Sleep all the sleep (part 2)

This will actually be a short one.  Part 3 will be on improving sleep.  I ran across these two graphs today and thought that the comparison is worth remarking on.

Map of Sleep Insufficiency:

The map below depicts age-adjusted* percentage of adults who reported 30 days of insufficient rest or sleep† during the preceding 30 days. Data is from the 2008 Behavioral Risk Factor Surveillance System, United States.‡

map

Source: http://www.cdc.gov/sleep/data_statistics.htm

brfss-self-reported-obesity-2012

Certainly this is not scientific.  I haven’t calculated the p value of correlation, but notice anything on these two maps? These are maps of self reported sleep deprivation (darker blue is more sleep deprivation) and self reported obesity (red is higher rate).  It’s not 1 to 1 perhaps, a few states buck the correlation, but the similarity of distribution seems obvious.

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Sleep all the sleep (part 1)

If you’ve read any of the posts I’ve made you’ve already heard my recommendation to get more sleep. In fact if you read any of the blogs that I read, you’ve read a few other sciency posts on why sleep is important.  Stephen Guyenet outlines a study in this one that found that people who got more sleep lost more weight from fat when they lost weight.

There’s a lot of information about why you should sleep more.  Many of us don’t get enough for a variety of reasons.  I have a strong feeling that our reduced sleep time is as influential as any other single factor in the rise of obesity.  The CDC calls it a public health epidemic!

http://www.cdc.gov/features/dssleep/

That report says: “According to data from the National Health Interview Survey, nearly 30% of adults reported an average of ≤6 hours of sleep per day in 2005-2007. In 2009, only 31% of high school students reported getting at least 8 hours of sleep on an average school night.”

Ok, so it seems pretty clear that lots of people aren’t getting enough sleep.  I think there’s a lot of emphasis on the effects on our movement and exercise when we are not getting enough sleep.  I’d like to highlight some big picture studies that talk about some of the hormonal impacts that occur from even short term sleep reduction.

We all know that one of the goals of exercise is to improve insulin sensitivity.  Well these two studies show that just 7 days of 4-5 hours of sleep resulted in signs associated with insulin resistance in healthy young men:

http://www.ncbi.nlm.nih.gov/pubmed/20585000  http://www.ncbi.nlm.nih.gov/pubmed/22844441

In one of the studies they tried to attenuate the effect with modafinil, an alertness medication, which had no effect.  This shows that it’s not just “fatigue” causing the metabolic changes, it’s neurohumoral.  The reduced sleep causes real modifications in the people’s biology.

The gurus try to tell us that it’s the carbs increasing our appetite.  Lustig is selling a “sugar blocks leptin” theory also.  That has some merit to it, but what if it was more simple then that?  What if we are sleeping on average 2 hours less per night then 40 years ago and THAT is making us hungry.  What if wide swaths of America are overweight as much because we stay up too late watching TV or doing facebook?  Well I’ve been thinking that may be the case ever since I saw this doozy:

http://www.ncbi.nlm.nih.gov/pubmed/23392199

This is a great study.  It was a group of normal weight but relatively sedentary individuals. They were brought into the hospital and all their food was measured, but they could eat ad-lib.  They were split into two groups and spent 2 nights in the lab getting used to the environment and getting their food measured, etc.  Sleeping how much they wanted the first nights the groups were matched for sleep.  Then they took the experimental group and limited them to 2/3 their normal, which in the study was an average of 5.2 hours while the control group continued to sleep an average of about 7 hours.  This lasted for 8 nights.  They continued to measure both groups calorie intake during that time and also measured their activity through a physical activity monitoring system (PAMS).

The results are pretty surprising.  Mostly surprising at how big the change is.  No change in activity levels between groups.  No change to levels of ghrelin or leptin (which was actually the hypothesis).  Huge change to calorie intake.  The sleep deprived group increased intake by over 600 calories and the control group decreased by about 100 calories per day during the experimental period.  Let me repeat: an hour and a half decreased sleep resulted in a nearly 600 calorie increase in intake.  This persisted even after two recovery nights (where the experimental group slept a lot more than their baseline) with the calorie intake still being increased by ~150 kcal.  This resulted in a statistically significant increase in weight over the study period of 0.9 kg (~2 pounds).in less than two weeks.

There are some limitations to the study. The groups were small and the experimental group had a much lower baseline intake during the free living period. This could imply some baseline metabolic differences between the two groups, but even that doesn’t bother me. Even without a control group this would be an interesting result.  The fact that the controls aren’t perfectly matched, but still had roughly static intake during the study period does help suggest the increase in intake is heavily influenced by the sleep deprivation.

By sleep deprivation of course I mean, “being forced to sleep like large portions of the American population.”

Go to bed.

On The Other Side

Written two and a half years ago:

I’m about 30 hours out from joining the legions of appendectomied people. For me the actual appendicitis wasn’t that terrible of an experience. Sunday afternoon had a vague feeling of abdominal discomfort. Largely right sided, though somewhat more around the belly button. (For anyone not medical reading this: my description of symptoms is basically directly out of a textbook for presentation of appendicitis.) We went walking around 3:30 PM and my baby’s bottom (she was in the carrier on my front) bouncing against my lower abdomen was sort of uncomfortable. I tend toward constipation so I was thinking constipation or gas pain.

As the evening wore on I developed increasing right lower quadrant (RLQ) pain. Around 9 PM I emptied my bladder which evoked a somewhat more significant but brief RLQ pain. I came out to the living room and was lying on the floor examining myself and told Dorothy, “I wonder if I have appendicitis,” to which she responded, “shut up”. I went back to playing at the computer and about 11 PM I took a shower and was starting to feel vaguely ill- like mild body aches. Dorothy has had a cold so I started hoping, “please start getting a sore throat”. I was asleep for about 30 minutes when I was awakened to terrible nausea, significant chills, and somewhat increased RLQ pain. I still only rated the pain at 3/10 at the worst. The nausea is what sent me to the ED. That was terrible. I knew at that point what I had. I woke Dorothy and told her I had appendicitis and she said, “Are you sure you don’t just need a laxative or something.” I’ve been joking since that she was trying to keep me home to collect the life insurance money.

I called up to St. Ben’s to make sure that we didn’t have a surgeon available (we didn’t) so I drove myself to St. Luke’s for evaluation- the baby was sleeping and I was well enough to drive myself.

What a strange, bordering on fun (if having appendicitis and eventually getting a few thousand $ bill can be called fun) experience being a patient. As an adult I had been to the ED once before for something minor, never for anything major. I also have a vague memory of getting stitches in the ED at age 3. Early Monday morning about 1:45 AM: They got me settled in, IV placed, the Physicians Assistant came and evaluated me (listened to my heart and lungs through my gown). Labs drawn. Then I carried my IV bag to X-ray and had my first ever chest x-ray and abdominal flat plate. Lying on the X-ray table was very uncomfortable with appendicitis. It’s a very flat and hard table that they must chill to about 10 degrees. I gave a urine sample after that, which was tricky with a gown on and my IV bag slung over my shoulder. Then I saw the ED doc (also examined me through my gown). He was basically like, “you’ve got appendicitis and the surgeon is on his way in”. Yup, I sorta thought the same thing. WBC was 10.5 (barely elevated), CRP was 2.9 (pretty  elevated- a general marker of inflammation).

I also saw Garth, whom is my favorite Murse of all time (one of my favorite nurses over-all too, but that’s largely because he acts and sings and I saw him in a local show of Jekyll and Hyde and he killed it as the main role of Jekyll/Hyde- unfair advantage), in the ED. He gave me a shot of promethazine after the 2 shots of Zofran had not touched my nausea at all. I did not enjoy the promethazine. It made me very altered (keep in mind it’s now about 2-2:30 AM and I haven’t really slept). Drowsy but not exactly falling totally asleep. I was slurring my words and couldn’t think straight. I think next time I’ll just stick with the nausea. I later wondered if they had given me some morphine or something too, though I don’t think so, I told them I wasn’t having much pain and didn’t need anything.

It dawned on me later that I was never afraid. I wasn’t just being tough or stoic. I knew what was wrong with me and I just simply wasn’t afraid. My personality is somewhat like that (which is why I quit bike racing- I had become afraid). I don’t get nervous about much anymore, which definitely comes from surviving the experience of medical school and residency- it changes you. It also just never really felt life or death to me, I pretty much felt like it was going to turn out fine. I really never was that “sick”.

Sometime after the promethazine I saw Dr. B, who’s quite a young guy. He’s a very calm person, I liked him immediately. I could barely follow him because I was altered. They took me to the pre-op area, which I can’t remember well because of the promethazine kicking my butt. I had to strip down (I left my socks on) and pee in a urinal so I didn’t have to get a foley catheter. I peed all over the edges of my gown. I think I was having more pain at that point and being all altered from the promethazine, not being able to stand up straight from pain, and trying to pee in a urinal in front of people was pretty awkward. I could feel my pee from the bottom of my gown on my leg when I was lying back on the bed to be wheeled into surgery.

They wheeled me back to the OR and I vaguely was aware of the anesthesia person giving me something in my IV. I scooted over to the OR table and my next memory is about 3 hours later with a nurse asking me all these questions and me falling asleep. The nurses were turning over at 7 AM and the outgoing nurse was trying to get her work done before the next nurse came on. It was sort of comical. I’m pretty sure I asked, “Is my appendix out,” which is so classic- ahhh anesthesia. Then about 8:30 I really woke up. Another very strange feeling. I was really awake. I was feeling pretty comfortably tucked into a bed and knew where I was and was clear minded. No pain to speak of, no nausea.I also knew at that point that I was clearly cured of whatever had been making me sick. A weird feeling to have post-operative pain which is worse then your appendicitis pain but to “feel better”.

I hit the button and called the new nurse in because I felt I needed to pee. Jessica was my nurse for the rest of the day and she was very nice. Getting out of bed was awful. I’d rate it as the worst pain I’ve ever felt. What’s weird was the pain was now in the left lower quadrant (LLQ) where the biggest of the laparoscopy ports was. I imagine that pain is what it feels like to be stabbed. If the appendicitis pain was 3/10 this pain standing up was about 8. Peeing in a bed-side urinal while a female nurse is 6 inches away was pretty weird. Trying to get the flow of urine started with 8/10 pain and a female nurse standing 6 inches away was not easy. I got about 600 cc and struggled my way back into bed. She gave me 2 mg morphine IV and two hydrocodone right after. I slept away much of the morning. I called various family members and eventually my wife and baby came to visit which was nice. Later I micturated an amazing 750 cc of urine!

I improved quickly through the morning. Getting out of the hospital bed was still a 6/10 pain struggle, but even walking or sitting up wasn’t that bad. I had solids for lunch and walked 150 feet in the hall without much trouble. I even danced a little jig for Jessica near the nurses station. Eventually I saw Dr. B and he discharged me home. I was home 13 hours after getting my appendix out.

I’m home now. I’m doing ok, still pretty painful moving around, but it’s a different kind of pain now, more like “man I worked out too hard” type of pain. I let myself go a little long without pain meds last night and had a weird response to the pain- shivering. Happened again in the middle of the night after I had slept soundly for 5-6 hours. Shivering for about 10-15 minutes until the pain medication kicked in. Very weird. At first I was getting a little spooked that I was having a sepsis response or something, but it definitely faded with my pain and it didn’t start until I tried getting out of bed in the middle of the night. It’s amazing how much you use your abdominal muscles. Even weird little things like passing gas or flushing the toilet uses a surprising amount of abdominal muscle.

I can’t say that I really learned much about how to be a better doctor or about how we can provide better health care at our hospital as a result of my experience. I’ll probably just have a bit more empathy going forward. I really feel for C-section patients more then before. The amount of pain I have from these little port sites, I can’t imagine the C-section incision- even more so because you want to get up and take care of your little baby. Less C-sections!

The worst part for me (besides the eventual bill) is not being able to play with Ruthie. I really can’t get down on the floor yet and I definitely don’t feel up to picking her up yet (she’s very squirmy). Just picking a shirt up off the floor is tough! I’m also sad about having to take several weeks off from Kung-fu. I was really starting to get into shape again. I imagine I’ll be able to practice some of the forms again in a few weeks, but I definitely won’t want to do anything aggressive for 6 weeks. That sucks.

Our first major medical situation as a family! I can’t thank my wife enough, I can’t imagine trying to get through stuff like this without her. Even just knowing that if I needed her to she would get me something or pick something up without griping about it- that’s love.

ETF (Eat the Food), except for this

Anyone reading my blog knows that I think food vilification is bad.  I think putting foods into “safe” and “unsafe” categories as a general rule is not good, it leads to binging and to obsessive avoidance.   I think most foods can just become fuel like any other food.  It’s not that I don’t think restriction of some things isn’t good: there’s no way I could say “smoking some cigarettes is fine”.  Even eliminating second hand smoke exposure in a town lowers heart attack risks in that town.  Yeah, even a little is harmful in some cases.  Cigarettes? They are out.

Likewise I think the data is clear that eating more whole foods and more vegetables is better than processed food for health.  But I also think that on some levels, there’s room for enjoyment.  Let’s say eating a “perfect” diet buys you a little time?  I’d take 94 years of cake, health and a lot of exercise over 96 years of no cake.  Sorry.  Some things are worth it and some degree of eating enjoyable foods probably reduces stress to the point that it’s a wash.  Rules like 80/20, 90/10…heck even 70/30 are probably good enough for most people.

Now I blow your minds by saying there’s one “food” that I think you should restrict.

Soda.  I just don’t think there’s room for soda as a regular part of a person’s diet.  I think if you go the movies twice per year or even a restaurant once per month and enjoy a soda….that’s probably ok.  But daily consumption or even 4 x weekly consumption of soda?  I think the risks are so great that the benefits to you (enjoyment, caffeine, taste) are rendered into the same category as cigarettes. In fact from a shear weight of research standpoint I don’t think there is any one thing that can compare to soda intake as being modifiably harmful to ones health (after cigarettes). Possibly even more so than obesity.

Speaking of obesity the correlation between obesity and soda consumption is mind boggling to the point of suggesting causation (more on that in a moment).  Again, I have an upcoming post on correlation and causation, but a brief summary of the difference I discuss in my facebook feed. It’s clear that soda has been poo-pooed by the health community for a long time, so to find correlation between poor health and soda drinking is not a stretch. It’s actually why some of the studies on eggs are such a problem. Take a food group that for 5-10 years everyone is told is “bad for you” and then 10 years later do a study where people are asked how frequently they ate eggs and look at people’s health outcomes.  You might then just measure a group of people that a) ignore health advice b) don’t care/aren’t aware of health advice c) ate more eggs and had worse health.  (Well designed studies have suggested that eggs/cholesterol intake probably don’t matter for health, fyi).  Soda could be the same.

Having said that the overwhelming magnitude of the data is……overwhelming.

Here’s a study that tried to control for a lot of variables (so eliminating some confounding factors) and found that those drinking one or more soft drinks a day had 1.4 x risk of developing diabetes (which is big in medical research):  http://www.ncbi.nlm.nih.gov/pubmed/17646581

Same with diabetes risk across ethnicities in diet soda consumption: http://www.ncbi.nlm.nih.gov/pubmed/19151203

Study of 90,000+ female nurses showed that  risk of DMII is increased by 1.83 when drinking one soda per day compared with those drinking 1 per month, those women also showed more weight gain: http://www.ncbi.nlm.nih.gov/pubmed/15328324

This very recent study used the doubly labeled water method to look at people who accurately reported caloric intake and found that drinking sugar sweetened beverages doubled the risk of overweight/obese. In-fact one of their conclusions is that other studies may underestimate the risk of soda drinking because of people underestimating calorie intake.  “When limited to true reporters [accurate record of intake], SSB intake significantly increased the risk of being overweight/obese by nearly 4 fold.Conclusion: Underreporting of SSB intake may be attenuating true associations of SSB intake and the risk of being overweight/obese.”    http://www.ncbi.nlm.nih.gov/pubmed/23867782

I mean this is a small sampling of the data.  It’s hard to find any studies that don’t find this correlation with diabetes, obesity and/or early death.

So again, it’s hard to show CAUSATION. Maybe if you eat and live like a non-soda drinker from one of these studies but also drink soda, maybe you are ok….except I have a theory. A theory on causation. I have independently noticed a finding of low magnesium levels in chronic soda drinkers.  In my area there is a large population of overweight middle age people who drink soda daily (usually more than one- they don’t drink any coffee or tea) and I’ve found that they frequently have diabetes/pre-diabetes and low magnesium.  I have a theory that the inorganic phosphate, which is known to be very hard on the kidney, was directly or indirectly causing magnesium wasting in the kidney.  I can only find bro-science level information to confirm my suspicions that the two are directly linked (inorganic phosphate from soda and magnesium). I will continue my search to find good science to suggest this causation may be true.  But what I do know is that there’s something to this association.

Magnesium is sooooooo important.  In fact it’s directly involved with both sugar metabolism and insulin sensitivity. In fact magnesium supplementation can potentially increase insulin sensitivity! This is covered so well by Stephen Guyenet, I’ll send you to his great site and this post here.

So what if soda is actually harmful and bad for health not because of the sugar load, but because of direct effects of magnesium wasting which leads to decrease insulin sensitivity (and eventually diabetes)?  For me that’s enough to recommend not drinking the stuff.  Too much correlation and the possibility of causation.  There’s also some mixed evidence that liquid calories don’t cause as much satiety, which could be a big issue also.  Again this data is very mixed, so hard to know if that’s a factor.  There may be some gender differences in that women may get less satiety from liquid calories then men.

I’ve been recommending against soda consumption while recommending ETF. Again, most people are drinking it for caffeine, which can be obtained from coffee or tea in a much safer and possibly even health benefiting way.  Likewise if one is religiously forbidden from coffee/tea consumption, then I suggest looking at the lifestyle that is forcing you to drink soda to stay awake.  In fact we should all take a hard look at why we need caffeine so much to stay awake.  I think someone is much better off eating a cookie as a snack (if you want something tasty and delicious or quick calories) then a soda.

So let me circle back around to causation and correlation.  All we really have is correlation here, despite my theory.  If you are metabolically healthy, eat a lot of leafy greens, nuts, and halibut, relatively normal weight (BMI under 30), and fit- then my recommendation to avoid soda probably doesn’t matter for you.  You aren’t showing any signs of the things I’m worried about, specifically insulin resistance or obesity.  But if you have diabetes, PCOS, obesity, poor metabolic health….oh man this is low hanging fruit here people.  If you are unhealthy but say “they’ll pry my coke from my cold dead hands”….then you really, really sound like a tobacco addict or alcoholic. I find that addicts frequently have just said “screw it, I choose unhealth”.  We should all be striving for good health.

Why your orthorexia may be killing your weight loss efforts

How many times have you heard on the internet:

“I just need to eat a little cleaner”

“Junk in= junk out.”

“Training is easy, eating clean is the hard part.”

“Six packs are made in the kitchen.”

Around here, I think there is some underlying truth to these principles, but the implied message is what I take umbrage with.  I can get behind the surface message: artificial ingredient laden foods probably aren’t as good for you as whole/homemade foods.

I think the underlying message is the issue. The veiled message is that there’s some kind of intrinsic “metabolic advantage” to “eating healthy”.  That if you would only eat healthy fat would melt off your stomach. This idea and the peddling of it by internet guru’s has even lead to a term orthorexia: which is preoccupation with the avoidance of foods perceived to be unhealthful.

I think food vilification often leads to more binging and guilt. Not only that, it avoids the fact that ultimately a goodly proportion of our calories are “just energy”.  Meaning coconut oil is equally for flavor and energy as any other vilified energy source (sugar, butter, etc).  There may be some health benefits to certain fats over others, that’s not my argument.  My claim is that if you head to the right website you’d think that coconut oil had some kind of miracle cure for obesity in it.

I’m eating ice cream right now, because I’m still hungry, ran a deficit today because of a busy work schedule and lifted heavy yesterday.  Need energy.  Ice cream is delicious, delicious energy. 

Ok, but there can’t be any harm in helping people understand that they should be eating “healthy” right?  Well…not so fast.  Hot off the presses:

Perceived ‘healthiness’ of foods can influence consumers’ estimations of energy density and appropriate portion size;  4 June 2013

http://www.ncbi.nlm.nih.gov/pubmed/23732657

This study shows that when people are shown equal calorie density foods, the ones they rate as “healthy” they thought had less calories and served themselves a larger portion.  Important to know that “ED” in this paper means “energy density” not “eating disorder”. I got very confused the first time I read the abstract quickly.

From the Introduction:

Consumers have an inherent tendency to categorise foods as ‘good’ (for example, fruit and vegetables or those associated with descriptors such as ‘organic’, ‘low fat’ and so on) or ‘bad’ (for example, foods high in fat or sugar, or those associated with descriptors such as ‘creamy’, ‘rich’ and so on).2324 In particular, low fat may be taken to indicate lower ED, which is often not the case. For example, some foods labelled low fat have on average 59% less fat but only a 15% lower ED compared with their standard alternative.22 Unbeknownst to the consumer, the reduced fat is often compensated for by other ingredients such as sugar to maintain the taste and textural properties. In fact, the consumption of low fat foods is often associated with a higher intake of carbohydrates and sugar, along with a higher overall energy intake.25

Now some circles think it’s healthier to avoid carbs and sugar and drench everything in butter or coconut oil.  I suspect the same mental mindsets that lead to overeating of one “healthy food type” will shift with the shifting sands of what your guru tells you is healthy.

Guess what? I’ve posted about this before: these effects are often more pronounced in people who already have trouble with their weight. Again from the intro of this paper:

Research has shown that foods labelled as being lower in fat can be viewed as a ‘licence to overeat’.26 A recent study has shown that when a lunch meal was labelled low fat, subjects consumed significantly more energy compared with an identical lunch meal labelled standard, with the effects on energy intake being most pronounced in overweight subjects.27

The meat of the results of the study is boring enough that you basically already know what’s important. In this study foods perceived as healthier were thought to contain less calories and people served themselves more.  The application is obvious- when foods are put into good/evil, clean/unclean, healthy/unhealthy categories it may actually end up leading you to eat more then you think/plan for.  When the relationship with food gets to a place where it’s about fuel, taste, how it makes you feel, and nutrition- you may get a better handle on how much you are really eating.

I Gained Weight by Doing Cardio….

ok not really.  But I’m going to discuss the phenomenon that people often experience of “cardio made me fat” by discussing my own weight loss/gain experience during my cycling racing stint.  It seemed so mysterious to me at the time, but I kept rigorous training logs through that period which included my body weight. Now several years later, it’s totally obvious what was happening.  There has been a lot of “cardio makes you fat” stuff around the internet, which was pretty well debunked by the guys at examine.com in a guest blog at Go Kaleo. I’m going to discuss what happened to me…because the same thing may be happening to you if you aren’t getting the results you want.

I’d like to make this a more personal post also and include some pictures.

This is what I looked like at my leanest and meanest (the one standing up).

431747_4691396203696_1356076590_n

I wrestled at 135 pounds my senior year of high school. I wasn’t a great wrestler by win:loss ratio, but I trained as hard as anyone. I was also wrestling at a weight class lower then I really should have. There was a state level competitive wrestler at 141, which (in retrospect) would have been a metabolically healthier weight for me.  I didn’t want to wrestle JV so I “sucked weight” constantly to 135.  I don’t know what my body fat was, but I almost always had to dehydrate to make weight. I once got a haircut day of weigh in because I was cutting it close to not tipping the scale at 135.0.  After season I hydrated/re-glycogened back up to about 150.  I continued to lift weights regularly at Gold’s Gym and actually ramped up my running and ran a marathon as a senior in high school. I mean…I was in good shape.  That summer I worked at Godfather’s PIzza, ate all you can eat pizza buffet (and salad bar actually), rode my bike to Gold’s, lifted like a body builder, and ran a lot.  I was basically carved out of wood. Weighing roughly 155, though I don’t have actual data to know that for sure.  Freaky hybrid athlete kid, great endurance, strong as bull, eating big, I did that for 2 months, then got what I think was mono was laid up for 2-4 weeks, summer ended, I moved to college.

Fast forward 5 years, I’m graduated from college and haven’t really been working out regularly since that summer. I’m 205 pounds, BMI firmly into obese.  I don’t know if people would call me “fat” per se.  In fact a lot of people and family members are amazed to hear I weighed that much. I had lifted weights some and was just kind of “big”, certainly not fit or “ripped” at all.  I had definitely just been eating too much food and drinking too much alcohol without any real regular exercise  I start applying for medical school and think “I can’t be like this”.  Back story: my dad had a heart attack at 40 and I started to get scared I was heading down that path.  I start running. Eventually that leads to biking and swimming, I get into medical school and join the University of Washington Triathlon team (club team, not school sponsored). There’s a lot of great athletes in medical school so I start a UW Medical School Running Team, and we win a bunch of team relays, etc around Washington.  I get back in decent shape, weight gets down to a low of about 165. This picture is from the US Collegiate National Triathlon Championships in 2004::

6151056625740l

It’s hard to tell in the picture, but I still look more like a “wrestler pretending to do aerobic sports”. Eventually I do a half Iron Man and decide “I like biking best” in the middle of that 6 hour race. I start bike racing.  Bike racing was great. Long rides with a huge team all winter, racing all summer.  I was pushing new envelopes metabolically with my body. Off season after my first year of bike racing I go on “Operation 158”- a concerted effort to shed body fat to make hill climbing and bike racing more efficient. It works.  I train all winter, long miles, lots of eating and weight stays down. Racing season comes around and I gain a reasonable amount of weight even while in the middle of a hard bike racing season.  I repeat this cycle two more times and can never keep my weight down while racing but easily shed weight during the fall after the season and keep it down during the winter of long slow distance. I got to a low of 154.  The best picture to show how lean I am also shows me after a crash with a ton of road rash. I’ll spare you all that one. My face is somewhat gaunt, my arms are really quite skinny for me.  Full six pack.  I’m low 160’s here:

Cycling 2007 002

I kept gaining weight every bike racing season!  Cardio was making me fat! I look back and really am amazed I couldn’t figure out what was going on at the time.

How was I losing weight? Greatly decreasing my calories for about two months after the season ends while lifting weights and cross training. Feeling a little hangry and couldn’t exercise very hard but losing weight. I was always working a ton, upwards of 80 hours per week so I couldn’t be very sedentary.  Almost certainly losing weight too fast.  Hard to know if I was losing lean mass, because I was typically weight training during that period, but I know my calorie intake was greatly reduced. Then when we started the long slow volume phases in November I would increase my intake.  I would usually gain about two-four pounds during that period, but I usually just attributed that to glycogen regain after going hungry for a month or two.  I would have to eat a lot during this part. I would frequently ride for 4 hours both Saturday and Sunday and a few 1 hours rides with higher intensity during the week. It was a lot of time on the bike for a guy in late medical school and into residency. My weight would stay pretty stable.

Then: the bike racing season would start and the efforts would get even more intense, though often shorter time on the bike (training rides would be longer than races for me). I would need more time to recover so the rest of the week I would ride less.  I continued to eat huge amounts of pasta during all this.  Like massive plates of pasta, beyond satiety.  I didn’t want to get carb depleted!  I wanted to make sure I had enough fuel for my races.

Summary: I reduced my mileage greatly (though relatively increase intensity) while keeping my intake very high…..I ate more then I burned.  Why I couldn’t see it at that time, I don’t know.  I have no idea if my body was still angry about the restriction from the fall before, because as you know- I now really, really don’t think rapid weight loss is a good idea or good for the metabolism.  I also know that before bike racing I never really had any tendency toward binging, but I started having episodes of significant overeating after I started bike racing despite knowing that I was going to feel ill from it.  Usually in the form of a pot-luck where I would eat way beyond what was comfortable. I even knew and dreaded a pot-luck because I knew I would eat so much that going to bed that night would be uncomfortable. Despite knowing that, I would do it anyway.  I suspect these periods of restriction helped initiate that in me.

I started to fall back into my sedentary weight gain phase after I stopped bike racing and moved to this small town, my wife had our first daughter and life was turned on it’s head. I continued to have issues (which I didn’t recognize at the time) of eating to excess, especially on dessert. I was using it as a stress management technique while trying to “eat healthy” in the context of not getting enough exercise.  That wasn’t working for me- it probably won’t work for you.  I gained weight, but more than that my body composition suffered. I ended at about 172 pounds.

I finally got to a good place when I was exercising regularly and figured out what I was doing. I realized that I was using food as a stress management technique and not for fuel or even just as food for enjoyment (because I didn’t enjoy that stress management eating very much).  I eat dessert now and sometimes if I’m hungry I’ll eat a lot of dessert, but since I’ve stopped vilifying food and gotten right with my relationship with body and food. I now just Eat the Food without the binging. It’s not a fight anymore, now that I have my mind right about my health and body.  I still can’t decide what I want my “goal” to be, but I have a future post to discuss that in greater detail. Below is me as I am now, right around 170 (though dramatic composition difference from 172 squishy me). Right now its basically two days of lifting a week and more movement and martial arts the rest of the week. More of a 4 pack abs guy now, but look at them triceps!  The picture on my front page is probably only a few weeks before this one.

7-6-13(b)

Metabolic Derangement- Extreme calorie restriction edition

This is my final post in this first series on metabolic derangement.

Subtitle is “One of the Mechanisms Through Which I Think Eat the Food May Work” but that was too long and untitley.

I’m going back to the touchier subject again. The subject of the people who report very low calorie intake and either lose no weight or even report weight gain. I will again be discussing some of the data out of the final study discussed in the first post and again in the second post.  I will be presenting more raw data from that study, but also getting into the realm of speculation and opinion.  Some of that speculation and opinion will revolve around why I personally think the concept of ETF may work.  If talking about calorie restriction triggers you to want to restrict, please do not read this.  My wish is for everyone to eat an adequate number of calories to support a healthy metabolism and enough activity to make substantive change in health.

Again the abstract for this study can be read here: http://www.ncbi.nlm.nih.gov/pubmed/7594141

In the first post of the series I examined the data to suggest that slowing of metabolism is a real phenomenon. Likewise there is likely a cap on how slow it can get and touched on this study showing that people greatly underestimated calorie intake.  In the second post I examined the demographics of people reporting very low calorie intake and found that some really weren’t as overweight as you’d assume someone would be for trying to eat 1000 calories a day.

In this post I’d specifically like to discuss two things.  I’ll get into details on the dramatic underestimation of calorie intake of almost everyone in that study and then talk about the infamous subject 10 who really did have a pretty slow metabolism and was accurately recording calories.

Before I launch into the full discussion, let me again reiterate that no where in here should you construe me as saying “no one can eat 1000 calories per day”.  I know that is a fact-people can and do. I wrestled at a weight class my senior year that required a very low body fat % and frequently restricted my calorie intake severely to cut weight. It got harder as the season went on (I’m sure as my metabolism slowed and possibly after I cannibalized some lean body mass).  Also wrestlers, boxers, MMA fighters, fitness competitors, and body builders frequently use severe calorie restriction for specific purposes.  I don’t think it’s healthy and it’s common in those groups to end up with metabolic derangement (frequently discussed in the female fitness competitor circle) as a result. Also, as discussed in my first post, anorexics often maintain severely low calorie intakes, resulting in low body weight and potentially ending in death.  They also slow metabolisms.

But then there’s another group that reports very low calorie intakes and no weight loss or even report gaining weight!  I made the case in my first post that those people are likely under reporting their calorie intake.  So let’s dive back into the study I mentioned above.  10 women reporting restrictive intakes and no weight loss. They are recording strict food diaries over a two week period. Their TDEE and calorie intake is measured using the doubly labeled water method.  Now let’s look at what I consider to be the most fascinating piece of information from that study.

calorie intake

So much to see here.  Let me briefly explain what you are looking at in the event that the figure doesn’t make sense. The subjects are numbered at the bottom.  The black bars are the total number of calories these women are burning per day.  The striped bar is the calorie intake they report through a food diary.  Before study entrance the subjects had completed a one week food diary (without training) that showed low calorie intake. All of the subjects from 1-8 had essentially normal metabolisms based on measured RMR.  At study entry each of the ten underwent training by a nutritionist and watched a video on preparing a food diary.

So these people all had more training than most of us on taking a food diary. How did they do?  Let’s zoom in on subject 1 because I think her history is so similar to a lot of women in our modern world. In the study they report that Subject 1 had first noted being overweight at age 8.  Had been on “hundreds” (her words) of diets.  History of depression, though currently stable and off treatment.  Normal thyroid function. Highest adult weight was 112 kg (246 pounds) and currently at 88.5 kg (195 pounds).  After training to take a food diary and knowing that they were going to measure her real intake she recorded taking in around 1100 kcal per day.  Her measured TDEE is 3000.  This is an active woman actually! Her RMR is actually higher than predicted.  Active, normal metabolism woman, thinks she is eating 1100 calories per day.  Really ate ~3300 calories per day.  Above her TDEE.  During a study when she knows that she is going to have her real calorie intake measured chemically and there will be no way to “lie”.

Let that sink in for a minute.  She’s not the only one, in-fact 9/10 totally underestimated calories.  It’s not like Subject 1 was even an outlier. Subjects 2, 6, and 7, also all recorded/reported intakes below 1000 calories and ate at or above their TDEE with intakes of roughly 2700, 2600, and 3100 respectively.

Four out of ten of these women (who knew their real calorie intake would be measured) underestimated their calorie intake by 1/3.  So far I’ve essentially just reported fact from the study. I’m now going to move into what I think this says.  I think this says that they aren’t lying.  How would 40% of these women choose to lie, even knowing their lie would be found out?  The demographics of these women can be seen in my second post, they are all somewhat different with different backgrounds so you can’t just speculate “They found a bunch of crazy people”.   I honestly think, that even when recording what they think they are eating, they eat more then they realize. I can’t speculate on if that is eating substantially larger portions, legitimately forgetting to record food, unconscious binging, binging at night or even in their sleep, or some combination of the above.  I really think that these people’s view of and relationship with food is so broken that through whatever combination of events they are eating 3 times what they think they are.  Even subject 8 with her normal BMI I discussed previously, she underestimated by 50% and ate over TDEE. I think people’s eating shame, food guilt, orthorexia, body image, mental state, etc becomes so injured, they are essentially blind to what they are really eating.  Even more philosophically- the ID takes over for the ego when you try to do stupid things to it, like feed it 1000 calories per day.

So back to a fact: the reason these women were not losing or even gaining while reporting 1000 calorie intake (or less) is they were eating more then they burned.  It’s the hard truth of how sucky we are at estimating our calorie intake (see section 2 of my first post).  In fact the hard truth is that only 20% -while under the watchful eye of a food diary and study conditions- were able to make a net negative in calories for the two weeks.  I know subject 10 did lose weight (more on her in a minute), they don’t report on subject 4, but I assume she also lost weight having created a ~800 calorie deficit per day.  Which, as my previous posts have suggested, is too much and you can see in her TDEE which is lower then many of the other patients that had similar body weights. While 20% in the study created a deficit, 50% actually ate above TDEE during the study.

So here’s where I suspect the concept of ETF comes in.  I suspect it maybe is less about “healing metabolism” as it is about “healing relationship with food”. Because frankly something isn’t working if you underestimate by 3-fold under strict study conditions when you know you are being observed.  I think if a person embraces the concept of ETF and begins to gives themselves permission to eat enough calories they heal their relationship with food to the point that instead of saying they eat 1000 and eat 3000, they can then sustain intakes of 2500-2700 and make slow loss over time.  Oh there’s certainly some metabolic healing in people with slow metabolisms which were only 40% of the people in this study in people who reported chronically low calorie intake. I have no idea how long it takes in those people. As I previously presented in severe anorexics their metabolisms are above predicted by 4 weeks of re-feeding- how that applies here, I don’t know for sure.

So back to subject 10. Not only was her metabolism super slow (23% below predicted) she accurately measured and recorded her intake.  During the study period she created a deficit of roughly 300 below her very low TDEE of 1600.  She lost weight, which again suggests that when not under the strict observation period of the study, she was probably eating at her TDEE.  Many people who report no weight loss or weight gain on very low calorie intakes will then look at this case and suspect that this patient is the one that applies to them. There are many confounders with her however.  She had hyperthyroidism treated with thyroid ablation 17 years before which is what led to her weight gain. She was also on three psychiatric medications which could be either slowing metabolism or affecting appetite.  At study entrance she had normal thyroid studies, but 18 months after the study ended was found to have hypothyroidism.  Ugh.  Complicated.

But beyond the possibly complicating factors for her having a low metabolism, let’s remember her demographics: age 52, weight 153, height roughly 5’3″. Knowing that her metabolism is almost 25% slow, when I look at the health calc and play around with the numbers- even for her to have a TDEE of 1600 requires her to be very sedentary. When put her in and put the sleep nob to 7 hours it would give her a predicted TDEE of 1950, which is 18% higher then her real TDEE.  There’s not much room for movement based on the information we have.  I’d suggest that I’ve presented information previously to suggest that her low calorie intake is in-part related to her low TDEE.  Also her weight may not be as much the issue given her weight and height (her body fat is reported at 44%).  I’d say she really does need to eat more and move more and work on some recomposition of her body fat, focus less on her body weight.  For her ETF really probably is about healing metabolism and having energy to move!

The rest of us, know matter where we are, need to give ourselves a break.  Chances are, depending on your age and weight, you need closer to 2500-3000 calories per day and thinking that you are going to be able to sustain on levels far below that is wrong headed.  Chances are, as suggested above, even if you try to get way, way below a healthy intake your body will find a way to protect itself. Eat the food, play more, just move.