Lifestyle interventions--what exactly does that mean? It means, basically, living healthily. (Or, as many people say now in a way that would make my 5th grade English teacher cringe, living "healthy".)Major disclaimer: Just because I am writing this post does NOT mean that I am some holier-than-thou-guru of lifestyle interventions. I am by no means perfect when it comes to healthy living habits. I have plenty of my own issues. I think I have an overall mostly healthy lifestyle, and I have been making improvements steadily over the course of my adult life.
Year after year, the primary care journals publish new reports and studies of just what healthy living can do. Plain old common sense tells us the same thing. Live right, eat right, and you should be healthier than if you don't.
So many of the problems I see in day-to-day practice are basically self-inflicted. The single biggest cause of self-inflicted medical problems is being overweight. Obesity or being overweight is the largest contributing factor towards hypertension, diabetes, arthritis, sleep apnea, and back problems. It is a significant contributor to depression. The second leading cause of self-inflicted medical problems is smoking.
One of the biggest political issues these days is health insurance and health expenditures. The Affordable Care Act, Medicare, Medicaid, etc. Everyone knows that we spend tons of money on health care yet the U.S. ranks 17th among the 17 wealthiest countries in the world in terms of life expectancy. We also rank near the bottom in infant mortality, injuries, homicides, teen pregnancy, STDs, HIV, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability. So many of these issues are related to lifestyle. I firmly believe that we could cut healthcare expenditures vastly if we could simply get Americans to live a healthy lifestyle. If we could get people to get their weight down before they are obese. Get people exercising, eating right, reducing stress, stopping smoking.
Obesity is insidious. The most common form of trouble I see is the thirty-something patient who every winter gains 10 lbs and every summer loses 7 lbs. This goes on for the next ten years, and the next thing they know they are 30 lbs over where they were. It just snuck right up on them. Now they are feeling overwhelmed by the fact that they are 30 lbs overweight.
It doesn't take much of a loss of control to snowball into a major loss of control. Many of the medical problems related to obesity involve a vicious-cycle effect: The weight is now up, so the person feels more sluggish, and doesn't want to exercise. They might start to have more joint pains, making exercise more uncomfortable. They may be getting depressed because they are not happy with how they look and feel.
Obviously the best way to prevent this scenario is to be vigilant about it happening in the first place. As people get on in their lives, they tend to eat more, exercise less, and their metabolism ratchets down considerably. It seems rare these days to see someone in their 50s who is at a "normal" weight.
There is some good news: In a meta-analysis study (a study of many studies) published recently in the Journal of the American Medical Association (JAMA 2013;309:71-82), it was found that people with a Body Mass Index (BMI) between 25 and 35 actually live longer than people with BMIs under 25. Not by much--about 6%, but the results were statistically significant. (My current BMI is 25.7.) It is not clear why this is so. The pattern does not continue, however. For people with a BMI over 35, their risk of dying earlier than a normal weight person goes up by about 30%.
According to this study, this means for an average 5 foot 10 inch tall male, once the weight starts moving over 235-240 lbs, the risk starts climbing. For an average 5 foot 6 inch female, weights over 200-210 lbs become risky.
The self-evident recommendation is to not let your weight creep up in the first place. I am a firm believer in weighing yourself every day, if not every few days. If the weight is slowly moving up, then take steps to get it back down while it is still just a couple of pounds. Of course, this recommendation only works for people already at an appropriate weight.For the large percentage of my patients that battle weight problems, the answer is nowhere that straightforward. Probably one of the most difficult problems I face in my interaction with patients on a day to day basis is when they ask me, "What can I do about my weight?"
Of course, there is a flippant, off-the-cuff answer that is basically true but entirely unhelpful: Eat less, exercise more. That is the basic physics of the problem. It takes a deficit of 3500 calories to lose one pound, in most people. Therefore, theoretically, if you burn off 500 more calories a day than you take in, you SHOULD lose one pound a week. The problem comes in how you accomplish that.
It takes perhaps a good 45 minutes of hard physical exercise, with sweating and moderately hard breathing, to burn up 250 calories. On my elliptical machine, in 30 minutes of moderate resistance, I am pushing just over 170 calories. So one option that makes some sense is to exercise hard for about 45 minutes a day, and keep your calorie count about 250 calories lower than "normal" on a daily basis, to try to reach that 500 calorie a day deficit. Sounds so simple, right? It is, in actuality, so much more difficult than that. First, it is very hard to get people motivated to exercise. I exercise regularly, but only for about half an hour a day. And I don't exercise every day--I average about 5 days a week. I try to shoot for daily, but sometimes my schedule just doesn't allow it. Peoples' schedules are often highly restrictive. In this economy, work is a priority. People have to figure out where to schedule their exercise. Some of my patients get up really early and work out in the morning. I personally prefer to exercise right when I get home from work. However, sometimes that means my family members have to delay their dinner plans for half an hour or so.
The other challenge to exercise is the transition to winter. I would say a large proportion of my patients have no problem being active or exercising during the summer and warmer weather months. However, come October/November when the sun goes down at 5:30 and the temperatures drop, all that activity ceases. I always encourage my patients to have a winter option for their exercise plan.
This is only part of the challenge to maintaining a healthy lifestyle. Under the pressures of work schedules, family responsibilities, and financial limitations, most of my patients have a great deal of difficulty trying to work exercise into their lives. The barriers to improving patients' diets are far more complex.
Dietary Habits:
Eating habits are tremendously personal. Unhealthy diet habits are as individual as each person who has them. The most common I encounter in my patients:
1. Eating on the run: "I don't have time for breakfast, and then I'm on the road and traveling from meeting to meeting, and I'm never sure when I'll get a chance for lunch so I grab a quick something at a fast food place and gobble it down." The problem here is two-fold. Skipping breakfast tends to make people very hungry earlier in the day (10-11 o'clock) so by the time lunch time arrives they are ravenous, and that drives bad decision-making as they rush through the drive-thru. Also, skipping breakfast primes the body into thinking it is in "starvation mode," so it tends to want to hold on to and save every calorie coming in, lowering metabolism and promoting fat storage.
2. Inappropriate portion sizes and meal timing: "I gotta have my big plate of meat and potatoes for dinner, then I park myself in front of the TV until I go to bed." Our general tradition in western civilization is metabolically backwards. Breakfast should be the most substantial meal of the day. Instead, many of us downplay breakfast, have a substantial lunch and our "main meal" of the day is dinner, just as we are becoming inactive prior to going to bed.
Metabolically speaking, the evening meal should more appropriately be sort of a healthy snack. Portion sizes are a (no pun intended) huge issue. People routinely over-estimate an appropriate portion size. Studies show that obese people have a significantly inflated estimate of what an appropriate portion size is compared to non-obese people.
3. We eat not because we are hungry: "I love going out with friends for drinks and dinner." In our society, eating and food are important parts of a social culture, not for nutritional sustenance. Many overweight people admit that they eat not just when they are hungry. In fact, many people with weight problems cannot clearly recognize when they are satiated. I don't mean gut-busting, bloated, unbuckle-your-belt stuffed, but merely no longer hungry. It takes about twenty to thirty minutes during eating to allow blood sugar levels to come up and levels of satiety hormones (such as leptin) to rise to a point where the brain can say, "I'm not hungry anymore." So when we sit talking to friends over a multi-course meal, paying attention to the social interactions and not to our level of satiety, we keep eating even when we are no longer hungry.
The whole "psychology" of the multi-course meal is designed to subvert the normal physiology of replenishing needed nutrients. We start with a salad. Most people don't "love" salads. But because we are "starving," we are willing to eat something that isn't really super appealing. After our salad, we are a little less "starving," but still reasonably hungry, so the entree is served. It is often very appetizing, with a standard protein, starch, and vegetable typically (and usually a high fat content which pleases the palate), and we finish it off. Now, if this has taken a good 20-30 minutes, we probably aren't hungry AT ALL anymore. But now there is that wonderful sweet dessert calling to us. Humans have such a desire for sweets that our craving for them usually completely overpowers our sense of satiety. So here comes another 300 calories that, had we been in a non-social setting, wouldn't have even been considered.
Adding alcohol to the mix just increases the calorie intake, and not just because alcohol has 7 calories per gram. (Protein has 4 calories per gram, carbohydrates have 4 calories per gram, and fat has 9 calories per gram.) Alcohol dramatically dulls our sense of satiety, allowing us to pig out even more.
4. Convenience eating: The healthiest foods to eat are fresh and unprocessed. Fruits and vegetables straight from the produce section. Meats straight from the butcher section that haven't been meddled with (such as processed into sausage). Whole-grained breads straight from the bakery or even better home-made. Keeping it simple reduces the addition of excessive salts, preservatives, and hidden fats and oils. Pre-packaged, pre-prepared, and pre-processed "convenience" foods in cans, jars, freezer packages, and boxes tend to reduce nutritional components (with the exception of frozen vegetables) and add unnecessary components. (And adds to packaging waste, if you're trying to remain "green.")
5. Habit-eating: "If I'm watching a movie at night, I gotta have a bowl of ice cream." The human brain loves associations. Movie = snack and relaxation. My wife and I are guilty of this. If we are watching a great movie in the evening, feeling all relaxed, we'll usually have a couple of cookies and a glass of milk. Or sometimes some parmesan crackers (those little Pepperidge Farm crackers shaped like goldfish). Sometimes both. It is just our "habit." We may not really even be hungry. We just associate that pleasure of movie + food. Sometimes I think the Superbowl is just an excuse to eat tons of chips, dip, sausage, tacos, shrimp cocktail, barbecue chicken wings, deviled eggs, beer, soda, popcorn...the list goes on. You see my point.
It seems to me, that if we changed our diet habits to the following, we'd be much more likely to not be overweight and unhealthy:
Eat a balanced breakfast consisting of some protein (dairy, egg, yogurt, cheese), and some carbs (whole grained toast or oatmeal), with some fresh fruit. Mid morning have a small snack of some fruit, a couple of whole grained crackers and a low calorie beverage (not a Venti Mocha). At lunch, a salad, soup or sandwich with an apple or banana or another yogurt. Perhaps a small piece of dark chocolate to reduce those sweet cravings. In the evening, a healthy "snack"-like dinner--perhaps tuna salad on whole grained crackers or single slice of whole grained toast. (Dinner is the real hard-core creativity challenge.) Snacking late at night, if allowed at all, should be non-carb snacking.
If you eat out, do not drink alcohol prior to the meal. Order only from the appetizer menu, avoiding things with creamy or cheesy sauces. If order from the entree menu, split it with a friend or divide it in half and take half home. Eat slowly. Put your fork down after every bite. Listen to your satiety center. Never order dessert unless sharing it with at least three other people at the table. Never eat at "all-you-can-eat" buffets.
So, healthy eating is not overly-difficult, it is just hard to adhere to. We've known for decades that "fad diets" don't work. The way you eat has to be something you can live with every day. Healthy eating habits have to be second nature. You shouldn't have to even think about it. It certainly should not feel like "work." It should not make you feel different or deprived. Combining healthy eating with reasonable efforts at daily or every-other-day exercise (again, where it gets to be second nature, just a part of your every-day routine) is the goal.
I counsel my patients who are truly serious about losing 40-60 lbs with the following advice that I've gleaned from 25 years of observing who in my practice actually does lose weight:
Part 1: Gradually move your exercise up to a goal of 1 hour of hard, sweating, breathing hard, aerobic exercise at least five days a week (and encourage some additional resistance work-outs also). The exercise needs to be fool-proof. No excuses such as the weather, boredom, inconvenience, or cost should be possible. So make your exercise plan work so that none of those excuses can derail you. If you are over 45 or have significant heart disease risk factors, we should consider doing a stress test first to make sure your heart can handle it.
Part 2: Join Weight Watchers with a friend. Weight Watchers is one of the most successful commercial weight loss plans out there. Their methods are psychologically sound, scientific, and proven. I have seen Weight Watchers members lose 20-60 to even 80 lbs and keep it off for years (if not for good) using their methods. (I have no ties to Weight Watchers--I don't own stock in them that I know of, and I get no kickbacks by referring patients to them.) A year ago, US News and World Report published an article reporting on a survey of various types of medical specialists from across the country and their preferred dietary recommendations for weight loss, high cholesterol, diabetes, and other conditions. Weight Watchers was in the top 1 or 2 across the board. Joining with a friend simply serves to provide you with potential "moral support" and someone who might be able to kick your butt to work on the program even if you are temporarily not self-motivated.
Part 3: Realize this is going to be really, really difficult. Probably around 95% of people who start out on this path will fail. You will have good weeks and bad weeks. You will get discouraged. You must not give up. It will be slow. Ideally no more than 1-2 pounds a week. You must make the changes in the way you live your life, and not look at it like a temporary means to an end. Have your radar up for excuses and rationalizations. They are your enemy. If you start making excuses for why you can't exercise, it is the beginning of the end. A slippery slope that just begets more excuses until you are back to your old unhealthy lifestyle again.
Life Balance:
Another major component of a healthy lifestyle is "balance." By that I mean balance between work and pleasure, work and family, outside commitments and time for self. Yes, there are only 24 hours in a day, so you have to budget your commitments wisely. Is it appropriate to take life balance advice from a physician? Do I practice what I preach? I think I do, most of the time. It is a constant battle, but I try to.
On the days I don't work, it is a hodgepodge of running errands, keeping up the housework (or at least trying to help my wife with the "honey-do" list), seeing friends, attending to the activities of family members, and keeping up with the aforementioned hobbies. I admit my favorite cold-weather activity in the morning is laying lazily in bed with my wife and our dogs just talking, then fixing a nice leisurely breakfast (I love to cook).
I have to fight to resist the efforts of other competing causes to usurp my time. I could easily volunteer for more committees and causes. I could easily guilt myself into constantly reading up on medical issues and continuing medical education. There is always "more I could do" as far as work goes. However, I have seen burnout and stress creep into my life from time to time, and it makes me far less effective as a clinician and far less responsive to my patients.
When I am asking my patients about their "social history"--their work, their lives, their smoking and drinking habits, their kids, their routines--I always ask about hobbies and what I call "passions." I firmly believe that people should have some type of passion in their lives. It might be sports. It might be their kids or grandkids. Maybe it is quilting. Maybe it is volunteering at the animal shelter. Maybe it is their job (I have a lot of patients who truly love their jobs!).
Unfortunately, I have too many passions: my wife, my family, outdoor photography, off-road jeeping, music, reading, science, antiques, medical history. Prior passions included rock climbing, flying and sailing. (I gave up rock climbing when I got married and had kids. I gave up flying because it was too expensive and sailing because I no longer live near a sailable body of water).
Without a passion, life becomes drudgery. Hobbies, interests, and passions give people motivation and a source of rejuvenation. When I am deep in my photography work or playing the piano, time stands still and I am unaware of any other issues/problems/troubles, if only temporarily. Most athletes describe the same sense when they are participating in their sport.
Women much more than men tend to feel guilty about taking time for themselves. "A woman's work is never done." There is always something you could be doing. But equally important, I think, is the rustic adage, "If mama's not happy, nobody's happy!" Women, wives, mothers, girlfriends--whatever, are going to feel more positive and fulfilled if they carve out of their schedules at least a little "me time."
One of the most common complaints I hear from women in my practice is, "I do everything for everybody else, and never feel appreciated," and, "I never have time for myself." I urge them to rationalize taking time for themselves from a positive mental health standpoint. Go to a day-spa for a massage, go to a movie with a girlfriend, turn off the phone and take a long bath, take an hour to curl up with a great book and tell everyone to leave you alone.
In the spring and summer my wife will plug her earbuds into her iPod and work out in the yard, listening to Linkin Park and Evanescence (among others). She'll be rockin' out, gardening for hours until it gets dark. She has told me and all family members that she is NOT to be disturbed, even if a phone call is for her. This is her rejuvenation time--she LOVES it.
It is important to guard against over-commitment. That includes over-committing the kids. Over-commitment of children is really a topic for another post, but the point is: if you commit yourself to too many activities and responsibilities, you'll soon have no time to yourself. Even if the activity is something you enjoy, if it sucks up too much of your time, you will start to resent it. Especially if it demands your time out of your control.
It is important to watch out for what I call the "over-commitment spill-over effect:" You commit to some cause, that then demands more of your time, which then takes you away from responsibilities to which you previously attended. You then have to have others (family members/friends) take over those things that you used to do, simply because you no longer can. It may be fine if you asked the family member/friend if they mind taking over and they agree. However, if your overcommitment is now impacting other peoples' schedules and lives, you will be engendering resentment among those who now have to fill in the gap.
Vacations: I am a huge fan of vacations. I usually ask my patients during a physical if they take their vacations. An amazing number of Americans DON'T use their vacation time. Yes, when I go on vacation it sometimes barely seems worth it--I have to work harder before I leave to get everything tidied up, and when I get back there is a MOUNTAIN of unfinished work I have to catch up on. But I still feel it is worth it. I used to take only week-long vacations, but always came back feeling like I didn't really feel like I got away. I now make it a point to take at least one full two-week vacation in the summer. Usually by the beginning of week two I finally feel the weight of work starting to fall away.
I enjoy planning vacations almost as much as I enjoy vacations. As soon as I'm home from a vacation trip, I'm on line researching our next getaway. I have tried the concept of the "stay-cation." But it was too easy to just get into the "daily grind" of home chores and mundane stuff. I really think we need to get out of our usual environment for a vacation to have more of an impact. Obviously, vacations can get expensive. In my younger days, though, I'd pack a kid or two into my Subaru Outback along with a bunch of camping gear and we'd car camp for days at a time, or spend an occasional night in an inexpensive motel just to get cleaned up. Those were pretty cheap trips, made a lifetime of memories, and were tons of fun. Anyway, the point is, get out of town!
Achieving balance in life is a goal, not always attainable all the time. It is a target to be aimed for. Mostly, be aware of the inner feelings that can signal your life is getting out of balance. Not sleeping as well, feeling sluggish, losing energy, not looking forward to things...hmm, sounds like the same list of symptoms of mild depression. Sometimes you have to shake things up a bit. Take time off, travel, go out on a date with your spouse, take a class from the community college in something you've always been interested in. Adopt an animal from the Humane Society.
Enjoy your life! It is the only one you've got.
No comments:
Post a Comment