An 86 Year Old Ironman Inspiration!

In line with last week's post about the amazing Olympic athletes, here's a woman who inspires me to the ends of the earth - meet Madonna Buder, who holds the world record for the oldest person to ever complete an Iron Man triathlon, at the age of... 82!

Buder caught the triathlon bug a little later in life, completing her first triathlon at age 52 and her first Ironman at age 56.  She has completed over 325 triathlons, including 45 Ironman distances (an Ironman is a 3860m swim, 180km bike, followed up by a 42km marathon run).

Now 86 years old, Buder is an inspiration to athletes everywhere, and was even featured in a Nike ad that was aired during the Olympics.

Way to go!!  Thanks so much to my friend Chantelle for telling me about this amazing woman.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2016

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Olympic Games - Best Weight At All Sizes

It has been a real inspiration and thrill to watch the elite athletes of the world compete at the Rio 2016 Summer Olympic Games.  Over the last couple of weeks, we have enjoyed watching a wide range of sports, from swimming, to basketball, to gymnastics, to track & field, and so much more.

Take a moment and consider the variation in body shapes and sizes amongst this year's incredible athletes:

Each of these sports have a fierce demand for the highest level of physical ability, the nature of which is unique to each individual sport.  Some require intense upper body strength, while others are more lower body oriented; some high anaerobic capacity; others are all about endurance.

I see a similar diversity in body shape and size in the athletes in my clinical practice as an endocrinologist: marathoners, crossfitters, cyclists, swimmers, football players, and so many others.  The sad reality is that those who are of larger body size will often tell me that they feel judged and assumed to be inactive or 'lazy' based on their shape and size by people who have absolutely no idea what that person is all about.

There is no more poignant reminder than watching these incredible Olympic athletes to never judge a book by its cover.

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www.drsue.ca © 2016

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Do Electric Assist Bikes Count As Exercise?

While highly frowned upon when snuck into the Tour de France (are you kidding me?!), electric bikes can be a very useful piece of equipment to zip around town.  These are bicycles that are equipped with electrical assistance, which is activated only when the rider is actively pedalling.  You may wonder – does using these bikes still count as exercise?  A recent study tells us – yes!

The study, published in the European Journal of Applied Physiology, enrolled 20 people who led sedentary lifestyles, and evaluated several measures of health after 4 weeks of using the electrically assisted bike for at least 40 minutes, three days per week. 

They found that using the ‘pedelec’ bikes provided a moderate level of exertion, similar to walking (4.9 METs on average).  After just 4 weeks, there was an improvement in their glucose tolerance, and an increase in their power output and VO2max (a measure of maximal aerobic capacity).    Participants also found the bikes to be fun, to the point where over half of participants ended up cycling over 50% more than the required amount.

So, while using a regular bicycle would provide more exercise, a pedelec bike is a great option for people who have knee problems, struggle to get uphill on a bike, or if you want to get further in a day than you otherwise would on a regular bike.  (We used them on a trip Kyoto last year so we could make it to all the far flung temples we wanted to see – fantastic!)    Pedelecs remove the potential deterrents of cycling such as longer distances or hills, and they can be incorporated into daily life as a means of transport when the weather/climate permits (rather than having to find specific extra time in the day to exercise).  

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www.drsue.ca © 2016

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Does Exercise Improve Fatty Liver Disease?

Nonalcoholic fatty liver disease is a potential consequence of carrying excess body weight, and is essentially caused by extra fat being stored in the liver. It is the third most common cause of liver cirrhosis, and affects up to 30% of the world’s population. 

Weight loss has been clearly established as the first line treatment for NAFLD, and we know that most successful weight loss strategies focus most attention on reducing calorie intake, with exercise playing only a minor part.  However, we know that exercise can have many cardiometabolic benefits even if a person doesn’t lose weight because of it, so it would be interesting to know if exercise itself could improve NAFLD.

A study was recently published in JAMA Internal Medicine which addresses this question.  In the study, 220 participants with NAFLD were randomly assigned to moderate exercise (brisk walking for 30 mins, 5 days per week) for a year, vigorous exercise for 6 months followed by moderate exercise for 6 months, or no additional exercise for a year.

They found that moderate and vigorous exercise were equally effective to reduce fat content in the liver, and that most (but not all) of the effect was mediated by weight loss. 

So, while actual reduction in weight remains the key factor in improving fatty liver, exercise may play some role even if the exercise itself doesn’t shed a whole bunch of pounds.  And it is good news that moderate activity is just as good as intense activity, as moderate exercise regimens like walking are more likely to be adhered to in the long run.

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The Pokémon Go Revolution - What Public Policy Couldn't Do

We've all seen it: Pokémon Go users are everywhere!  Since it's launch earlier this month, we have seen people everywhere, more enraptured by their smart phones than ever before, playing the game with a joyous enthusiasm.

The engagement in Pokémon Go is paying off in physical activity.  Tracking devices such as Jawbone have seen a major increase in physical activity since the game was launched:

We have never seen any public policy or population based strategy have such an incredible effect on physical activity.  I had a patient in my office this week (who had just found a Pokémon under my examination table) tell me that the game had caused her family's 15 minute walk to turn into a 45 minute adventure where the family enjoyed extra fun time together, and a whole lot more exercise! These stories are abundant on social media.  So cool!

I felt like a massive LED light went on in my brain when I heard about this game - of course!  What a great way to motivate activity, by blending a fun smartphone game with real life exercise.  While this particular game may be a fad, I'm sure that other games are now in hot pursuit to develop the next ones.  I hope that this is the beginning of what may be one of the most successful (and hopefully sustainable) population level 'interventions' to motivate physical activity.

A note to be careful when using this or other games - there have been reports of people falling off of cliffs and standing in freeways playing the game, or playing the game in sensitive places like graveyards - do be careful and mindful when you are enjoying your Pokémon Go adventures.

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www.drsue.ca © 2016

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(In)Accuracy of Your Wrist Technology for Estimating Calorie Burn

There are many different kinds of wrist technology out there - Garmin, FitBit, and Jawbone UP just to name a few.   In response to concerns that these devices may not be accurate to measure energy burn, researchers have now conducted a study to test how accurate they are.


The study, published in JAMA Internal Medicine, examined several brands of wearable energy tracking technology, and compared them to gold standard research methods of measuring energy burn, including both a standardized day (indirect calorimetry using metabolic chamber) and fifteen free living days (doubly labeled water method).  Brands studied included the Garmin VivoFit, Jawbone UP24, and FitBit Flex.

They found that these wearable devices were overall quite inaccurate, with inaccuracies ranging as high as 590 calories per day. !  Most of the inaccuracies were underestimates of caloric needs, while some overestimated needs.

So does this mean that these devices are totally useless?  No.  They can be great motivation for keeping track of daily activity and steps taken per day (pedometer) - though there are inaccuracies here as well.  But I do see a lot of people with weight struggles feeling frustrated that they seem to be burning way more calories (according to their device) than the food they are eating, yet they are not losing weight.   Overall, the biggest benefit of these devices is probably motivation to move, and keeping us engaged in mindful eating (ie we think more about what we are eating if we are keeping track of it).

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www.drsue.ca © 2016

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New 'Real-World' Obesity Clinical Practice Guidelines

It is an unfortunate fact that despite the high prevalence of overweight and obesity in our society, most health care professionals receive little training in obesity medicine.  I am asked by colleagues just about every day: ‘How do I treat my patient who struggles with excess weight?’  Health care providers often feel lost in this arena.  

There are a number of obesity management guidelines that try to guide the care of people with obesity, but they often do not provide a consensus on a clear and concise approach to management or treatment goals.

Good news! The American Association of Clinical Endocrinologists and American College of Endocrinology have produced a new set of Clinical PracticeGuidelines for obesity that they describe as an evidence based, real-world approach, that gives health care providers practical, straightforward, and tangible algorithms for diagnosis, assessment, and management of people with excess weight.

The theme of these guidelines (which I fully agree with) is that management of obesity is not about the numbers on the scale, but about improving overall health and well being.

The approach to diagnosis and management in these guidelines are nicely packaged into a handful of algorithms and tables that you can access here.  Some of the highlights:

1.  The diagnosis of obesity is not just about the numbers on the scale.  They break down the obesity diagnosis into two components: the anthropometric component (numbers: BMI, waist circumference), and the critically important clinical component (complications of the excess weight, of which they have included a convenient checklist of things to look for and how to screen for them).

2.  There is a beautiful table that lists how much weight loss is recommended to improve any particular complication of obesity (eg 5-15% for type 2 diabetes, 5-15% or more for polycystic ovary syndrome, 7-11% or more for obstructive sleep apnea).

3.  They break down lifestyle treatment into three components: meal plan, physical activity, and behavior modification.  They review pros and cons to different types of diets and where evidence exists for improvement of parameters of health (while emphasizing that the dietary approach needs to be individualized to each patient).

4.  They review pros and cons of medications to treat obesity (note that only two of the medications reviewed are available in Canada – namely, liraglutide and orlistat), along with clinical features that may favor the use of one antiobesity medication over another.

In the spirit of focusing on treating to improve weight-associated health complications rather than focus on numbers on the scale, they suggest more intensive treatment approaches (eg medication or bariatric surgery) in situations where complications of obesity already exist.  Personally, I am inclined to favor a more proactive approach, not only looking at these treatment options to improve upon existing complications of obesity, but also to prevent these complications from developing in the first place.

Overall, these guidelines and nicely packaged tables and algorithms provide a great framework to help health care professionals with a real-world approach to obesity management.  Check it out!

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www.drsue.ca © 2016

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Just How Much (And For How Long) Does Metabolism Slow Down After Weight Loss?

Many people who struggle with excess weight find that they are able to get weight off, but keeping it off seems next to impossible.

So what exactly happens to our metabolism when we lose weight?  And are any changes in our metabolism temporary, or there for the long term?

A very elegant study was conducted that answers this question – and you may be surprised by the results.

The study enrolled people in groups of three, all three of which were of the same gender and weight: one who was weight stable at their maximum lifetime weight (ie had not had any weight loss); one who had lost at least 10% of body weight and kept it off for at least a year; and one who lost at least 10% of body weight over the most recent 5-8 weeks (using a liquid diet for 1-2 months before the study testing was performed).  The average body weight of people in the study was 98 kg (216 lb), and the age range was 19-41 years. All participants lived at the research centre for the duration of the study, and were fed only a liquid formula diet, to ensure their weights were stable for at least 2 weeks before measurements of metabolism were taken.  (a very impressive and dedicated protocol for both participants and investigators, wow!)

They found that in these study participants, the 24h calorie burn was about 450 calories lower for the people who had previously lost weight, regardless of whether that weight loss was just weeks ago, or whether it was years ago (and similar for males and females in the study).  Many full meals come in under 450 calories - I googled this recipe website to give you an idea (though I have not reviewed the recipes per se).  So this means that the person who has lost weight has to eat this much less, EVERY DAY, for years (and possibly forever) in order to maintain that body weight, compared to someone who weighs the same but has never weighed more than that.

Here's an example from that website: it's a lot of food!

While this 450 calorie drop in 24h calorie burn was partly due to a drop in energy burn at rest, the biggest drop was seen in the energy burned by activity (called non-resting energy expenditure). (Read more about all components of daily energy expenditure here). 

So does this mean that people who have lost weight simply exercise less?  No.  Actually, the literature overall suggests that it is energy burn during low-grade activity that declines (ie activities of daily living), because our muscles become more efficient at low levels of physical activity with weight loss. 

So what can you do to combat this reduction in energy burn that happens with weight loss?  Two things.

1.  Be NEAT! NEAT, or non exercise activity thermogenesis, is low grade activity of daily life.  Give up your parking pass and take public transit (which involves more physical activity than driving). If you do drive, park at the far end of the parking lot.  Stand while you talk on the phone.  Take the stairs instead of the elevator.   Read more on NEAT here!

2.  Exercise more.  Easier said than done, and not all may be able to do this because of physical limitations - but it is because of this drop in metabolism that the US Obesity Guidelines recommend more moderate physical activity to prevent weight gain (200-300 mins per week) than they do for weight loss (150 mins per week).  We have only to look at the National Control Weight Registry to see the proof – 90% of Americans who have lost 30 lbs or more, and kept it off for more than a year, exercise for at least an hour each day.

***Be sure to talk to your doctor before starting or ramping up your exercise program, and also to help you find assistance to learn about modified exercises that may work for you if you have physical limitations.***

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www.drsue.ca © 2016

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Caution FitBit HR Wearers - Don't Trust That Your Heart Rate is Accurate!

In the effort to track calorie burn and activity, I have seen many patients coming in wearing a FitBit HR.  So, I decided to get one myself to check it out.

I use a Garmin to track my heart rate during exercise, which requires a sometimes uncomfortable chest strap, so the idea of tracking my heart rate with my neat little FitBit HR wrist band was very appealing indeed.

Unfortunately, what I have found is very disappointing - for me, the FitBit is completely useless to track higher heart rates (and based on online reviews and even lawsuits in the US, I am not the only one).

When I am at rest, my FitBit HR measures my heart rate very well.   Now, watch what happens when I put the pedal to the metal on my spin bike.  Pictured below is my Garmin (white watch, left), measuring my heart rate via the chest strap; on the right is my FitBit HR.

While my actual heart rate was 167, my FitBit HR registered only 108.  

This is beyond shockingly inaccurate and actually quite dangerous - for example, if a person with a heart condition has been advised to keep their heart rate under a certain target, the FitBit HR could dramatically underestimate their actual heart rate and mislead the person to think they are under their maximum target when they are not.

When I drove my output near my max with a heart rate of 180, the FitBitHR didn't register at all, which is safer, as at least it is not misleading the wearer with a wildly incorrect heart rate:

***NOTE: Discuss with your doctor to find out what your appropriate target and/or maximum heart rate should be before embarking on an exercise program. ***

It was only after I had stopped my exercise and my heart rate came down into the 120s that the FitBitHR became accurate again:

 

For those who are wondering if the problem could be the Garmin, it's not - I checked each of these heart rates manually against my own pulse, and the Garmin was accurate (though it too can be inaccurate, for example if you are in a cold environment and/or not sweating).  I have also carried out this experiment with different activities, and yes, I have also tried moving the FitBit HR further up my wrist. The results are the same.

The reason for the inaccuracy comes from the technology used to monitor HR.  While the Garmin strap uses electrical activity from the heart measured via the chest strap, the FitBit HR use optical technology to measure heart rate.  This involves using a LED light to illuminate your capillaries (tiny blood vessels) as blood runs past.  Capillary blood flow isn't as distinctly pulsatile as the bigger blood vessels (arteries), and at higher heart rates, it may be very difficult for this technology to distinguish higher heart rates.    I have not tested any of the other wrist devices using optical technology out there, but I suspect they may be at risk of similar inaccuracies.

What I do like about my FitBit HR is the sleep tracker, and the pedometer (step counter) - though both of these features have their limitations as well.

Thus, please exercise caution in your interpretation of your FitBit HR data - your heart rate, particularly during activity, may be highly inaccurate.

***NOTE: Before starting any moderate or vigorous exercise program, be sure to speak with your doctor.***


Thanks so much to Ryan, Jacqueline, and friends for the fabulous discussion that led to this blog post.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2016

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#Active365 Goes Public!

Here's a chance to get motivated to stick with those New Year's resolutions you're trying to keep.

Lisa Taylor, a Calgary high school teacher (and, I'm proud to say, my amazing sister), launched a Twitter initiative #active365 to help her phys ed students feel inspired to engage in daily physical activity.  When they get active, they take a picture and post it on Twitter - this gets their classmates hyped about being active, stimulates some friendly competition - and Miss Taylor even gives them bonus marks towards their report card!

We are now taking #active365 outside of gym class and to the general public!  Here's your chance to get friends, family, and work colleagues involved and see who can rack up the most #active365 tweets each week, each month, and for all of 2016.  Being #active365 will mean different things to different people - it can mean walking to work or school instead of taking a bus or car; taking the stairs instead of the elevator; taking your kids for a swim in the local pool; going to the gym; ice skating; starting a new exercise class... use your imagination!  You can choose to tweet with or without a picture, but be sure to describe what you did!

So start racking up those bonus marks to your health - let's tweet up #active365 and motivate each other every day of the year!

I would love to know when my readers are Tweeting at #active365 - my Twitter handle is @drsuepedersen - please add it to your Tweet so I can cheer you on!

Important note: Be sure to discuss with your doctor before starting any new activity or exercise program. 

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2016

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