of cardiovascular fitness. Congratulations!

Then, when you have achieved this schedule, which is reasonable to maintain, you can continue to pursue your fitness by maintaining your heart rate targets as you become more fit. As you do this, you will actually work harder and the the "10% rule" will continue more or less automatically by allowing you to "do more work" at the same heart rate as you become more fit. This is called the "training effect".

Next time, we'll talk about issues with motivation and what to do when you "fall off the wagon".

A Series on Getting and Staying Healthy: Exercise, Part I

I was reflecting on an earlier post I wrote after reading the book "Younger Next Year" and decided I'd write a series of blog posts on some of the basic principles of getting and staying healthy. These include eating a good, well balanced diet, avoiding smoking, avoiding excessive alcohol intake, managing your stress levels and exercise.

I'll start with the last item, exercise. I'm going to start by telling you what I do now, then backtrack and talk about aspects of an exercise program in more detail in subsequent posts. I'll include motivation, getting started, how much and what kinds of exercise are needed, staying on track, avoiding injury, hydration, warm up and cool down, stretching, rest days, exercise for weight loss, and exercise and staving off depression.

So, let me start by telling you what I do now. I was doing about 30 minutes a day of aerobics about 4 or 5 days a week, but after reading the book, committed to increasing that to at least 45 minutes a day for 5 days or more a week. Most weeks, I work out six or even seven days. I used to be a runner but, since I had my knee replaced a little over two years ago, I've completely given this up. My favorite exercise is on my road bike, a custom-built titanium beauty that is really fun to ride. I often use a pulse monitor to assure that I stay in the aerobic zone (I'll say more about this later). This is, for me, between 70 and 80 percent of my maximum heart rate which is about 130 beats/minute. At that level of work, I am "working" not just playing or having fun. So, one of the key things I tell people is to consider exercise as enjoyable work, not just play or fun. In order to get the benefits of exercise and stay physically fit, you need to do this "work". So many people stroll along on their walks or bike in an upright, comfortable mode and their heart rates are likely not above 100 beats/min. They will get some benefit from this, but nowhere near the maximum result.

On most days, I go on a ride that combines hills and flat terrain about 10 to 12 miles and that takes me about 50 or 55 minutes. On weekends and on some days when I don't have an early meeting, I enjoy going longer about 1 1/2 to 3 hours. One of my favorite rides takes in the Arkansas river, over the Dam Bridge and along the river trail walking/biking trail. In the mornings, with mist coming off of the river, with gulls flying, deer in the pastures, and energetic fitness enthusiasists around me I learn to rejoice in the moment and recognize for those brief swatches of time that "it doesn't get much better than this!".

When weather doesn't permit outdoor biking, I often hop on my reserve bike that is tethered to an indoor magnetic trainer (called a Kurt Kinetic) that does a great job of simulating the road and allows me to get a very good workout indoors. Again I typically use a pulse monitor and will say more about that in subsequent posts. Indoor bike workouts are typically for 45 minutes in front of ESPN SportsCenter or, sometimes, with a workout video to guide me.

For a change of pace, I get on an indoor elliptical machine. It is a good idea to have at least one or two alternative aerobic activities that allow resting of some of the muscles that get maxed out in the other training modes. I either do a programmed workout that does a good job of pushing me through some fitness improving intervals or I just put the machine on manual mode at about a 10 or 12 level that keeps my pulse at the target rate.

I save the sports section of the paper for cool downs and breakfast with cereal and fruit before showering and going to work. This program has served me well for years and allows me to go to work energized and ready for the day.

Next time I'll talk about how to get started on an exercise program for those who may not be doing it on a regular basis.

Could My Body Fat Lead to Dementia?

One of the great fears we all have is to lose our mental ability as we grow old. No one wants to end their life with dementia (such as Alzheimer's Disease). We all should be highly motivated to do things to avoid this tragic outcome. We already know that regular exercise is good for the mind and may reduce the risk of dementia. Recent evidence shows that the use of statin medications to lower cholesterol may help reduce dementia risk. Now we have evidence that the roll of fat around your waist may be a marker for increased dementia risk.

The University of California, Berkeley Wellness Letter (February, 2010) reports on a study published in the journal Neurology that followed 1500 Swedish women for 30 years. Those with more fat around the waist were twice as likely to have dementia by age 70 compared with thinner women. A 2008 study from Kaiser Permanente that included men and women showed similar results.

The fat around the waist is a better marker for internal fat than the fat around the hips. If a woman has a waist of 35 inches or greater, and a man a waist of 40 inches or greater, that is evidence of increased cardiovascular risk and dementia risk. The leaner the better as we get older.

Losing this fat is hard work. It requires an excellent diet and regular physical activity. Medications should be used if needed. A healthy body and mind in the senior years cannot be taken for granted. We may be lucky with good genes, but we all must live a healthy lifestyle in order to earn our good health later in life.

Fibromyalgia--Is it Real?

Every Tuesday, I conduct a diagnostic clinic at the University of Arkansas. This clinic sees patients referred throughout the state with complex or hard to manage medical problems, or patients that the referring physician is not sure who to turn to for advice or answers.

One of the most common problems I see is a patient with diffuse, hard to categorize soft tissue pain. Most of the patients have a diagnosis of "fibromyalgia". The patient that I saw this week told me her physician sent her to our clinic because "he doesn't believe fibromyalgia is real". Physicians often become frustrated with these patients because the pathophysiology of this condition is not well understood, and because effective treatment takes time and patience. The physician cannot rely on brief office visits and prescription refills to adequately address the issues of most fibromyalgia patients.

Fibromyalgia is very real and is a common problem in practice. Any busy primary care physician will attest to the fact that a significant number of patients with this condition visit our office every week. Fibromyalgia is a rheumatic condition whose characteristics include widespread muscle and joint pain and fatigue as well as other symptoms. Fibromyalgia can, and often does, lead to depression and social isolation because patients are so uncomfortable and fatigued. Patients with chronic fibromyalgia are often really miserable and need the help of a competant, sympathetic physician. Patients with fibromyalgia often complain of "total body pain". They almost universally have great difficulty sleeping. Most have tenderness when you press on the muscles of the upper back and shoulders. Females are 10 times more likely to complain of these symptoms than men.

How well do patients respond to treatment? I have yet to find a single patient who responds quickly or dramatically to any treatment. Rather, they tend to gradually improve with effective treatment of sleep and depression and tend to improve with stretching and exercise and, occasionally, with certain medications.

There are no blood tests, biopsy findings or imaging studies that confirm the diagnosis of fibromyalgia. This lack of clarity and specificity has led many to assert that this diagnosis is "not real". But many patients, mostly middle aged women, have chronic, diffuse, muscle and soft tissue pain and they all need help managing this condition.

The best treatment approach for those who suffer from this problem includes drugs, as well as alternative remedies and lifestyle habits that may help decrease pain and improve sleep. Medications include antidepressants to help alleviate the pain, fatigue, depression, and anxiety that comes with the disease. In addition, your doctor may recommend physical therapy, moist heat, regular aerobic exercise, relaxation, and stress reduction to help you self-manage your symptoms. There is no one "pill" that treats or cures fibromyalgia. A multidisciplinary approach that uses both medication and alternative or lifestyle strategies seems to work best. Medications that help in certain patients include Cymbalta, Savella, and Lyrica.

Patients with fibromyalgia badly need a compassionate, patient primary care provider who can see the patient at regular intervals and who will take a multidisciplinary, long-term approach to managing this condition.

Ideal Cardiovascular Health

You too can have ideal cardiovascular health. What is that you may ask? The American Heart Association has come out with a new report that defines it.

Ideal cardiovascular health means you do all of the following:

1. You do not smoke
2. You are not overweight (normal body mass index, or BME less than 25)
3. You get regular physical activity, about 5 hours a week
4. You eat a healthy diet low in saturated fats and simple sugars

You also have the following:

1. Your total cholesterol is normal (generally below 200 or a healthy ratio of total cholesterol and HDL (good) cholesterol)
2. Your blood pressure is aroung 120/80
3. Your fasting blood sugar is less than 100 (better yet 90 or less)

All of these are within reach of most everyone, with or without treatment. Ideal health is a choice and requires a commitment to action. Go for it. There are no justifiable excuses.

Reference: Circulation: January 20, 2010

Reflections on the State of Online Health

As 2009 draws to a close, the US health care system is ailing and quasi-reform proposals are frantically being debated and voted on. Although some type of reform is likely in 2010, we will have only scratched the surface of what still needs to be changed. One particular aspect relates to the ease with which patients can use the internet to improve their health care. At eDoc, we've been using the internet to improve the health of our users for over a decade. Ten years ago, I predicted that patients would routinely use internet messaging to interact with the health care industry by now, but I was wrong. Although, increasingly, web 2.0 approaches are providing innovative communication and health management tools for patients, the growth of interaction between patients and doctors has been much slower than I predicted it would be. And the future still remains cloudy. The issues are nothing new and include:

1. Many patients still lack ready, reliable internet access. This is especially true for those who need it most: sick, elderly, and financially disabled persons.
2. Most insurance companies do not recognize e visits as reimbursible under health insurance plans. This provides a powerful disincentive for physicians to spend significant amounts of time answering e mail questions from their patients, since they are reluctant to bill patients directly for this type of service.
3. Professional liability issues have not been well worked out, leaving physicians and malpractice insurers feeling squeamish about supporting this approach.
4. Licensure issues remain the domain of individual states, are not consistent from state to state, and maintain unachievable standards in their definition of "doctor patient relationships". This requires a physician who wants to provide "on line care" to have a license in every state for which they provide this care (edoc provides medical information, not on line practice). Moreover, they define the minimum requirements for establishing a doctor patient relationship as an "in office" history and physical examination performed by that individual.
5. Physicians and health care providers who are interested in providing online care are dissuaded from getting involved lest they be tarred by the brush of thousands of online health care supplement companies, bogus care recommendations from quacks, and illegal drug distributions sites.

So, how will we deal with this, and in what direction will we go in the future? Hopefully, my predictions for the next few years will be more accurate than my last ones:

1. Online care will continue to grow, in spite of the obstacles mentioned above, because the internet an incredibly powerful and efficient resource for patients. The growing demand will eventually overwhelm the remaining barriers.
2. Patient and peer groups will become increasingly sophisticated, with or without the cooperation of health care providers, and will increasingly rely on each other, rather than sole reliance on trained professionals.
3. Grudgingly, more payers will begin to support online care as the patients/employee groups realize the benefit and demand it of their employers and insurers.
4. Access to online services will continue to grow, including adaptation on cell phone applications, which will lower the bar for patient groups that are currently left out of the action.

The ability to communicate with a physician via secure e mail has tremendous benefits, including saving unnecessary office visits, allowing patients to optimize the timing of their visits to physicians, and increasing patients' confidence to act on issues and questions. Moreover, it allows physicians and patients to emphasize and more efficiently monitor preventive practices such as healthy diet, exercise programs, weight loss programs, smoking cessation and others.

Health care reform may increase the number of patients who have some type of insurance, but thus far, has not included proposals to reform the online environment to encourage or stimulate more communication between doctors and patients.

As always, your comments or dissenting opinions are welcome.

Merry Christmas and Happy New Year to all, and thanks for being a part of eDocAmerica!

Do Diet Sodas Make You Fat?

You would expect that diet sodas would help you lose weight since they have no or minimal calories. Drinking a diet soda rather than a regular soda saves you all that sugar, right? Many people develop diet soda drinking habits due to several factors, the caffeine, the sweetness or just wanting to drink something without the calories.

The link between diet sodas and weight is not what you might expect. Reviewed recently in the medical journal JAMA (Dec. 9, 2009), a major heart study showed that people who drank more than 21 diet sodas per week had twice the risk of becoming overweight or obese compared with people who don't drink diet soda. In another major study, daily consumption of diet soda was associated with a 67% increased risk of developing type 2 diabetes (cause by excess weight). Drinking diet sodas gives you the same "sweet tooth" behavior as other sweets and actually results in people eating more calories than if they stayed away from sweets in general.

Other research is even more disturbing about the addictive nature of diet sodas. When rodents are fed artificial sweeteners, not only do they consume more calories and become obese, but they become very addicted to the sweeteners. When given the option of repeated use of cocaine or diet soda, they preferred the diet sodas!

There are so many options for healthy drinking than diet sodas. Water is the healthiest beverage to complement natural foods. If you want some caffeine, coffee or tea would be healthier than diet sodas. Be mindful of what you put in your body and I'm sure most of you have thought that diet sodas are not very good for you.