By Any Means Necessary, Part 2

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About a year ago, I wrote about the reasons we buy food pouches for Riley. He’s six and a half, and we’re still using them, because my thinking is I’m going to get those fruits and veggies into him by any means necessary. And the battle continues.

Some evenings we have a battle royal over eating vegetables. Riley would rather eat pasta and nothing else almost every night. While he will eat pouches with just about any vegetable in it but broccoli, he won’t eat the same vegetables on his plate. The other night it was green beans. He’s eaten them before, but he’s demonstrating a rebellious streak lately. We’re not insisting he clean his plate, just eat a few green beans. Paula will wait him out; she’ll sit at the table and read a book on her Kindle until he’s done eating them.

Me? Not so much. I decided we will enhance the flavor of the green beans. Hot sauce—which I knew wouldn’t make it onto his plate. Cinnamon sugar. Whip cream. Paula thought of a savory flavor and added a sandwich sprinkle blend. The winner? Close between the cinnamon sugar and the whipped cream with ketchup, which doesn’t taste nearly as bad as you might think. Even the sandwich sprinkles got a thumbs up. All the green beans were gone in short order.

I know that’s not a traditional approach to getting kids to eat vegetables. And yet, people who would never touch an onion will eat a deep-fried one with fat imploded into it and a creamy sauce to dip it into; compared to that, I think a dusting of cinnamon sugar is just fine. My philosophy is: by any means necessary. The benefit of the vegetable outweighs the little bit of sugar or whipped cream in my opinion, especially for a kid in the 4th percentile of BMI for his age.

It’s a long holiday weekend so we’ll be back with the Memo in a week. Be safe if you’re traveling. If you’re going to spend the weekend with picnics and such, don’t forgot about eating those vegetables—by any means necessary.

What are you prepared to do today?

        Dr. Chet

Why Errors in Food Intake Matter

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What is the big deal about errors in food intake in studies most people never hear about? It’s a problem because decisions on gaps in the diet, impact of nutrient intake, and the potential benefit or hazards of food and supplement intake are based on studies that use these techniques. I’ll give you a couple of examples, but let me start with something that has become common knowledge.

Obese subjects underreport food intake at a greater rate than subjects who are normal weight. Female obese subjects are more likely to underreport food intake than male obese subjects. Don’t assume they intend to deceive; I think many people are simply unaware of how much they eat, especially when they graze or sample food as they eat, pick at the kids’ leftovers, or eat little snacks at work.

Diet Change and Heart Disease

The Women’s Health Initiative is one of the largest studies done on examining the role of diet and heart disease in women. Results published in 2006 demonstrated that after a number of years on a low-fat diet, there were no differences in the rates of different forms of heart disease. What struck me at the time was that the goal was to reduce fat intake to 20% of total caloric intake, but using a form of dietary recall, the experimental subjects were able to lower their percentage fat intake from 35% down to 28%. That’s still much higher than the goal of 20%. If we were to estimate an average error in food intake based on dietary recall, it could very well be that these subjects actually had well over 30% fat intake due to under-reporting.

Why is that a big deal? Two reasons. First, they were not on a diet that was designed to reduce fat intake enough to impact cardiovascular disease. Second, in a review just published in 2021, a scientist is calling for the repudiation of the results of that study claiming that a low-fat diet does not work to reduce heart disease (or type 2 diabetes either). Based on the results of that WHI trial, we don’t know that for sure because of the potential for under-reporting food intake including fat, as well as the inability of the subjects to meet the goal of 20% fat in the diet. One error begets more errors. In this case, it’s being used to suggest that low-fat diets are not the way to reduce heart disease, and I’m just not ready to make that leap.

Nutrient Studies

There are a number of studies that have used FFQ as the method of assessing food intake in individual nutrient trials. Aside from the “How many portions of beef did you eat per week over the past year” type of questions, the total number of questions ranges from 138 to 164 on most FFQs. The degree with which people will report that accurately is suspect to begin with. Add to that the potential under-reporting of food intake when you’re trying to assess iron, calcium, folic acid, and other nutrients in the diet can provide significant errors in determining how much nutrients people are getting. As the saying goes: garbage in, garbage out.

One more thing. The FFQ were validated by three-day diet histories, which are also prone to significant error.

The Bottom Line

Research that examines dietary intake may be prone to errors. It doesn’t make it worthless; it just means we have to interpret the results carefully. This is especially true when determining whether any specific diet can help reduce disease or prove whether a nutrient is beneficial or not.

What we can do is speak in global terms. Eat better. Eat less. Move more. Do that first and worry about the details later. Even with the potential errors in assessing food intake, there’s no question about that.

So here’s what I challenge you to do: for the next month, make a strong effort to eat better than you do right now. I think if you take this first step, you’ll feel the difference.

What are you prepared to do today?

        Dr. Chet

References:
1. Front. Endocrinol. 2019. 10:850. doi: 10.3389/fendo.2019.00850
2. JAMA. 2006;295:655-666.
3. Open Heart 2021;8:e001680. doi:10.1136/openhrt-2021-001680

How to Assess Food Intake

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If you’ve been reading the Memo for any length of time, you know that I’m not fond of the methods used for determining food intake in free-living individuals, especially the Food Frequency Questionnaire. When looking at the validity of the doubly-labelled water technique for last week’s Memos on metabolism, I happened upon a review article that examined several methods of collecting food intake in nutritional studies; they also assessed metabolism to see if the calories used equaled the calories taken in.

Researchers from Australia reviewed the published research and selected 59 articles that examined which method of assessing food intake was the most valid as verified by metabolic data. Besides the FFQ, with and without food models, they examined food diaries, food histories, and 24-hour diet recall with and without the use of technology.

They found that with a couple of exceptions, every method of collecting food intake underreported energy intake by 1.5% to 47%. The researchers concluded that while every method had high variability, 24-hour diet recalls were the most accurate with a variability of 8% to 30%. The highest degree of underreporting? The FFQ which had one study top 47%—that’s right, almost half of the food eaten wasn’t reported!

It makes sense to me; Paula and I rarely have pizza or bacon, but do we remember how many times we’ve had those in the last year? Of course not. Here’s a harder recall issue: Paula has a bite or two of chocolate almost every day, but rarely eats a whole chocolate bar. How would she report that accurately? And I often eat Riley’s leftovers—how do I report those two chicken nuggets or one-eighth ear of corn? In the real world, it’s hard enough to accurately record what you’re eating right now, let alone a month or a year ago.

Besides my personal satisfaction of being correct, the real question is: “What does this mean in the real world?” I’ll cover that on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Front. Endocrinol. 2019. 10:850. doi: 10.3389/fendo.2019.00850

Metabolism Across Our Lifespan

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It might not surprise you to learn that adjusted for body weight, infants under one year have the highest metabolism of all age groups. It makes sense; they’re growing so fast at that point. From there it’s all downhill, metabolically speaking, at a rate of about 3% per year until about 20 when metabolism stabilizes. The lowest metabolism? We reach that sometime after 60. If we live to 90, researchers found that caloric needs declined by 26%.

That’s the “what.” More important is the “why”; researchers had some but not all of the answers.

Metabolism and Life Events

Researchers examined metabolism during adolescence. The expectation is that metabolism would increase during this period of growth, but they found that it didn’t change significantly.

There was also no significant increase in metabolism during pregnancy, at least, more than what was expected. In Healthy Babies, I talk about the caloric needs of pregnant women by trimester. Those caloric needs prove to be spot on. Sorry, but there’s no need to eat for two.

One more point: carrying extra fat results in an increase in metabolism. That makes sense because every extra pound means the muscles work harder in moving the weight, the heart pumps harder because there are more blood vessels, and so on. But when extra body fat is accounted for, there’s no difference in metabolism on a pound-for-pound basis.

Why Does Metabolism Decline?

Why does our metabolism start to decline faster at around 50 or 60? One factor is the loss of muscle mass; that’s why it’s so important to increase muscle mass and hang on to it as we age.

This study measured caloric use over 24 hours, so the age-related decline in physical activity may play a role in why metabolism declines: most of us are much less active over 50.

But one of the many researchers involved in the projects stated it this way: the reason for the decline in metabolism is that “cells are slowing down.” He went on to say that these changes occur in ways we don’t yet understand. Do the cells get tired? Have a harder time with cell division? Or are there some as yet unknown signal chemicals that are controlling the aging mechanisms that impact metabolism? We don’t know yet.

The Bottom Line

One study is not enough to find out all the answers to what happens to metabolism as we age, but it does provide some insights in where we can look to find the answers. One area that might be interesting is the mitochondria, the powerhouse of the cell; what happens there impacts our ability to make energy and that can definitely impact metabolism. We’ll keep an eye on this research as time goes on.

What are you prepared to do today?

        Dr. Chet

Reference: Science 13 Aug 2021. 373 (6556):808-812. DOI: 10.1126/science.abe5017

What Happens to Our Metabolism?

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Have you ever said or heard someone else say, “I could eat whatever I wanted when I was young and I never gained weight!” What usually follows is something like, “Now I seem to gain weight just by thinking about a donut!”—the type of food may vary depending on the individual. Kids seem to eat anything they want and stay rail thin. Riley grew five inches between his five-year and six-year physicals but gained only three pounds. The logical question is what happens to metabolism as we get older?

Researchers in the Pennington Biomedical Laboratory attempted to find out together with researchers from around the world. As a combined effort, they recruited over 6,000 subjects between the ages of six months and 95 years old. The reason they needed so many research facilities is that the technique used to assess metabolism is labor intensive; it would have taken a decade for a single facility to do it. They didn’t test only resting metabolism. They were able to test the metabolism of subjects over several days under a variety of everyday conditions—in other words, people just living their lives.

There was no surprise from the aging perspective: metabolism declines as we get older. But when metabolism peaks and when it declines the most was surprising. I’ll cover that on Saturday as well as what we might be able to do to deal with it.

Tomorrow night is the Insider conference call. If you have questions you need answered about nutrition, supplements or exercise, this is the forum to get the most complete answers. If you’re not an Insider, join before 8 p.m. Eastern to participate.

What are you prepared to do today?

        Dr. Chet

Reference: Science 13 Aug 2021. 373 (6556):808-812. DOI: 10.1126/science.abe5017

Rehabilitation Becomes Prehabilitation

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After giving some thought to the discussion I had with our physical therapist, I’ve scheduled my knee-replacement surgery. I’ve already been doing everything he recommended to rehab the knee: avoiding any high-impact exercise, using an exercise bike, stretching. His verdict is that none of those will help the problem. The compounding issue is that my lower right leg is roughly 14 degrees off center; if I wait much longer, it becomes more difficult to make the leg straight with knee replacement.

It helps that the surgeon my PT recommended happens to be the surgeon I’ve already been seeing. While the decision is made, the work is now moving to another level. Having been an advocate of surgical prehabilitation for a few years, I get to test it firsthand; I’ve already seen how much it helped Paula before her foot surgery and hip replacement years ago.

I have three prehab goals: to increase my fitness level, to increase the strength in my right leg, and to reduce my body weight a reasonable amount before the surgery. Concurrently, I want to train myself to endure more pain, because it will surely be needed after the surgery.

Prehabilitation Goals

Fitness

Due to localized muscular fatigue, I haven’t been able to push myself as hard as I want during high-intensity interval training (HIIT). As a result, I don’t feel I’m in the physical condition I want to be in, surgery or not. It’s time to double down. That requires cycling adaptive training and HIIT with longer intervals.

What do I mean by cycling adaptive training? It’s spending more time at a higher resistance—higher than normal but not as high as during intervals. The energy systems have to be trained to adapt to higher lactate levels. Fortunately, I’ve been doing that a little bit anyway. Now I’m on a mission.

Strength

Part of the problem is the muscle mass I’ve lost. My right thigh is just over an inch smaller than the left. I know I’ve been compensating because of the perceived muscle weakness in my right leg, and I’ve been limping more than I should.

I’m increasing my effort in leg-strengthening exercises. Nothing fancy, just squats, leg extensions, and leg curls. I’m using as much weight as possible and focusing on overcoming the natural inhibition arthritis pain causes. I’ve already noticed a difference in just a couple of days.

Body Fat

You’ve heard me complain about the fat we all gain due to aging. I can’t lose all of it, but I’m going to bump up the effort a little. Less weight going into surgery and rehab means less force necessary to overcome gravity later.

The Bottom Line

This is not the outcome I wanted, and I still think that the ideas around knee replacement could use some major innovation. However, we play the hand we’re dealt when we’re dealt it, not five years from now. I have things to do, and being mobile is important to those objectives. I’ll provide updates as time goes on as well as provide details on the prehabilitation program.

What are you prepared to do today?

        Dr. Chet

Overcoming Discomfort

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Last month, I did 70 push-ups on my 70th birthday. They were not full push-ups; they went about halfway. It took a year to be able to overcome shoulder weakness and discomfort because of torn bicep muscles in both arms. But by doing push-ups every day, I gradually pushed out the number every few weeks, beginning with 10 and culminating with 70. Most importantly, I don’t have any pain nor discomfort when I do them now.

I attempted to do full push-ups this past Sunday. I was able to do four with the shoulder discomfort starting on the fifth one. But I know the process and I know over time, by gaining strength in the other muscles and with a consistent effort, I will do 70 full push-ups before this year is out.

Now, I’m turning attention to my right knee that’s bone on bone. I saw my physical therapist yesterday to get his direction in strengthening my knee. There’s a lot of work ahead of me, but I’m determined to make my knee function better than it currently does—15 minutes at a time.

While all discomfort is not the direct result of soft tissue problems, many are. The only thing you can do is to get the best direction from physical therapists and other health professionals and then get to work. It will take time and you must be consistent. It may get worse before it gets better.

But stop and think: what if you had 50% less discomfort or 30% more range of motion or 60% more strength? Would it be worth the effort? Only you can decide, but from nothing you get nothing. What can you get from 15 minutes per day?

What are you prepared to do today?

        Dr. Chet

What It’s Like to Have a Colonoscopy

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A colonoscopy is a procedure designed to examine your colon, and for that to happen effectively, the colon must be clear of all food and waste material. Based on my personal experience as well as Paula’s, the preparation for the colonoscopy is infinitely worse than the actual colonoscopy. There are several medical websites that will give you details of the procedure complete with diagrams and video. That’s not my purpose in this Memo, so there will be none of that sh*t here (sorry, I couldn’t resist).

The Colonoscopy Preparation

Preparing for a colonoscopy requires that you consume no solid food for 24 to 36 hours before the procedure. What you consume are laxatives and fluids designed to completely empty your colon. The reason is simple: if there’s any waste material in the colon, the physician won’t be able to see the lining of this organ and thereby will be unable to examine its health.

The best way to describe the prep is to take the worst case of diarrhea you’ve had and multiply it times three. You won’t necessarily have the cramping that goes along with a bacterial or viral infection that causes diarrhea, but soon after you take the laxatives, you will have to visit the bathroom again and again and again—and then again. I’m going to predict that you won’t always make it in time, so be sure you don’t plan to be anywhere but at home close to the bathroom.

But here’s the upside: you can use it as a legitimate colon cleanse because that’s exactly what it is. If you want to reset your digestive system by emptying it completely, a colonoscopy will certainly do that.

The Colonoscopy Procedure

The medications they use today during the colonoscopy are far different from what they used to be. I fell asleep in about two seconds and remember nothing; Paula was semi-awake throughout so she remembers a little. The point of the procedure is to visually inspect the entire length of the colon for abnormalities. The equipment is a long tube with a camera and a secondary tube to add air to the colon to make it easier to inspect. The two most common concerns are polyps and diverticula.

Our Results

My colonoscopy was completely uneventful, but Paula had two columnar polyps that were completely removed to be tested. The lab technologist found no indication of abnormal cells, so she’s in the clear; there are many types of benign polyps, and hers seem to be the most common. What does it mean? It means she’s fine for now but has to do the colonoscopy (and its prep) all over again in five years instead of ten.

The Bottom Line

If you’re serious about taking charge of your health, you have to know its status. A colonoscopy is a part of that process as we get older or if we have genetic tendencies toward colon cancer. I understand the personal nature of the procedure. Really, no one wants to see a 15-foot hose and think, “You’re going to put that where?” But it’s another point of taking charge and aging with a vengeance.

If it’s time for you to get it done, don’t delay any further; call your primary care provider and get a referral. Ignorance is not bliss, and it has no place in Aging with a Vengeance.

What are you prepared to do today?

        Dr. Chet

Protecting Your Colon Health

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I’m sure you’ve heard the Benjamin Franklin quote “An ounce of prevention is worth a pound of cure.” That axiom is true about many things from fire prevention, as Franklin intended, to our cars and lawn mower. The same is true when it comes to our bodies. Paula just had a colonoscopy, so I thought it appropriate to talk about preventive colon health.

To set the stage, experts estimate a colon cancer growth rate of 2% to 3% per year globally. Early stage detection increases the survival rate, which is close to 100% at Stage 0 and goes below 5% at Stage IV.

One of the primary risk factors for colon problems such as colon cancer and diverticulitis is age. Therefore beginning about the age of 50, a baseline colonoscopy is recommended. Depending on the results, it’s repeated every ten years if your colon is clear or more often if growths called polyps are found.

In the future, we’ll also have our microbiome health examined as well. In a recently published study, researchers examined the microbiome of centenarians of Asian descent. There appears to be a similar pattern of microbes between people who live to 100 and longer in that culture. There’s a lot of research to go to establish both patterns and testing procedures. For now, we have to stick with what we know.

What’s a colonoscopy like? How did Paula fare? What can we do to improve our colon health? I’ll talk about all that in the next Memo.

What are you prepared to do today?

        Dr. Chet

Reference: Nature. 2021. https://doi.org/10.1038/s41586-021-03832-5.

Addressing the Systems of Health and Disease

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A systems approach to dealing with diseases and conditions is not what we currently do: if you have pain, you want to relieve the pain. That approach may fix the symptom, but it also may not fix the failure of a complex system that caused the problem. If you’ve broken a bone or had a torn ligament surgically repaired, that was not a system failure, but the approach to get things back to normal would be the same. Multiple systems would be involved, not just pain control.

To illustrate the point, I’m going to talk about one of the most complicated conditions: carrying too much body fat. It affects 70% of the population of the U.S. and is a growing problem around the world. My advice for dealing with it goes like this: Eat less. Eat better. Move more. Those recommendations really don’t change, but to permanently lose the weight and keep it off, the number of systems involved is staggering.

A Systems Overview of Obesity

Here are some of the questions yet to be answered about organs and systems that are involved in weight reduction:

  • What will happen to fat cells? The fat cells manufacture hormones that can impact appetite and hunger. At this point, there’s no research to suggest they’re ever reabsorbed.
  • The pancreas produces digestive enzymes and insulin. How will less food or different foods along with more exercise impact their involvement in digestion and metabolism?
  • Our taste buds have developed over the years. Will they change to reduce the taste and feel of sugar, fat, salt, and umami we may crave?
  • Can the impact of insulin on the liver change? Your liver develops a process to convert carbohydrate to fat and store it. Will that be reversed?
  • Will the adrenal gland respond to the decrease in fat intake and cholesterol production to reduce the production of cortisol and lower inflammation?
  • What happens to the microbiome in the long term? Does it adapt? Does it stimulate hunger or decrease it?

I could go on and on, but I think you get the point. It’s complicated to deal with complex systems. We don’t have the answers yet because we haven’t been asking the right questions.

The Impact of Aging on Complex Systems

We know as people age, we lose muscle mass, gain body fat, and lose bone density among many other changes. What we don’t know much about is the specific changes in every type of cell, organ, or system. If we don’t have that, we may not be able to address the correct cog in the system. That doesn’t mean we shouldn’t try; we can take what we currently know about how our bodies change over a lifetime and use that as a starting point. The earlier in life the better, but we still have to deal with individuals and the bodies they have right now.

We live a lot longer than we did 100 years ago. It’s time we began making those years better in every way rather than simply managing pain and other infirmities.

The Bottom Line

This challenge lies before us: Find a way to manage complex systems in order to not just survive but thrive throughout our entire lives. That’s where I’m headed in developing Aging with a Vengeance. We have to deal with the changes from aging that contribute to where we are today, regardless of age. Along the way, we’ll find out the optimal age for preventing some of those issues or at least slowing them down. I’m pumped for this journey to be the best version of ourselves, regardless of our current age or physical state. We just have to keep our heads in the game.

What are you prepared to do today?

        Dr. Chet