Posts Tagged ‘Exercise’

Taking Exercise on the Road

by Joshua Goldman, MD, MBA |

Summer vacations provide the opportunity to travel all over the globe.  While you can’t take your gym with you during your travels, there are plenty of ways to exercise while on the road.  Follow these tips to stay in shape while enjoying your time away from home:

  1. Make the commitment: We have a tendency to abandon our workout routine while traveling.  Our recommendation: Don’t!  Commit to working out 3-5 times per week no matter what during your travels and stick to it.  You’ll have more energy and feel better throughout your trip (it’s science).
  2. Take advantage of the local resources: Each region of the world has unique natural resources to enjoy.  Incorporate each region’s unique attributes into your exercise routine.  Try rock climbing in Utah, rowing on the Charles River in Boston, biking in the Swiss Alps, running in the streets of Florence or the hiking in the jungles of Panama.

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07 2010

Type II Diabetes: A Beginner’s Guide

by Rebecca Shatsky, MD 2011 |

According to commercials for the OneTouch glucose monitoring device, rock and roll legend B.B. King hasn’t let Type II diabetes give him the blues. In commercials, little computerized finger stick devices might even look kind of fun, a sentiment we would guess that few diabetics probably share. But, while drug companies and the popular media may try to downplay the gravity and life-altering nature of this chronic disease, few physicians see diabetes as something to be taken lightly.

If you live in America these days, chances are you know someone who either has or has been affected by Type II diabetes. The disease has ravaged the country leaving no stone unturned. Recently rising to epidemic proportions, diabetes has become the leading cause of kidney failure, amputations and blindness in the US. It is also a major contributor to the number one cause of death in the industrialized world: heart disease.

Unfortunately, even though diabetes has become exceedingly common, few doctors really take the time to explain the disease to their patients. This lack of education has led to widespread confusion amongst patients and poor compliance with treatment regimes, a vicious cycle that benefits no one. So, on that account, we want to take this opportunity to summarize things and simplify, providing the basics without all the confusing medical jargon.

What is Type II Diabetes??

Diabetes is a disease of metabolism (the breakdown of sugar for energy) so to understand diabetes, we have to first look at what normally happens in the body after we eat a meal.

Usually, when we eat a meal rich in carbohydrates (sugar), the sugar that we eat enters our blood steam and causes blood sugar levels to rise. When blood sugar levels rise, the body responds by secreting a hormone from the pancreas, called insulin, which allows the sugar floating around in the blood to be used for energy. When the pancreas releases insulin into the blood, blood sugar levels go back down to their normal pre-meal values. The picture below shows how this occurs in your body.  Simple, right?

In diabetes, however, something in this sequence of events goes haywire and the body either doesn’t respond to the insulin in your blood or doesn’t secrete enough insulin to lower blood sugar levels to a healthy range. When blood sugar levels no longer decrease appropriately in response to insulin, we call this “insulin resistance.”

The idea of insulin resistance is central to the development of Type II diabetes. Most studies suggest that in the early stages of the disease, the body’s response to insulin becomes progressively worse over time (4). With increasing insulin resistance we become more and more unresponsive to the normal (life-sustaining) effects of insulin. It’s a little bit like alcoholism, where the body needs greater and greater amounts of alcohol to get drunk; when we become insensitive to insulin, the pancreas needs to produce and release more and more insulin just to keep the body’s blood sugars in a healthy range.

During the disease development period, the body’s blood sugar levels are normal or mildly elevated before meals and then high directly after. If you are screened for diabetes at this stage, blood glucose levels will be higher than normal, but not quite high enough to be classified as “diabetes.” We call this stage “prediabetes.” Clever, we know (we are a bunch of nerdy doctors after all).

Eventually, the pancreas can no longer produce enough insulin to keep up with your body’s increasing insulin requirements. When this happens blood sugar levels soar out of control, both before and after meals. Blood sugar levels that remain high first thing in the morning (after not eating for hours!) are a true indication that diabetes has developed and that treatment is necessary.  The diagram to the right compares the blood sugar levels of a healthy individual with that of an individual with diabetes after having a drink containing 75g of glucose (called a Glucose Tolerance Test).  As you can see, the blood glucose levels soar out of control in the individual with diabetes.

What’s wrong with a little extra sugar?

While it might not sound so bad to have a little extra sugar floating around in your blood, having poorly controlled blood sugar is actually incredibly damaging to your organs, especially your blood vessels. When the cells in your blood are exposed to high levels of sugar for long periods of time, the sugar attaches to the blood cells making them sticky and less flexible. We can measure the percentage of blood cells that have been affected by high sugar levels with a blood test called the hemoglobin A1C level. The hemoglobin A1C level gives doctors a good estimate of how high blood sugar levels have been for the past three months and can be useful in predicting how much damage may be occurring to various tissues in the body.

The best way to explain the complications of diabetes is to look at the different parts of the body the disease affects. The most pervasive and significant complication of diabetes is damage to blood vessels. Damage to large blood vessel results in an increased risk of heart attack and stroke in diabetics, while injury to small blood vessels damages the kidneys (causing kidney failure) and the eyes (leading to blindness). Damage to small blood vessels can also affect the peripheral nervous system (i.e. all nerves not in your brain or spine) and may cause pain, tingling and numbness in your arms and legs, particularly the feet. Finally diabetes has some dangerous effects on the immune system, which puts diabetics at increased risk of infection and increases the time it takes to heal from injuries and surgeries (4). While some of these adverse effects may occur in all diabetics, it is important to remember that the severity of complications is directly related to the length of time a person has had the disease as well as how well blood sugars are controlled.

Who gets diabetes and why?

There are many different theories as to why things go haywire with the body’s insulin response, but what we do know is that the greatest contributing factors to the development of the disease are obesity, physical inactivity and genetics (1).

The importance of obesity in the development of type II diabetes is demonstrated by the tremendous increase in children and adolescents diagnosed with type II diabetes (2).  Once upon a time, Type II diabetes was unheard of in children; so much so that we used to called it “Adult Onset Diabetes.” However, since the obesity crisis swept the nation, the number of children diagnosed with Type II diabetes has increased dramatically and virtually all childhood cases occur in children who are overweight or overtly obese.

The role of genetics in diabetes is well documented but still poorly understood. Certain ethnic populations are at increased risk for Type II diabetes. Those at highest risk include African Americans, Latinos and American Indians (2). We also now know that having a family history of Type II diabetes markedly increases your risk of developing the disease (so if Grandma Mildred had Type II diabetes, you are at an increased risk of developing it). The exact extent to which having a family history of diabetes increases your risk is still hard to predict since the disease is caused by both environmental factors(obesity), as well as genetics. The take home message: If you do have a family history, it’s essential to tell your doctor so they can screen you sooner rather than later.

What does this mean for me?

The most important thing to keep in mind with diabetes, whether the disease has affected you or your loved ones, is that aggressive treatment makes a difference. The surge in Type II diabetes that has occurred over the past 20 years is, without a doubt, intimately related to the obesity epidemic. And, just like obesity, the first weapon in our arsenal against diabetes is diet and exercise. If diet and exercise are not enough, then the key to staving off complications is strict blood sugar control. We cannot emphasize this point enough. It is absolutely essential to take prescribed diabetes medications every single day and to check and record blood sugar levels on a regular basis. If the medications you are taking aren’t doing the trick, make an appointment to see your doctor so that you can find the right combination of medications for you.

Lastly, although discussion of the prevention and treatment of diabetes could be an entire article in itself, it’s important to be aware of the various resources out there available to diabetics. Most insurance plans have good coverage for diabetes medications and many give out free or low cost glucose monitoring devices. The American Diabetes Association is a great resource for information. There are even health care professionals called “diabetes educators” specifically trained to help diabetics learn to live with their disease and make specific lifestyle changes to decrease their risk of complications (nobody wants to go blind as a result of poor glucose control). Ultimately, the best way to manage this disease is to be proactive and take charge of your own health. Successful control of diabetes isn’t just luck, it’s all about lifestyle.

Questions? E-mail the Author:

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1. Braunstein, Glenn D. “Diabetes Mellitus.” Andreoli and Carpenter’s Cecil Essentials of Medicine. By Philip S. Barnett. Philadelphia: Saunders, 2007. 676-95. Print.

2. “Diabetes Research and Statistics.” Centers for Disease Control and Prevention. Web. 18 June 2010. .

3. Ligaray, Kenneth Patrick L., and William L. Isley10. “Diabetes Mellitus, Type 2: EMedicine Endocrinology.” EMedicine – Medical Reference. 10 June 2010. Web. 18 June 2010. .

4 .Powers Alvin C, “Chapter 338. Diabetes Mellitus” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17e:

5. Steppan, CM, ST Bailey, EJ Brown, RR Banerjee, and CM Wright. “The Hormone Resistin Links Obesity to Diabetes.” Nature 409.6818 (2001): 307-12. Print.


06 2010

Breaking the Obesity Cycle

by G. John Mullen, DPT 2011 |

The United States is the most obese nation in the world. Awesome…well done, America. 30.6% of Americans are believed to be obese, 6% higher than the next country, ironically, our Americanized neighbor… Mexico (3)! It is estimated 50% of Hispanics born since 2000 will become diabetic. Mississippi currently holds the crown as the fattest state in the fattest union and has been for the past 5 years, with obesity estimated at 32.5%3. Mississippi also holds the award for fattest children at 44.4% of 10-17 year olds (3). Five states have a current adult obesity percentage over 30%3. To top it off, obesity rates have more than tripled in the past 30 years! These obesity rates are out of control and are a huge weight on the United States budget. On the other end of the spectrum, Colorado is the thinnest state in the union with an obesity rate of 18.9% and is the only state with an obesity rate under 20% (3).  The take home message: America has a weight problem.

Where is all this weight coming from?

The cause of obesity is relatively simple: weight gain occurs when caloric intake exceeds caloric expenditure. Despite the simplistic nature of obesity, weight maintenance and loss are thought of as difficult or impossible tasks. Roughly 25% of American adults report no leisure time activity and 60% report activity levels less than the value shown to reduce their risk of disease (5). No wonder we’re overweight! To add insult to injury, overweight individuals are more inclined to be inactive, with 33% of men and 41% of women reporting inactivity (5). At the same time, roughly 50% of women set a New Year’s resolution to lose weight2. We, as a society, acknowledge the problem and are committing to fixing it each January 1st but seem to fail over the course of the year.

What does it take to lose weight?

Federal guidelines suggest a minimum of 150 minutes a week of moderate-intensity exercise to obtain “substantial health benefits” (4). These health benefits are not associated with weight management, but rather with lowering rates of chronic disease. A recent publication in the Journal of American Medical Association followed 34,079 healthy US women from 1992-2007 studying their activity level and associated weight gains/losses. This study concluded that (amongst women consuming a “normal” diet) physical activity was associated with less weight gain (5 lbs) in women with a BMI lower than 25. The “activity level” was defined as 60 minutes of daily moderate-intensity activity for the duration of the study (4). However, only 45% of women in America are estimated to have a BMI of 25 or less. This study does a great job looking at activity level for weight management, but does not tell us about the volume of exercise necessary for weight loss.

Weight Loss vs. Weight Management

The Harvard study discussed above looked at women with an average age of 54.2 years with no medical complications (cardiovascular disease, cancer, etc.) (4). Women with a BMI of 25 were able to maintain their weight within 5 pounds of their weight at the beginning of the study if they exercised with moderate-intensity activity for 60 minutes a day throughout the study. Moderate-intensity exercise includes bicycling, callisthenics and fast walking (~3.0 MPH or 55-69% of maximal heart rate). However, these same protocols were not successful for weight management in females over a BMI of 25, which constitutes more than half of Americans! This research suggests that overweight or obese women need to change one of the two variables associated with weight management: decrease caloric consumption or increase caloric expenditure. The most important piece of a weight management program is consistency. As stated, many New Year’s resolutions include weight loss goals (fitness centers see an exponential membership increase during January), but the volume of people in the gym returns to normal within a month. The intent is correct but the execution falls short. There are many theories for this. We believe that lack of interest and enjoyment plays a huge role in the gym attrition rate between January and March. If someone does not like riding a stationary while bike watching CNN report another Earthquake in a third world country or another vandalism case by their neighborhood, then it is highly unlikely they will exercise consistently. If we don’t like it and we don’t have to do it, we don’t do it. It’s called human volition. The American view of exercise needs to shift dramatically from a chore to a hobby. The Harvard study used METS (metabolic equivalent) to assess activity level and determined a total of 14 MET hours per week or 3 MET hours a day was sufficient in weight management for women with a BMI of 25 or less. As stated, activities with a 3 MET or higher rating include biking, fast walking, etc. 3+ MET activities also includes various hobbies not typically viewed as exercise: canoeing/kayaking, dancing, ice/roller skating, hiking, gardening and racquetball to name a few (full list of activities with their MET ratings). If you perform these activities at a more rapid pace (really start cruising with that paddle!) these activities can reach the upper echelon of METS. The take home message: Make exercise fun. If you don’t, you’ll quit. If you do, you can potentially burn more calories than you would boring yourself to death on a stationary bike watching Larry King.

Weight loss is a tougher nut to crack and is often person-dependent. Common sense makes it sound as simple as increasing caloric expenditure, but exercising greater than one hour a day is unrealistic for many and leads to failed goals and the aforementioned NYE resolution abandonment. Often times, physical activity is not sufficient in weight loss due to the multivariable nature and complexity of the problem. Many of these issues are related to diet.

Diet is the number one contributor to weight loss. Here are a few simple tips for those trying to lose weight (be sure to stay tuned for more from our staff dietitian):

  • Do not limit yourself to strict caloric restriction diets. The math is complicated and the stress at each meal is unnerving. This approach is hard to consistently maintain leading to failed goals and disappointment. Strict diets can decrease metabolism making the body more likely to gain weight once the diet is discontinued. Instead, monitor diet and decrease consumption of high caloric foods. For example, you can eat four bananas or one McDonald’s double cheeseburger…they have the same number of calories. We guarantee that eating four bananas will be just as filling as a double cheeseburger and the four bananas cost less and have more vitamins than the McDonald’s double cheeseburger.

  • Monitor drink consumption. Energy drinks, frappuccinos, etc. contain high quantities of unfilling calories. Replace these high calorie, high cost options with….water! Simple and effective.

  • Prepare your own food and eat foods that require some work. When was the last time you ate an uncooked carrot? It takes a while to consume and requires a lot of chewing. Increasing the amount of chewing can trick the mind regarding the amount of food being consumed, decreasing hunger.

These three tips are easy to perform and are, most importantly, cost efficient. Some additional factors affecting your ability to lose weight include:

  • Sleep: Inadequate sleep impairs hormones (ghrelin and leptin) that regulate hunger and satisfaction following food consumption. One study found people who slept less than 8 hours a night had lower levels of leptin (controlling satisfication) and higher levels of ghrelin (controlling hunger) AND higher levels of body fat (1).

  • Stress: Cortisol is a hormone produced in response to stress. Cortisol release causes insulin release resulting in increased hunger. The take home message: Relax! You can use multiple stress reduction techniques including deep breathing, meditation, visual imagery, and exercise. Take your pick.

We all know that weight management is an issue in America as obesity rates continue to rise. An undeniably effective approach to weight loss is exercise. The goals is a calorie expenditure > calorie intake. Remember that exercise should be a hobby and not a chore! Find activities you enjoy and stick with them. Set realistic goals that target three areas: appearance, health and consistency. If exercise alone does not achieve your weight goals, diet, sleep and stress can also be manipulated to make your weight goals a reality.

Questions? E-mail John:


  1. Bouchez C. How Sleep Affects Your Weight. 2007.

  2. Losing Weight Is One Of The Most Popular New Year’s Resolutions. Medical News Today. 2005.

  3. F as in Fat 2009 – Trust for America’s Health. 2009.

  4. Lee I, Djoussé L, Sesso H, Wang L, Buring J. Physical activity and weight gain prevention. JAMA. Mar 2010;303(12):1173-1179.

  5. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Kaplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA JAM Aabbr. Journal of the American Medical Association 2001;256:1 195-1200.


05 2010

Holiday Health: A Holiday Eating Survival Guide

by Leah Frankel, MS, RD

Holiday FeastWith a plethora of special occasions and excuses to indulge, the holiday season can wreak havoc on your diet unless you’re prepared to tackle those festive buffets and eggnog-filled nights. Preventing holiday weight gain and maintaining your normal healthy diet is definitely possible with a little planning.  First, don’t accept the mentality that you can indulge now and start your diet and exercise regimen when New Years comes around.  You’ll be fighting an uphill battle with even more calories to burn!  Food is meant to be savored, just not in excess!  Enjoy the tips below that outline how to navigate your way through the holiday season as well as some ideas for healthy variations of your traditional holiday favorites!

Tips for Holiday Health:

Have a plan before attending a holiday gathering. Adjust your diet and workout schedule, if necessary, the day of the party to compensate for the food you’ll be eating later that night. If you know you’ll be at a party tonight, skip the desserts at work during the day.

RunningMaintain your exercise schedule, or modify it to fit your situation. If you’re not going to be home for your usual workout, bring running shoes with you to enjoy exercise outside with family and friends.  A game of catch or tennis before dinner is a great way to spend time with family and stay fit.  You can also research gyms in the area where you’ll be staying and make exercising a family activity.  Remember that working out can help reduce stress, regulate your appetite and maintain your weight.

Eat a snack before hitting up the holiday party. If you go to a party or holiday dinner hungry you’ll be more likely to overeat and will have more difficulty resisting the tempting high calorie and high fat treats. A good pre-party snack should include a glass of water, some protein and high fiber carbs, such as an apple with peanut butter or whole grain crackers and cheese.

Use small plates. This is a good tip for all year, not just during the holidays. Studies show that people who switch to smaller plates or bowls consume fewer calories. Grab an appetizer plate instead of a large entrée plate to prevent overindulging.

FeastAssess all the food options and choose which foods you really want to eat. While you might really love chocolate chip cookies, remember that your Aunt Molly’s pecan pie only comes once a year.  Think through which foods you really want and choose a combination of small portion of your “treats” mixed with healthy foods like fresh fruits or vegetables.

Stay away from the buffet table. Once you’ve filled your plate, moving away from the table can prevent overeating. Remember that the holidays are about spending time with family and friends, so enjoy their company instead of eyeing the food table. If your hands feel empty once you’ve finished your food, keep them busy with a low- or no-calorie beverage.

Bring your own dish so you can guarantee a healthy option. Most hosts would love help with the cooking.  Ask them what they’re preparing and suggest some dishes you could prepare. Check out the suggestions below for some healthy culinary ideas.

EggnogBeware of calorie-laden drinks. Alcoholic drinks can pack more calories than a burger and fries at McDonald’s and drinks during the holidays are no exception (see our previous article, Know thy Liquor: What’s in a Drink).  Eggnog, hot cocoa and cider all contain excess calories.  Try to stick with your low-calorie choices such as wine, light beer or mixed drinks made with low- or no-calorie mixers. Also, try to drink a glass of water between alcoholic beverages.  It helps prevent hangovers (see The Hangover: Make it go Away!) and keeps your waistline the way you want it.

Pay attention to what you’re eating. Food is meant to be enjoyed so slow down and savor the foods you’ve chosen. Take small bites and chew your food thoroughly to prevent overeating and to truly appreciate your food. Your host has spent hours slaving away in the kitchen.  Why not slow down and savor all that hard work?  Also, beware of mindless eating which can happen if you settle down on the couch with your hand in the chip bowl.

Beware of snacking. Mindless snacking while cooking or socializing can add hundreds of excess calories that you don’t ever realize you’re consuming. Eat a nutritious snack or chew gum while cooking to prevent yourself from snacking mindlessly.

If you’re full don’t be afraid to say no to seconds.  While family members or friends may push you to eat more, remember that it’s your decision what you eat.  You’ll feel better afterwards if you say no to seconds when you’re full, than if you keep eating.Fitness Class

If you overeat don’t beat yourself up. Just because you ate too much at one meal doesn’t mean you should give up your health-conscious ways and stop eating healthily. Make sure your next meal is lighter and then return to your usual eating pattern. Remember that one meal alone won’t make you gain weight.  It takes 3500 excess calories to gain a pound.  Lastly, a nice long workout later that day or the next can help burn those excess calories you consumed during your holiday splurge.

Begin a tradition of hitting the mall on Black Friday, going on a family bike ride, or playing a game of touch football the morning after a holiday meal. This will force you to get in some exercise the next day while enjoying time with family.

Don’t turn the day after a holiday meal into round 2 of holiday eating. With your fridge filled with leftovers it can be difficult not to indulge in these foods the next day. Try supplementing the leftovers with healthier items, like fruits and vegetables, so that you can enjoy your favorites again without the extra calories.

Transforming Holiday Classics into Healthy Well-Balanced Dishes:

Sweet Potato CasseroleInstead of Mashed Potatoes: Choose mashed sweet potatoes which contain more nutrients including fiber, vitamin C, potassium, and vitamin A. If you want to make traditional mashed potatoes, consider replacing milk and butter with broth. Adding cauliflower to mashed potatoes provides extra fiber and nutrients and will be equally filling with fewer calories.

Instead of Dark Meat Turkey with Gravy: Choose white meat and skip the skin. Turkey is a great source of lean protein if you choose the right parts. If you want to drizzle a small amount of gravy on top, try refrigerating the gravy beforehand and skimming the fat off the top to cut calories and fat in your savory topping.

Whole Wheat StuffingInstead of Corn Bread Stuffing: Try making your stuffing with whole wheat bread and add healthy additions like nuts, fruits, and vegetables. The added fiber in the bread, fruit, and vegetables will keep you full with fewer calories and less fat.

Instead of Pumpkin Pie: Serve pumpkin pie filling with cool whip.  Cutting out the crust will save calories and fat, and pumpkin is a good source in beta-carotene. You can also substitute low fat evaporated milk or light cream into your pumpkin pie recipe.

Instead of Green Bean Casserole: Modify the recipe by choosing a low fat cream of mushroom soup or using light butter. You could also serve green beans as a cold salad with nuts, onions and light Italian dressing.  Green beans are a great source of many nutrients including vitamin C, vitamin K, vitamin A and potassium and can be an excellent healthy addition to a holiday feast if prepared correctly.

Instead of Cranberry Sauce: Cranberry sauce from a can is very high in sugar and not nearly as nutritious as whole fresh cranberries. Cranberries are an excellent source of vitamin C and cooking cranberry dishes from scratch is a healthier way to enjoy the fruit. Trying cooking your own cranberry sauce, adding dried cranberries to a salad, or baking cranberry muffins.


12 2009

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