# Blood Pressure

What Do The Numbers Mean?

Blood pressure is expressed as a fraction, as in 120/80. What do those two numbers represent? The top number is called “systolic”. It represents the force of contraction of the heart sending a pulse wave down the artery. The bottom number (diastolic) measures resistance of the artery to compression, either due to the amount of blood in the artery or the stiffness of the artery wall.

When I take your blood pressure using a stethoscope, I inflate the cuff on your arm until the blood vessel I am listening to is compressed and no blood is flowing through that artery. Then, I slowly let off the pressure until I first hear the sound of your pulse. I am watching the dial on the cuff and make mental note of the number (in millimeters of Mercury pressure) when I can first hear that pulse. This represents the force that your heart is pushing blood through your artery. It is pushing hard enough to get through the compressive force I am applying using the cuff.

I continue listening as I let air out of the cuff until I can no longer hear your pulse. This is the pressure at which compression from the cuff is equal or less than the stiffness of the artery. In other words, I am no longer compressing the artery so the pulse wave passes without resistance or noise.

Most offices (and of course home units) measure blood pressure without a stethoscope. The machine listens and records the numbers. Either way of measuring works fine. I just explained it (above) using a stethoscope because the process and it’s meaning is easier to understand that way. The first number (systolic) is the force of contraction of the heart. The second number (diastolic) is the amount of compression that no longer compresses the artery.

What Is Normal?

Most people know that a normal blood pressure is 120/80 and that healthy women often have a blood pressure ten points lower than men, i.e., 100/70. At one time, it was believed that blood pressure rises with age, but that the threshold for hypertension was 140/90 for people under age 65 and 150/90 for those 65 and older. The guidelines changed in 2017 to much stricter (lower) pressures.

These current guidelinesi are

Normal is a systolic lower than 120 and diastolic lower than 80.

Elevated is a systolic of 120 – 129 and diastolic less than 80

Stage One hypertension is a systolic of 130 – 139 and diastolic of 80 – 89

Stage Two hypertension is a systolic of 140 or higher and diastolic of 90 or higher

Hypertensive crisis is systolic higher than 180 and/or diastolic higher than 120

What changed?

The impetus for the 2017 guidelines was a study called SPRINT that included over 9,300 participants who were at high risk of cardiovascular events. (There was no group who were treated with diet, exercise and lifestyle interventions to lower their overall risk).

Participants were divided into two groups. One group was controlled with pharmaceuticals to a systolic of 130. The other to a systolic of 120. In the 130 systolic group, there were 8 deaths. In the 120 group, there were six deaths. This was reported as a 25% reduction in mortality risk. That makes it sound like 25 people out of 100 had their lives saved but it was actually only two people out of 4,550. Looked at this way, researchers needed to aggressively treat 4,550 patients to save two lives. In other words, the Number Needed to Treat (NNT) one patient is 2,275 patients. What was the cost both in dollars and side effects?

The dollar cost was estimated by the researchers as between \$28,00 and \$47,000 per “quality adjusted life year”, whatever that means. Using the lower number, it would cost (\$28,000 times 2,275 patients) \$63,700,000 to save one life. For that cost, you could hire a personal trainer and give healthy, organic food to all the participants.

As to side effects, researchers noted “higher risk of hypotension, syncope and accelerated reductions in GFR”. Hypotension is low blood pressure. Syncope is fainting. GFR or glomerular filtration rate is a measure of kidney disease. In other words, the intensive drug regimen advocated by the SPRINT study leads to fainting and a reduction in kidney function. Since the study was stopped early, there was no long-term assessment of reduced kidney function on morbidity and mortality.ii

Official Criticisms of the New Guidelines

A lot of physicians, particularly gerontologists were upset by the new guidelines. They pointed out that their elderly patients are at high risk of falling. Blood pressure rises with age to support normal perfusion (oxygen delivery) in the brain. Lowered blood pressure puts their patients at risk of falling, hitting their head and dying of a sub-dural hematoma, or falling and breaking a hip, leading to death by pneumonia.

The American College of Physicians wrote in the Annals of Internal Medicine, Are the harms, costs, and complexity of care associated with this new target justified by the presumed benefits of labeling nearly half the U.S. population as unwell and subjecting them to treatment? We think not and believe that many primary care providers and patients would agree

In the New England Journal of Medicine, Drs Bakris and Sorrentino concluded that, “The unintended consequence may be that many people, now labeled as patients with hypertension, receive pharmacologic therapy that’s unlikely to provide benefit given their low absolute risk, and they may therefore experience unnecessary adverse events.” They go onto say that while a “target of less than 130/80 mm Hg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.iv

There is also a risk that the lower blood pressure readings in the SPRINT study were artificially low because of the way they were measured. Patients in the study were measured after sitting alone in a room for five minutes. Then they were re-measured twice and the results averaged. How often has any doctor measured your blood pressure that way? Would those who measured 130 have measured 140 under normal conditions?

Like it or not, doctors will slowly conform to these new guidelines at risk of malpractice, or pressures from insurers and hospital administrators. As Dr Welch put it in a New York Times editorial, I suspect many primary-care practitioners will want to ignore this new target. They understand the downsides of the relentless expansion of medical care into the lives of more people. At the same time, I fear many will be coerced into compliance as the health care industry’s middle management translates the 130 target into a measure of physician performance. That will push doctors to meet the target using whatever means necessary — and that usually means more medications.”v

High Blood Pressure Is A Risk

Criticism of the new guidelines aside, high blood pressure is a serious risk. Cardiovascular disease is the leading cause of death worldwide. Elevated blood pressure accounts for 62% of stroke and 49% of coronary heart disease cases.vi Statistically, the risk of cardiovascular disease doubles for every 20 points of systolic increase and for every 10 points of diastolic increase (i.e., doubles at or above 140/90).vii Untreated hypertension can shorten life expectancy by 15 to 20 years due to heart attack, stroke and kidney disease. Bear in mind however, that until the SPRNT study, the increased risks have been associated with blood pressures above 140/90.

The Framingham study followed 5,200 individuals from age 28 through 62 for a period of 27.5 years. They divided participants into three groups; under 120/80 BP (normotensive), 120-139 BP (high normal) and greater than 140 BP. What researchers found was, “Significant increases in mortality were observed among hypertensives but not among participants with high-normal BP levels compared with viiinormotensives.”In other words, there was no significant increase in morbidly or mortality in the group with systolic blood pressures between 120 and 139.

I am not advocating that we ignore rising blood pressure. I am saying that we need to do everything we can to get our blood pressure to a normal range, but let’s focus first on diet, exercise and lifestyle change. Most of those recommendations can be found in https://drwells.net/cardiovascular-and-metabolic-disease/

Low blood pressure is of course a serious problem as well. Without blood, our hearts, brains and every other organ quickly dies. We need Oxygen and other nutrients to be delivered constantly. Low blood pressure reduces that delivery. The usual first symptoms of low blood pressure include feeling lightheaded, difficulty concentrating, headaches, exhaustion, feeling out of breath and fainting. At very low pressures, the heart stops.

So How Low Is Low?

110/75 Is low normal. No treatment needed.

90/60 Borderline low end of functional. I evaluate patients in this range for hypoadrenia, hypothyroidism, eating disorders or other causes of low metabolic function.

60/40 Too low. This patient could become critical. I consult with the patient’s primary care provider or send my patient to an emergency room. I had a patient below this reading only once. She literally had to hold on to the walls while walking down the hall towards my office. She told me she came for nutritional advice. I asked what she usually eats. She replied, “Instant breakfast and candy.” I asked, “What else?” She said, “No, that’s it. Just the one glass of milk each day for my instant breakfast. The rest of the day I eat candy. Her history included multiple types of cancer, pneumonia and kidney disease. She was in her early 40’s. The only nutritional advice I could give her was to, “Eat food, a wide variety of real food and lot of it.” I also recommended she get psychological support.

Systolic-Diastolic Spread (Pulse Pressure)

The common normal blood pressure of 120/80 has a 40 point difference between the systolic and diastolic pressures. The same is true of 110/70. This is normal. So what does it mean when there is a 30 point difference as in 110/80? This is called a “narrow pulse pressure”. What about a 60 point difference as in 130/70? This is called a “wide pulse pressure.” A greater than 40 point spread between systolic and diastolic, such as 140/80 where the systolic number is out of normal range is called systolic hypertension. A wide pulse pressure within the normal range is generally ignored but as you will read, it shouldn’t be.

According to Anthony Dart, a Professor of Medicine in Melbourne, Classically, a wide (high) pulse pressure is a sign of aortic valve regurgitation and a narrow (low) pulse pressure is a sign of aortic stenosis. In the absence of valvular disease, a high pulse pressure may be a sign of stiffness in the arterial walls, and is a risk factor for coronary artery disease and myocardial infarction.” x

In addition to aortic stenosis, a narrow pulse pressure may also be due to congestive heart failure, particularly if the spread is 25 points or less. I should note that a pulse pressure of 30 points is the limit of normal variation and may simply be due to deconditioning. In a sedentary but otherwise healthy individual, regular walking may be all that is needed to correct this. If the spread is 25 points or less, you should see your primary care provider or a cardiologist.

A wide pulse pressure may also indicate valve regurgitation, hyperthyroidism or severe iron deficiency anemia. Having a wide pulse pressure also increases the risk of developing atrial fibrillation. The usual risk for atrial fibrillation is 6%. That goes up to 23% for those with a wide pulse pressure.xi

A wide pulse pressure where the diastolic is lower than 65 indicates an increased risk of myocardial infarction.xii Again quoting from Dr. Dart, The fall in diastolic pressure seen with pulse pressure widening may be particularly important for coronary perfusion since this occurs predominantly during diastole. In stenotic coronary arteries the reduced diastolic pressure could be expected to lead to impaired myocardial perfusion. He goes on to say, “Reduced perfusion is likely to be more relevant with a shortened diastolic duration (i.e. fast heart rate) and this may indicate the value of choosing therapy that will limit this reduction.”What he is intimating here is that medication to reduce overall blood pressure that results in a diastolic below 65 while the pulse pressure is greater than 60 and the pulse rate is high (let’s say above 80) may put the patient at greater risk of heart attack.

As referenced in a JAMA network article, The Hypertension Detection and Follow-up Program reported that all-cause mortality increased by 11% per 10-mm Hg increment in pulse pressure but only by 8% and 5% for similar increases in systolic and diastolic blood pressures, respectively.”In other words, we should all be paying more attention to the pulse pressure spread, instead of just the systolic and diastolic numbers. From what I can tell, this message has not reached most of the medical community, let alone the public. Or, as that JAMA article went on to say, In older hypertensive patients, pulse pressure, not mean pressure is the major determinant of cardiovascular risk.”xv

To paraphrase a study entitled, “Pulse Pressure, Not Mean Pressure Determines Cardiovascular Risk”, a wide pulse pressure 10 points greater than normal increases the risk of cardiovascular events and premature death by nearly 20%xvi

According to research cited in Wikipedia, For most individuals, during aerobic exercise, the systolic pressure progressively increases while the diastolic remains about the same. In some very aerobically athletic individuals, for example distance runners, the diastolic will progressively fall as the systolic increases. This behavior facilitates a much greater increase in stroke volume and cardiac output at a lower mean arterial pressure and enables much greater aerobic capacity and physical performance. The diastolic drop reflects a much greater fall in systemic vascular resistance of the muscle arterioles in response to the exercise (a greater proportion of red versus white muscle tissue). Individuals with larger BMIs due to increased muscle mass (bodybuilders) have also been shown to have lower diastolic pressures and larger pulse pressures.”

So as we might expect, exercise conditions us to be better at exercise. Even our blood vessels adapt. According to an article in the American Hypertension Association Journal, In cross-sectional studies, aerobically trained athletes have a higher arterial compliance than sedentary individuals.” xviii The word “compliance’ in this context means that the aorta has greater elasticity. That’s a good thing. However, individuals doing strength training or other maximum exertion exercise (including high-intensity aerobics) increase the stiffness in their aorta and the arteries of their legs, widening the pulse pressure. The authors did not speculate if a wide pulse pressure in athletes might lead to increased risk of cardiovascular events, but did note that moderate aerobic exercise has multiple positive benefits without known adverse consequences. Personally, I think the risk of some stiffening of the aorta with high intensity exercise may not be significant. After all, Jack LaLanne (who among other things did 1,000 pushups in 20 minutes) lived a very full and active life up to his death from pneumonia at age 96. Other than being shot by a jealous husband at that age, I doesn’t get better than that.

Folic Acid

One of the possible causes of arterial stiffness is oxidative damage resulting from an excess of the amino acid Homocysteine. This amino acid is a byproduct of incomplete conversion of Methionine to Cysteine. That conversion is dependent on adequate Vitamin B6 and Folic acid, particularly the folic acid. The most common food source of folic acid is leafy greens. That’s why the name for folic acid or folate is from the same Latin root as “foliage.” Deficiency of these vitamins can cause homocysteinemia or an excessive level of homocysteine in the blood. Up to 40% of patients diagnosed with premature coronary artery disease, peripheral vascular disease, or recurrent venous thrombosis present with elevated levels of plasma homocysteine.xix

There are some people who are genetically unable to utilize folic acid because of an alteration of the gene that converts folic acid to methyltetrahydrofolate. These people are said to have the MTHFR genotype. This genotype is actually pretty common. According to Kaiser Permanente, “Between 10%-15% of the Caucasian population and more than 25% of the Latino population have variants in both copies of the MTHFR gene.”xx Numerous supplement companies sell methylated folate, which can bypass this genetic deficiency. We have it in a 5 mg dosage in our office.

A very interesting study found that, “Folic acid supplementation at 5 mg doses for three weeks reduced pulse pressure by 4.7 +/- 1.6 points.”The authors of that study concluded that, “Folic acid is a safe and effective supplement that targets large artery stiffness and may prevent isolated systolic hypertension.” Interestingly, treatment did not correlate with plasma folate or homocysteine levels and it worked regardless of MTHFR genotype. This suggests that folate reduced arterial stiffness by some unknown mechanism.

Before going out to buy vitamins though, make sure you are getting regular, mild exercise like walking, eating a low-salt, heart-healthy diet and are also reducing stress, losing excess weight, avoiding nicotine, caffeine, excessive alcohol and recreational drugs. These diet and lifestyle modifications will make the biggest difference.

Three Position Blood Pressure

This is a test that is rarely performed but can reveal a lot. It is particularly indicated when the patient complains of feeling lightheaded or has recently suffered falling for an unknown reason. It should also be performed in geriatric patients and others at high risk of falling including patients with vomiting, diarrhea and blood loss. The classic presenting symptom is “feeling lightheaded on arising from a sitting or lying position.”

The procedure is to take blood pressure in a supine or semi recumbent position, then sitting and finally standing. We allow you to lie on the table for 3-5 minutes before taking the first pressure reading. Then let you sit for a minute before taking the sitting reading. We ask if you are feeling dizzy or light-headed and observe you for pallor or sweating. If you have these symptoms or signs associated with sitting up or a blood pressure less than 90/60, we let you lie down and do not proceed to the standing measurement. If it is safe to proceed, we measure your blood pressure as soon as you stand up, then repeat the standing measurement three minutes later.

How To Interpret The Results

According to the Agency for Healthcare Research and Quality. “A decline of ≥20mm Hg in systolic or ≥10 mm Hg in diastolic blood pressure after 3 minutes of standing = orthostatic hypotension.
A heart rate increase of at least 30 beats per minute after 3 minutes of standing may suggest hypovolemia, independent of whether the patient meets criteria for orthostatic hypotension.
A blood pressure drop immediately after standing that resolves at 3 minutes does not indicate orthostatic hypotension. However, this finding may be useful to confirm a patient’s complaint of feeling dizzy upon standing and may lead to patient education about using caution when arising from a lying or sitting position.”
xxii

This test can also be supporting evidence in identifying hypoadrenia or poor sympathetic tone. Normally, under the influence of the sympathetic nervous system and adrenals (which are themselves an extension of the sympathetic nervous system), blood vessels and muscles constrict slightly when we rise from lying to sitting or from sitting to standing. This constriction ensures adequate blood flow to the brain. Thin people (usually female) with poor muscle tone and chronic low blood pressure are more at risk. The evidence for adrenal insufficiency in people with postural hypotension is inferred from it’s presence in people with Addison’s Disease (adrenal failure).xxiii Postural hypotension in isolation does not confirm a diagnosis of hypoadrenia.

Those over age 65 should also be evaluated for carotid artery occlusion using sonography. The combination of postural hypotension and carotid artery occlusion is a common cause of falling in the elderly. Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults.”

What Does It All Mean?

Like anything else, context is key. If you have a lot of risk factors, you may need to control your blood pressure more aggressively than someone with fewer risk factors. If your pressure is too high, the place to start is always with diet, exercise and other lifestyle choices like eliminating smoking, caffeine, alcohol and substance abuse. Medications should be a second line of defense (unless your blood pressure is critically high) but taking medication doesn’t eliminate the need to make the hard lifestyle changes. There is no substitute for good habits.

Like the other vital signs, we don’t just look at blood pressure in a vacuum. If you have a high BMI or waist to weight ratio, let’s address that. If you have low temperature and pulse, let’s address your low metabolism so you can lose weight. Low thyroid function is also implicated in elevated blood pressure because thyroid hormone is the main driver for producing Nitric Oxide in the endothelium (lining of the blood vessels). Nitric Oxide lowers blood pressure by relaxing blood vessels and increasing perfusion. Exercise also stimulates more nitric oxide production. The foundations of good health always come back to proper diet, exercise and lifestyle. We all know this but we don’t always follow what we know, instead reaching for a quick fix, whether it is a nutritional supplement or a drug. By monitoring vital signs, we can provide ourselves with accountability and knowledgable guidance on our path to recovery.

Recommendation

David Wells, D.C., L.Ac.

ii https://www.acc.org/latest-in-cardiology/clinical-trials/2015/09/23/10/40/sprint

v https://www.nytimes.com/2017/11/15/opinion/blood-pressure-guidelines.html

vi World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization. http://www.who.int/whr/2002. Accessed May 28, 2010.

vii https://www.ncbi.nlm.nih.gov/books/NBK9634/

viii https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

ix https://www.ahajournals.org/doi/full/10.1161/01.hyp.0000173433.67426.9b

x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

xii Owens P, O’Brien E. Hypotension in patients with coronary disease: can profound hypotensive events cause myocardial ischaemic events? Heart 1999;82:477-81. 10.1136/hrt.82.4.477

xiii https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

xiv Abernethy  JBorhani  NOHawkins  CM  et al.  Systolic blood pressure as an independent predictor of mortality in the hypertension detection and follow-up program.  Am J Prev Med. 1986;2123- 132

xvhttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485285

xvi Blacher J, Staessen JA, Girerd X, Gasowski J, Thijs L, Liu L, Wang JG, Fagard RH, Safar ME (Apr 2000). “Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients”. Arch Intern Med. 160 (8): 1085–9.

xvii https://en.wikipedia.org/wiki/Pulse_pressure

xviiihttps://www.ahajournals.org/doi/full/10.1161/01.hyp.33.6.1385

xix https://www.nature.com/cdd/journal/v11/n1s/full/4401451a.html

xx https://mydoctor.kaiserpermanente.org/ncal/Images/GEN_MTHFR_tcm63-938252.pdf

xxi https://pubmed.ncbi.nlm.nih.gov/16002796/

xxiihttps://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3f.html

xxiii https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/547882

xxiv https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/

# Get Out of Your Comfort Zone!

Dr. David Wells shirtless inside a glacier in Iceland, February 2019.

Since the dawn of time, humans have struggled to get enough to eat, to rest and to stay warm. Naturally, we continue on this path despite most of us being over-fed, sedentary and completely climate controlled. The point of this article is to show the upside of being a little uncomfortable. Don’t worry, I will not advocate in favor of misery. I am only suggesting a little challenge to the way we live and motivate ourselves. To that end, I suggest making friends with being a little bit hungry, a little bit sore and a little bit cold.

A Little Bit Hungry

The hungry lion runs fastest” anonymous

Intellectually, I know I will not starve to death if I don’t eat all the food on my plate, but part of me thinks I should eat it all just in case I never see food again. The self discipline of leaving some on the plate is hard but I actually feel better if I leave the table just a little bit unsatisfied. “Two bites short,” I call it. The alternative goes something like this; I order a large burrito at a restaurant. When it comes, I see that I really only need to eat half of it to be satisfied. If you think of your stomach as being about the size of your fist, it should be readily apparent that we over-stuff ourselves on a regular basis. If I am smart about it, I cut the burrito in half at that moment. If not, I soon find that I have become engrossed in conversation and eaten two thirds of the burrito before realizing that I am no longer hungry. This is because there is a lag between the time when I swallow my food and my brain gets enough nutrient to know that I have had enough. At that point, I have a third of a burrito remaining on my plate. Being a child of Depression era parents, I can’t waste it and it’s really too small to take home. What to do? Hmm? I guess I’ll just eat it. Does that sound familiar?

I once read an article in a small town newspaper in Oregon about a former cowboy who at the age of 103, rode a horse in the annual town parade. When asked to what he attributed his long and healthy life he said,” I have one rule and one rule only. I always leave the table a little bit hungry.” Damn. Why couldn’t he have said, “I always eat a little bit of chocolate,” or “I get a massage once a week,” or anything pleasant. No. He always leaves the table a little bit hungry. Despite not liking his answer, I gave the matter some thought. After all, the leading causes of death in this country are all related to our diet and lifestyle. Here is what I learned.

Hunger is an exquisitely tuned signaling system to keep our body about the same size as it was a couple of weeks ago. If I starve myself or exercise enough to lose a pound, I will be hungrier until I gain it back. On the other hand, barring interference from emotional signaling, I will stop eating if I am no longer hungry. Observing my kids and grandkids has taught me that kids stop eating when they are no longer hungry. The exception to this if the diet is too high in simple sugars and does not have sufficient nutritional value. Kids (and adults) keep eating to try to get the missing minerals, vitamins, amino acids, fatty acids, etc that they need. Empty calories are just that. They will not satisfy our hunger.

Rule Number One: Eat only high-quality, nutrient-dense foods.

What’s the practical application of this? What has worked for me and many of my patients is to eat just a little bit less than the amount I want. This is because I don’t usually know I have had enough until after I have eaten more than I need. This is one more reason to take time and savor your meal. As I said earlier, “just two bites short” is about the right amount. I tell myself that if I am still hungry in an hour, I can always have an apple or something. Usually, I am not hungry later. The trick is to keep this up for a couple of weeks. After a few weeks, my body adapts to this new normal. This is my new weight. This is my new hunger set point. Obviously, this does not produce dramatic weight loss. If you need a medically supervised fast, this is not for you. On the other hand, if you just want to lose 5 or 10 pounds – and you want it to stay off – this slow, steady physiological change really works.

When I say slow, you can expect to lose about 2 to 4 pounds per month. That may not sound like much but faster weight loss is commonly just water loss anyway. I once lost seven pounds in one day while working in the sun. In a couple of days it was back because I re-hydrated. A lot of “miracle” diets work by causing water and feces to leave. Sure the number on the scale is encouraging, but it is an illusion. Here’s the math for an average person; If you don’t eat for one day, you will lose about a half pound of fat. What about exercise? I will get to that shortly but in terms of weight loss, if you eat until you are satisfied, you will replace what you have burned with exercise. So my “two bites short” recommendation will create a calorie deficit that will enable you to burn one half to one pound of fat per week. Don’t even bother to weigh yourself more than once per week. The variables of water and fecal material make more frequent measurement irrelevant.

There are hundreds of strategies for losing weight from various forms of fasting various restricted diets. Theoretically, they all can work. Do whatever diet you like as long as it contains a variety of nutrient rich, whole foods. What won’t work (unless you are taking dangerous stimulant drugs) is losing weight without feeling hungry. Feeling hungry is the key to success. “Making friends with hungry” is what I call getting over the fear that hunger is a sign of something going wrong. It is a form of mild discomfort similar to feeling sore after exercise. Like breathing in and breathing out, hunger is the counterpoint to satiety.

This technique works best if you are close to your healthy weight. The reason is because the sensation of satiety depends in part on the production of signaling hormones called “leptins”. These leptins tell your body you have eaten enough. The more fat you have stored, the less sensitive your body becomes to leptins, making you think you are hungry when you have in fact had enough. This is why your body may keep signaling you to eat more food, despite being overweight. BAs you lose weight, you gradually become more sensitive to leptins (making you less hungry) . You can also increase your sensitivity to leptins by cold exposure. Read on.

Rule Number Two: Eat Only Enough To Satisfy Your Hunger If You Want To Remain At Your Current Weight.

Rule Number Three: If You Want To Lose Weight, End Most Meals About Two Bites Short.

A Little Bit Sore

Most people who exercise regularly know that feeling a little sore after a workout is a good thing, so I won’t belabor the point. I do want to underscore the idea that we are talking about a little bit sore. Many people begin an exercise program a little too enthusiastically, leading to being way too sore the next day, which in turn leads to quitting the exercise program. Building muscle requires stressing the muscle with exercise, eating enough and sleeping enough to rebuild the muscle. Any time you start a new program, do about a third of what you think you can do and build on that. Take your time. Growing muscles is not a quick process. When I say do a third of what you think you can do, I am talking mostly about intensity as opposed to duration or repetitions.

You can think of this principle most easily in terms of weight lifting but it applies to any activity. So for example, if you think you can lift 30 pounds 10 times, try lifting 10 pounds 10 times on your first day. Note how you feel the next day. If you are not too sore, then build up the repetitions until you can lift 10 pounds for 3 sets of 10 times each without feeling more than a little bit sore. Now increase the weight and reduce the repetitions. For instance, lift 15 pounds 10 times, rest and repeat twice more. Most serious bodybuilders do around 10 to 15 repetitions, 3 to 4 times (sets) on any given muscle. Those repetitions are usually paired with alternatively working an opposite motion for the same number of reps and sets (as in biceps and triceps or chest and back). Eventually (or if you are already in very good condition), you can lift very few times at closer to your maximum resistance. You might for instance do 3 sets of 3 to 5 reps. The point is to have a very hard time completing the last set.

Most weight lifting programs are described in terms of sets and reps. You may wonder why they don’t prescribe how much weight to lift. This is because the amount of weight varies from person to person and is based how many reps and sets you can do before the muscle is unable to do another repetition. This is called muscle failure. Strength training is one endeavor where your goal is to reach failure. You can reach failure by doing a single rep or a hundred. Strength and muscle gains are achieved either way though if you are training for a specific activity, it’s best to do that activity. Training is specific because a lot of it happens in your nervous system. In a study where the subjects trained only one bicep muscle, researchers found that while the trained side increased in strength by 35%, the untrained side increased by 20%. This proves how much of strength training is actually neural facilitation.i

Try to avoid the temptation to lift more to boost your ego or social standing. That often results in injury and at the very least, results in poor form and consequent poor results. One of the best ways to gain muscle and strength is to lift light to moderate weights very slowly. Think Tai Chi speed. Perfect form, very slowly with a light to moderate weight will give the best results and also greatly reduce the risk of injury. For more on this, see my article on Super Slow, High Intensity Training.

If you really overdo it, you may get what is called Delayed Onset Muscle Soreness or DOMS. This is a condition in which proteins have leaked out of the muscle and cause a delayed inflammatory response. DOMS is characterized by appearing two days after the exercise (as opposed to the next day) and getting progressively worse over the next few days, taking about a week to subside. This is not a case of “if a little bit is good, more must be better.” DOMS is muscle damage that does not lead to muscle growth.

If you do it right, you will feel just a little thick and sore in the muscles you worked yesterday. People who do resistance training call that feeling “pumped” because the muscle feels bigger. It actually is a little bigger because the muscle slightly inflames during the healing process. Don’t work that same area until the feeling subsides. Work another body region or function. There are a multitude of programs to rotate through the major muscle groups on a weekly basis. After you have been doing one program for a month, change it up a little. As a body builder once told me, “The best program is the one you’re not doing.”

Rule Number Four: Do Resistance Training Sufficient to Feel Just A Little Bit Sore The Following Day.

If I’m not a little sore when I wake up in the morning, I figure I’m not trying hard enough. Or as one of my patients said, “If I wake up in the morning and absolutely nothing hurts, I’m dead.” Make friends with being a little bit sore.

If you are trying to build muscle mass, you will also have to eat more, particularly more protein. The minimum recommended amount of protein per day to maintain your weight is .8 grams of protein per kilogram of body weight. You will want to double that amount to gain muscle. You also need to consume more calories. This means eating a few bites more than you need to satisfy your hunger. Again, it’s not a good idea to stuff yourself at any one meal, so you may have to eat every few hours to get enough. If you find yourself producing intestinal gas, you are eating more than you can digest. If that gas smells like rotten eggs, you are eating more protein than you can digest. In addition to protein, you need to consume enough calories to support your desired muscle mass. To be sure that you are building muscle rather than fat, measure your waistline. You will want to gain weight without increasing your waistline.

Of course it is also important to do aerobic exercise. The same principle applies. Start with walking thirty minutes. If you want to take it another step (see what I did there), add a little intensity by going uphill for part of the walk. Of course, you can also walk farther and or faster. To challenge your heart, add intervals of race-walking or sprinting, mixed with walking. Go hiking up hills. You get the idea.

If you are moving at a comfortable pace, you will be mostly burning fat for energy. That means that you can go a long time without refueling. In fact, you can run a Marathon distance on about a half pound of fat. If you have been running or going uphill, you may feel muscle soreness related to breaking down and building muscle, but feeling sore after a long walk is most likely due to dehydration, rather than the effects of exertion. Nonetheless, for 24 hours after aerobic exercise, you will be burning energy at a higher rate. You will sleep better, digest better, feel better. It’s not exactly feeling sore, but there is a “spent but energized” feeling that comes after aerobic exercise.

Just A Little Bit Cold

Our bodies respond to cold by increasing our metabolism, and increased metabolism is what we want. Increased metabolism means more energy and faster fat burning. It also means less risk of killer diseases. So why do we avoid cold? For most of human history, we had to work very hard to get enough calories to sustain life. We know that being cold costs calories, so we avoid it, despite the limitless availability of restaurants and grocery stores. We try very hard to conserve energy.

How cold are we talking about? Just a little bit. If you are shivering, you are too cold. What we want to trigger is literally called, “non-shivering thermogenesis.” When we shiver, we burn glucose for energy. When we are cold but not shivering, we burn fat. Better yet, we train our bodies to keep burning fat preferentially, as if we were doing aerobic exercise. To explain this, I have to explain how different fat cells work.

We usually think of fat cells as passive storage depots but actually, they are metabolically active. They come in two basic types, white and brown. The white ones are primarily storage depots but they do make hormone-like molecules that send signals to increase hunger, blood pressure, risk of heart disease, etc. White fat is primarily stored in the trunk around the viscera. Too much white fat is not good. Brown fat cells on the other hand are brown because they are full of energy-producing, fat-burning mitochondria. You want more brown fat cells. Here is where it gets interesting. Exposure to cold stimulates brown fat cells to burn fat faster. That’s right. Your body starts burning fat at a faster rate to raise your temperature in response to cold. Better yet, exposure to cold causes white fat cells to become “beige” fat cells! These beige fat cells have more mitochondria and burn fat more efficiently. It all makes sense if you think about it. To stay warm in a cold environment, you need to burn more fat and make more energy.

So how do we use cold to our advantage? Be just “a little bit” cold. Not enough to shiver but enough to feel uncomfortable. The winter I first learned about this, we set our thermostat at 63 degrees Fahrenheit. I continued to wear short sleeve shirts despite feeling uncomfortably cool. I did wear thick socks. If I had been sitting still for awhile and was getting cold, I would get up and move around to warm myself. After a couple of months, my basal temperature went from it’s usual 97.6 (low end of normal) to a the ideal 98.6. My energy level increased and my TSH (a measure of thyroid function) went from slightly high (indicating a sluggish thyroid) to the ideal range. Some other symptoms and signs improved as well. In short, being cold kick-started my metabolism. During the summer months, swimming is a good way to get some cold exposure. I take cool showers all year. In the winter, I mix in some warm water with the cold. The rest of the year, my shower is at whatever temperature comes out of the cold tap. I actually shower outdoors most days but that’s another story.

How much fat is burned? That depends a lot on the individual and how much exposure to cold. One study of lean, young men who exercised for 45 minutes in 68 degree water found that they ate 41% more food compared to when they exercised in 91 degree water. This suggests but does not prove that they burned 41% more calories. If you think of how hungry you get after swimming in cold water, this makes sense. If you are trying to lose weight, the hard part would be not eating as much as you want to after the swim.

I can’t give you an exact number of calories burned per time in a particular temperature range but I know I lost eight pounds in a week when I was out photographing in Yellowstone in January. Despite being dressed for cold, I was cold all week (at one point the temperature got down to 27 degrees below zero). I didn’t have the option of just eating more food, so I lost weight.

If a little cold is good, is a lot better? In a word, “No”. As I mentioned above, cold to the point of shivering does not increase brown fat conversion or produce other changes leading to increased metabolism. You may have read about people like Wim Hof who swim in ice water or meditate naked in the snow, claiming to have found the fountain of youth. I don’t think extreme cold is an unqualified good. Many of the effects of exposure to extreme cold result from increased production of cortisol, an anti-inflammatory hormone. Suppressing inflammation in general is a good thing but cortisol also suppresses immune response so you don’t produce symptoms of illness even if the illness is continuing to spread. It does not make you free of infection and there is a rebound effect. Your adrenal glands can only produce cortisol for so long. Stress also causes in increase in cortisol but no one advocates more stress. If you feel an exhilarating rush from a cold shower or dip in the ocean, you are feeling the release of noradrenaline, another stress hormone that produces a kind of high. While this is a good thing if you have enough energy, adrenaline is also a stress on the body and should be avoided if you are feeling weak or are recovering from an illness. Adrenaline consumes a lot of glucose. If you feel tired later in the day after exposure to cold, you may want to dial it down. Cold, like exercise or hunger is a stressor. We want to challenge our bodies but not to an extreme.

I prefer just being in a slightly uncomfortable cool environment. When I feel like I need to shiver, I breathe deeply and try to relax more, bringing blood to all parts of my body. I am trying to get my body to produce heat without stressing or shivering. This is my way of calibrating my response.

Despite my cautious statement above, mild cold exposure can improve immune response. This is mediated in part by noradrenaline. A study of lean young men who sat in a cold bath for an hour found increases in their immune response, including an increase in natural killer cells.ii The immune enhancement was even better if they exercised prior to cold exposure. Personally, I hike or bike early in the morning when it is still cold outside. I under-dress for the occasion (shirtless while hiking), using exercise instead of clothing to warm myself.

If exposure to cold enhances immune response, why do we “catch cold” more frequently when in cold environments? This may be due to drying of mucus membranes in the upper respiratory tract, losing the protective benefits of a mucus coat, along with a withdrawal of blood (and therefore immune cells) from mucus membranes due to cold. I wear a buff or other facial covering when exercising in cold air. I do the same or put a little lubricant in my nostrils when flying because airplane cabin air is extremely dry.

One of the great things about cold exposure is that it can help your body repair telomeres. Those are the ends of your DNA that fray and degrade a little every time cells divide. The slow degradation of telomeres is how we age. Eventually, cells can’t divide properly and cells die. If enough critical cells die, so do we. Hunger, particularly fasting, also stimulates telomeres to repair.

Rule Number Five: Allow Yourself To Be Just A Little Bit Cold At Least Part Of The Time.

Conclusion

I am advocating living a richer sensory experience. As implied by the old saying “Hunger makes the best sauce”, we enjoy our food more when we are hungry. Feeling fully spent after exercise is a lovely mix of peaceful and vibrant. Diving into cool water feels exhilarating. Feeling the sun warm your skin afterwards is also delightful.

There is an emotional spinoff as well. We have greater confidence when we are not worried about being hungry, cold or facing the challenge of exercise. When I travel overseas on photography trips, people who know I am particular about what I eat ask, “What if you can’t find anything there to eat?” My reply is, “I’ll be hungry.” I know I will be uncomfortable but I won’t die. I have made friends with hunger. I do not fear it. There is a lot of freedom in that.

This embrace of life’s challenges and discomforts may even translate into more willingness to take social or emotional risks. Speaking up for what you want, even when it is uncomfortable may lead to actually getting what you want. At the very least, you will feel better about standing up for yourself. Telling truth to power isn’t comfortable, but that’s how the world gets better. As Chicago Tribune columnist Mary Schmich said, “Do one thing every day that scares you.”iii What I am saying is that courage to face some discomforts in life may lead to courage in other areas as well.

iNeural Factors vs. Hypertrophy in Time Course of Muscle Strength Gain,’ Am. J. Phys. Med. Rehabil., vol. 58, pp. 115-130, 1979

iihttps://journals.physiology.org/doi/full/10.1152/jappl.1999.87.2.699

iii1997 June 1, Chicago Tribune, “Advice, Like Youth, Probably Just Wasted on the Young” by Mary Schmich, Page 4C, Chicago, Illinois. (ProQuest

# Ice or Heat? Rest or Move?

Some of the most common questions we hear after an injury are, “Should I use ice or heat? Movement or rest?”. While all rules have variations to account for individual circumstances, more often than not the answer will be ice and movement. Let’s break that down.

Immediately after an injury, there is inflammation. Like the name suggests, this is a hot condition and is helped by using ice. The hallmarks of inflammation are heat, swelling and tenderness to the touch. Ice helps all of that.  Normally, we recommend using ice 2 -3 times per day for the first few days after an injury. The upper limit of frequency for using ice is ten minutes per hour. Continuous ice can cause frostbite. Another risk for frostbite occurs with using ice directly on the skin. Normally, a cold pack is separated from the skin by a layer of cloth. If your ice pack stings to the touch, use a thicker piece of cloth. Your ice pack can be kept in the refrigerator section, not the freezer. That way it will be soft and conform better to your injury. Most refrigerators keep food around 38 degrees. That is plenty cold!

In a severe injury, the acute inflammatory stage can last for 3 to 5 days. This is the time for ice and also the time for rest. After that, the body shifts focus to repairing the injury with less inflammation. This sub-acute stage is probably still a good time for ice but it is also the time to begin moving the injured area. The way to tell if the injured area is still inflamed is to check for tenderness to pressure. Another way to tell is that pain from inflammation is present even when you are not moving. So if your sprained knee is aching while you are lying in bed and it is tender and puffy to the touch, it is inflamed and would benefit from ice.

Movement during this time prevents the injured area from filling in with scar tissue. The most common mistake we see is people who wait until there is no pain to begin moving. This results in decreased range of motion and often, permanent disability. Early mobilization is the key to a full recovery. In the case of our hypothetical sprained knee, this means performing range of motion activity such as using a stationary bike, not activities with high forces like playing tennis or basketball. Let common sense and pain guide you as you return to full function.

After 4 to 6 weeks, you enter the chronic or remodeling phase. During this phase, emphasis should be on obtaining full range of motion and developing strength. At this point, there should be no pain at rest, no redness and no palpable swelling or tenderness. There is likely to be some pain when you attempt to stretch the muscles. This is the phase where heat is often recommended, but the best form of heat is actually exercise, not a hot pack. Why is this? Heat applied to the surface only penetrates about a half inch. Your problem is usually much deeper than that. Another reason is that heat applied externally usually only gives relief for a short time, often a half hour or less. Heat generated by muscle activity will last for 24 hours. Finally, exercise is not only warming the muscles, it is strengthening the muscles and restoring normal range of motion. As a result, we rarely recommend or use heat to help recover from an injury.

To illustrate, I’ll tell a story about one of my injuries. One Sunday evening, I fell hard onto my driveway, smashing my left palm and right knee onto the cement. After my wife helped me up and into the house, we applied ice to my knee and my left elbow. I didn’t hit the elbow but I could see it was swelling. After about a half hour, I couldn’t move my elbow at all and I realized it was fractured. I decided to go to the local hospital and get it X-rayed. Sure enough, there were signs of fracture, so the doctor put my elbow in a cast and offered pain medications (which I declined). Back at home a few hours later, I developed a burning pain and numbness running down my forearm to my little and ring fingers. I realized that I should never have let them cast me, because the cast was trapping the swelling in my elbow and crushing my ulnar nerve. Good thing I didn’t take pain meds or I would have woken up in the morning without the use of my hand.

I went back to the hospital and had them cut off the cast. The next morning, I went to a radiology lab I use and got an MRI of my elbow. The fracture was much more clearly visualized. The bone was split lengthwise at the elbow and there was a lot of swelling. I then went to an orthopedist I know and asked for his advice. He asked if it hurt, probably because I didn’t look to be in obvious distress. So he put a syringe in my elbow to draw out blood that had leaked into the space between the separated sections of bone. The syringe completely filled with blood. So put another syringe on the needle and it too filled with blood. His eyebrows raised. Then he put another and another and finally, blood stopped coming out of my elbow. It was such a relief, I told him it felt like my elbow gave birth. I asked the doctor what I could and could not do during recovery. He said I couldn’t externally rotate my forearm for six weeks, but I could begin moving it as I felt able.

I wore a sling for four weeks to prevent accidental movement. All I did the first week was wiggle my fingers and gently make a fist. I used ice, acupuncture and a little massage on the forearm to reduce inflammation and muscle spasm. I increased my range of motion during the second week. By the third week, I began doing isometric resistance exercises with my forearm and increasing my range of motion. By the fourth week, I was lifting light weights and doing deep massage in the muscles to prevent scar tissue build up. By the fifth week, I had regained full range of motion and the ability to make a strong fist. I increased the weights. By the sixth week, I was doing bicep and tricep exercises with 30 pound dumbbells. When I returned to the orthopedist, he said there were two ranges of motion I would not get back after an injury like mine. To his surprise, I could do those motions with ease.

If I had worn the cast or even the sling without doing any exercises or treatments during those six weeks, I would indeed have lost the full function of my elbow. This is one example among many of the value of early mobilization.