Maggie's Farm

When we walk into a patient’s room, we are entering a story.

That's the correct medical attitude. It doesn't apply to the purely technical specialties, though. 

Why Hard Belly Fat Is More Dangerous Than Soft Fat

People always say "Diet and Exercise." Unless you hike 10 miles daily, or work out 2 hrs/day, I just say "Nutrition" to lose bad fat. Not "diet," "nutrition" because diets fail but appropriate nutrition is a way of life. Just enough of pretty good things for the fitness you want. That article more or less says the same thing. 

Daily exercise is great for fitness, but not for fat. The bonus is that the less fat you are carrying, the better your exercise and activity endurance. 

That's enough annoying preaching for today. 

Brief article here.

Never forget that pain relief is one of the miracles of modern medical practice. 

Joseph Henry Green  (1791-1863), an English surgeon who became the literary executor of Samuel Taylor Coleridge.  The word was spoken upon checking his own pulse.

Joseph Henry Green, a surgeon and professor of anatomy, suffered from inherited gout and died of an acute seizure at his house in 1863.  

An account of his final moments has been given by Sir John Simon:

“I would show that not even the last sudden agony of death ruffled his serenity of mind, or rendered him unthoughtful of others. No terrors, no selfish regrets, no reproachful memories, were there. The few tender parting words which he had yet to speak, he spoke. And to the servants who had gathered grieving round him, he said, ‘While I have breath, let me thank you all for your kindness and attention to me’.

Next, to his doctor, who quickly entered – his neighbour and old pupil, Mr. Carter – he significantly, and pointing to the region of his heart, said – ‘congestion’. After which, he in silence set his finger to his wrist, and visibly noted to himself the successive feeble pulses which were but just between him and death. Presently he said – ‘stopped’. And this was the very end. It was as if even to die were an act of his own grand self-government. For at once, with the warning word still scarce beyond his lips, suddenly the stately head drooped aside, passive and defunct for ever. And then, to the loving eyes that watched him, ‘his face was again all young and beautiful’. The bodily heart, it is true, had become more pulseless clay; broken was the pitcher at the fountain, broken at the cistern the wheel; but, for yet a moment amid the nightfall, the pure spiritual life could be discerned, moulding for the last time into conformity with itself the features which thenceforth were for the tomb.”

You have to admire someone who takes his own pulse and pronounces himself dead.  Now that’s cool.

"To lengthen the life, lessen the meals."

Benjamin Franklin 

That's in Bill Bryson's excellent new book The Body: A Guide for Occupants. Even doctors can enjoy it.

The terror of medical opioids is on an upswing. I have seen the upswings and downswings during my career. I wish we could find a middle course, because medical opioids are a blessing to suffering people. Yes, I include Oxycontin in that because it is an excellent medicine.

Of course opioids are habit-forming. For refractory pain, they are also life-giving. For people with life-impairing chronic pain, there is something called "pseudoaddiction."  AGAINST AGAINST PSEUDOADDICTION

These days, I have seen people in that category treated like drug addicts. Sooner or later, there will chemicals with the pain effects of opioids but without the habit-forming effects. Not yet.

Excellent summary on the mental and physical benefits of exertion: The New Science of Exercise:

Doctors, researchers, scientists--even ancient philosophers--have long claimed exercise works like a miracle drug. Now they have proof.

As I have said before, a rigorous exercise program might not extend your life. It will definitely enhance and extend your quality of life even if you begin it at any age. Everybody knows that they ought to do it, but it's hard and it hurts and we're lazy and "busy."  Plus there is that terrible part: delayed gratification. Everybody hates that. As I say, "The flesh is willing but the spirit is weak."

Our quite well-informed recommendations for general fitness and conditioning for the ordinary person who wants to achieve or maintain maximal functionality for life:

1. Nutrition: Don't be visibly overweight - it's the worst thing you can do to yourself besides being an addict, and no exercise can help being fat. Does a demanding exercise program require a specific pattern of nutrition? Yes. We have discussed that in previous posts here. With a serious exercise program, you have to keep up with the protein and fats - approx. 70-90 gms of protein/day.
2. Weight training - as heavy as possible, approx 50 minutes twice a week
3. 1-2 hrs total of calisthenics/wk for mobility, balance, and athleticism
4. 2 or 3 twenty-min sessions of cardio intervals/wk  (HIIT). (For HIIT, I do stairs once, elliptical once, rowing once. Occasionally sprints in the pool.) Can add an hour of endurance cardio.

Under age 35, it can take 12 months to be whipped into decent shape. Over 35-40, depending on your fitness starting point, 18-24 months. Intense sports like basketball can substitute for calisthenics. Yoga is excellent, but does not substitute for any of the above. Many men find Yoga to be quite challenging and helpful. Lots of pro football players do it. If your day job is physical, all of the above recommendations would differ.

Choosing a Good Death

It's never too soon to have a Will, and a Living Will. Trouble can strike at any time as we all have seen.

Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. So why are doctors—to a striking extent—still drawing upon misinformation in their everyday practice? Dr. John Ioannidis has spent his career challenging his peers by exposing their bad science.

The press makes it all even worse, just to make a story. People of the press rarely have STEM degrees. 

It is well-known that vigorous exercise does not "work up an appetite." On the contrary, it tends to reduce hunger and appetite.

That might not apply to 8 hours on the Appalachian Trail or a day job as a lumberjack, but it is certainly true for me with my 1-hr daily exercises. The more consistently I exercise, the less interest I have in food and the smaller the portions I can handle. This effect is most pronounced with demanding cardio and calisthenic exercise, not with strength exercise or with sports. There is a theory that the effect has something to do with Peptide YY.

Nobody wants to eat anything after a hour of tough cardio exercise and that suppressive effect tends to last 24 hrs. at least. 

Maybe it makes some genetic sense. If you need to move yourself vigorously and frequently, the less fat you have on you the better you can avoid becoming part of a Tiger Dinner Party. Hunger is an interesting instinct and only recently has it been studied biochemically. One thing we know for certain is that subjective hunger or attraction to food is not a signal for a need for nourishment for most adults in a food-rich environment.

Overweight people seem to have the strongest subjective hunger, and sedentary people tend to have stronger appetites. Cause or effect?

Not what they were cracked up to be: Meta-analyses were supposed to end scientific debates. Often, they only cause more controversy.

When and why did "medical care" become "health care"? It has been a puzzlement to me. When I first heard the term, I thought "What?!?"

Is it just euphemisn, or something more?  

At least 80%,  likely more. Genes plus errors in wiring.

Given the complexity, I have always been amazed by how often the wiring works fairly well. 

I still think it's a good idea to get your share of natural sunlight daily, and even more so if healing or recovering from something.

Still, much of the Vit D research was apparently wrong:  Millions of Americans take vitamin D. Most should just stop. Outside of rare cases, rigorous studies of the supplement don’t find any health benefit.

Like many other stories, the moral of this one is that there is no settled science. 

Yes it is. Your waist size is not your belt size or jeans size though, especially if you wear them on your hips which most people do these days. Your waist is above your belly button, the potentially narrow space below your rib cage.

How to Measure Your Waist

How do you measure your waist? Sounds simple enough, but it’s not always obvious where your waist is. Posture and other variables can affect the reading, so here are some basic guidelines to follow:

Position a tape measure at the narrowest point between your lower rib and the top of your hip bone, or at the midpoint in between. It should be snug but not compress the skin. If you can’t find the narrowest point (it may be difficult if you’re very overweight), measure just above your belly button.

Stand straight and breathe out normally; don’t suck in your belly.

Measure your waist first thing in the morning, before breakfast.

Though there’s no magic cutoff point, values over 37 inches for men and 32 inches for women indicate increased health risks, according to the World Health Organization; values over 40 for men and 35 for women represent substantially increased risk.

Doctors have become fearful of prescribing opioids. I hear stories about terminal cancer patients being denied adequate analgesia out of "fear of addiction."

Until new non-opioid and promising pain meds are available,  I am in favor of adequate dosing for pain when nothing else works. Chronic pain is a terribly disabling thing, mentally, spiritually, physically, etc.

The two best things medicine has provided mankind have been antibiotics, and anesthesia/analgesia.

 Can the Damage Done by the CDC's Opioid Guidelines Be Reversed?

Celebrities are always touting the latest nutritional fads like "clean eating", veganism, etc.  Now it's the Fasting Plan. Of course, these people know nothing. In fact, little is known about human nutritional needs but we do know some simple things to prevent starvation. For example, your nutrition requires fats.

There seem to be all sorts of variants of the Fasting Fad, but there may be something useful in it. For example, no adult without an all-day manual labor job (or a heavy lifter or a distance runner) needs three meals/day unless they are underweight. Three meals/day was designed for farmers, just like summer school vacation.

Furthermore, most hunger is what we have described as "false hunger" (meaning it represents no need for significant nutrition) for anybody even 5-10 lbs overweight. Our fat cells are a massive storage battery waiting to be used.

So what about fasting, whether it means just skipping one of the conventional meals or even taking a day or two off from food every week?  Not as a weight-loss plan, but just as a plan. Many find it increases their energy.

When you think about it, during almost all of the 300-500,000 years (except the past few thousand agricultural years) of human life and evolution, food scarcity was the norm. Humans are designed for food scarcity rather than for today's abundance. That's why eating is fun rather than necessary.

This is interesting:  MIT study: 24-hour fasting regenerates stem cells, doubles metabolism. This gives credence to the 5–2 diet, which has recently gained in popularity thanks to a large celebrity following.

Thank you, reader:

This month’s Harvard magazine has an article on just this topic. Scroll down to the section titled, ‘Eating to Excess: Metabolic Inflammation’.

“The metabolic stress that is a hallmark of modern life, the stress that the body has not evolved to handle, is constant eating, he continues. When people eat, energy and nutrients enter the body rapidly, are processed, produce in turn a lot of by-products, and then need to be reduced to “functional substances that are distributed throughout the body, and then disappear very quickly. Many cells and tissues actually undergo a huge amount of stress during this process,” he explains, “as they store appropriate nutrients and dispose of harmful intermediates.” Part of this process also involves mounting an immune response. “The pancreas, for example, must secrete four to five hundred milliliters of enzymes every day” to be able to manage the incoming energy load with every meal. “If you place these organs under constant stress, they start malfunctioning.” The consequence is that “right now, one out of every 10 individuals has diabetes. One out of every four individuals has fatty liver disease. And if you reach a certain age, one out of every three individuals will develop neurodegenerative disease.”

The metabolic stress that underlies these conditions comes from the daily imbalance between how much energy people consume and how much they need, and can process in a healthy manner. The long-term consequence of overconsumption, combined with lack of sufficient expenditure, is stored energy—the accumulation of fat...”

Also interesting in that article is a bit about the benefit of muscle inflammation due to stressful exercise. Muscle damage, of course, is how we build strength. 

Inflammation and health in Harvard Magazine

It's a crazy subject, fraught with myth. Animals do not need to read articles about when to have a drink of water, but seemingly humans do. 

Where I live most of the time, females go around with a plastic bottle of water. In the car, in the gym, on the tennis court, at the supermarket, as if living in the Sahara. There are hardly enough public bathrooms for them all.

A few points:

Coffee is not dehydrating. Beer is hydrating. When you work out hard, especially in the heat, a little water is good. There seem to be extremes: people who are insensitive to their thirst, and people who drink too much. If confused about one's needs for liquid, the frequency of peeing, and the concentration of one's pee, are good indicators.

I have had outdoor adventures when my fatigue was entirely due to a touch of dehydration, when I perked up like a wilted plant with a bottle of water. 

A healthy body alerts us to dehydration by making us feel thirsty. How much water should you drink a day Whether you’ve had fatigue or even dry skin, you’ve probably been told to drink more water as a cure. But this advice comes from decades-old guidance… and may have no scientific basis.

A friend recently went vegetarian just for kicks, as an experiment. In 6 weeks, the friend lost the 8 lbs that no amount of exercise could burn off without quitting dinnertime wine. (This friend is an athletic sort, a strength and fitness buff but not a fanatic.) She asked me how that could happen since she goes light on carbs.

It turned out that the answer was easy: Too much protein.  

That sounds crazy, doesn't it?  It's not crazy because any excess protein (protein in excess of what you body needs to maintain or repair muscle) is converted into and stored as fat. Many people are not aware that most of their steak ends up as body fat.

So whether you are sedentary (less than 6 hrs/week of fairly intense exercise/wk, not including walking)  or not, your protein needs might be less than you imagine because you can only use about 20 gms of protein every 4-6 hours.

That's why people who restrict carbs, and replace the food volume with protein, have trouble losing body fat.  

People who pursue daily strength-building (weights) or daily endurance training (ie triathlete types) can need more than the basic 45 gm/day for women or 55 gm/day for men - maybe up to 100-150 gms/day. That's why they tend to go for 4-5 smaller balanced (carbs, protein, fats/oils) meals/day. 

Nutrition and fitness go hand-in-hand, and it takes a little bit of thoughtfulness. A few simple recommendations:

If you do barbells/powerlifts 3+ times/week, eat a lot of everything. If in daily endurance race training, eat a lot of everything. Until "stuffed". If a regular daily exerciser (some wts, some calis, some cardio, some endurance), 45-60 gms/day is plenty in divided doses. For weight loss, cut the volume dramatically. If overweight, you do not really need hardly any food at all other than some protein and vitamins and minerals. Overweight people have no caloric needs.

Grams protein conversion to lbs for all sorts of foods are easily found online. For one example, a regular chicken breast contains around 55 gms of protein. So if you eat one in a meal, about 30 gms of that protein goes to body fat and some in excretion. Sliced into thirds or quarters over the course of a day, that breast would be plenty for a full-grown male who works out.

So, again, volume management matters for weight-lifters, and for the overweight. It's a "First World Problem." And do not imagine that protein does not become body fat. It does.

We've all had it.  It only lasts about 24 hours, but it is miserable and not treatable.

It's not treatable because the Staph bacterium (Staphlococcus aureus) produces a toxin which causes the physical reaction. The toxin is the problem, not the Staph. Staph is everywhere.

Food poisoning is avoidable by proper food management.  Specifically, don't leave susceptible foods out of refrigeration for more than 2-3 hours. Yes, I know, we all do sometimes but it's not "best practices."

My last food poisoning incident was from a shrimp dish. 

Historic life expectancy data can be highly misleading. In fact, life expectancies in the western world have not increased dramatically since Victorian times - if you delete infectious diseases of childhood and young adulthood.

So when there was once a bimodal distribution of mortality - infancy and youth, and then old age, now there is only one.  All of those deaths in youth skew average or median statistics to the point of meaninglessness. Antibiotics and immunization have made a huge difference.

For adult women, perhaps the main improvement  was the work of Semmelweiss and his approach to childbirth. 

Regarding infant mortality, it is difficult to compare the rates across countries because it depends on at what point the medical system declares an infant viable. In the US, where almost every infant is viewed as possibly viable, many more infancy deaths are named as such than in other places. It's the same phenomenon that rates Sloan-Kettering (cancer) hospital the worst hospital in the US. Many of their patients do not survive, obviously, despite possibly being the best cancer center in the world.

After the huge effect of public health,  immunization, and antibiotics, medical advances have accomplished remarkable things in improving the function and independence of the elder cohort even though I have seen no stats to measure and compare this. In some ways, this is more valuable than life span alone. A generation or two ago you never saw people in their 80s playing tennis, skiing, or hiking up Mt. Washington. Now, it's common in the US (not so much in Europe).

The blessing we all have now, whether we are the half who live past the mid-late 70s, or the half who do not, is the opportunity to live what we're given with as much richness and independence as possible. 

Your internist might give you a Cardiac Stress Test every few years to check your cardiopulmonary function, but other than that never a physical fitness evaluation beyond, maybe, a body fat composition. A very thorough physical exam might include an SF-36. This is not used often enough. (It is used in $5-10,000 "Executive Physicals," but that is often because companies take insurance on the functioning of their essential execs.)

The reason doctors don't do it is because your physical fitness at any age is your problem, not his or hers. OK, they will advise "exercise," but they know you won't do much of it, or "watch your diet" but they know you will do no more watching than looking at what is on your plate.

Serious fitness evaluations are done by the military, police, fire departments, etc. For us civilians, the only people who will give us a serious fitness evaluation are skilled fitness trainers. Trainers tell me that 3/4 of their new clients are in terrible shape. That's why they are there. About 1/4 are in decent condition, but want to get to a higher level of fitness. 

Fitness evaluations include basic measures of cardio function, endurance, strength, agility, and balance. The Mayo Clinic offers this do-it-at-home fitness evaluation.

Regardless of age or level of condition when you decide to get serious about conditioning,  The Maggie's program of HIIT cardio, endurance cardio, calisthenics, and weights (plus proper nutrition for a svelte physique) addresses all of the areas of fitness.

Avoid sunburn, especially in youth. Problem is, youth don't avoid sunburn. 

In any event, getting some unfiltered sunshine is healthy, about 20-30 minutes/day, and a nice tan seems fine if you have the right skin for it.  One view: Is sunscreen the new margarine?

Pediatricians these days are complaining that the kids are sun-deprived, due to sun-phobia of parents.