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Dr. Darrell White's Personal Blog

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Posts Tagged ‘exercise’

Musings on “Exercise as Medicine”

The “exercise is medicine” movement is kind of a confusing thing. On the one hand we in CrossFit are the uber example of how exercise as an independent variable can enhance health. On the other we have the “Big Sugar” industry funding research and promoting the notion that exercise is all that you need, that there is no effect of nutrition on health. Train your way out of any kind of diet, if you will. This has led to the toxic effect of “BS” industry money supporting academic research that is in effect little more than marketing for their products. (Visit TheRussells.CrossFit.com for details). Indeed, the soda industry in particular has come in for some very pointed criticism which includes being accused of acting like the tobacco industry ( https://blogs.scientificamerican.com/food-matters/if-soda-companies-don-t-want-to-be-treated-like-tobacco-companies-they-need-to-stop-acting-like-them/ ). Pretty harsh, but probably deserved.

Here’s the rub: exercise really is a medicine equivalent for a very large number of medical problems. Heck, if it were only to work for cardiovascular health and Type 2 diabetes it would be considered, or should be considered, a miracle treatment. Not only that, but exercise very well might work independently of diet. While exercise should not be used as an excuse to consume a poor, dangerous diet, you may actually be able to at least partly out-train a poor diet to at least some degree.

In 2009 a study was published in the International Journal of Epidemiology (http://m.ije.oxfordjournals.org/content/39/1/197.full) examining the effect of aerobic exercise on longevity (hat tip to Michael Joyner, MD at Mayo). Mind you, the study was enrolled prior to the creation of the CrossFit fitness program (completed in 2003), so the definition of fitness (aerobic health) will be viewed as incomplete by CrossFitters since it includes only aerobic fitness. In addition, what is defined as an unhealthy diet would only partially pass muster here; we would agree that simple carbohydrates (sugars) are unhealthy, but there is a plethora of more recent data that strongly suggests that red meat and healthy fat do not render a diet worrisome in the least.

A careful reading of the study revealed a couple of nuggets that should not surprise even a little bit. Eating the unhealthiest diet was associated with a 40% increase in all-cause mortality in comparison with the healthiest diet. Those who ate that worst diet and reported that they did moderate or greater levels of exercise had a 13.5% decrease in mortality. That group of bad eaters who exercised and were proven on a modified cardiac stress test to actually have greater aerobic fitness levels had a 55% decrease in mortality. Let that sink in for a minute: people who ate a shitty diet who exercised to the degree that they were fit by the testing criteria in the study were half as likely to die in any period than those who were unfit.

Boom.

Frankly, I don’t care who funded this study. Eating a shitty diet that is high in sugar increases your risk of death by 40%. Proof. Exercise that produces improved fitness, even fitness that I would view as partial or incomplete, reduces all-cause mortality in people who eat a diet high in sugar by more than half. Proof. Yeah, sure, I get that this could be used to justify or excuse eating that way, but the reality has always been that most people don’t exercise at all. Nada. Bupkis. Those who do certainly don’t achieve much in the way of any kind of fitness because they don’t exercise effectively—saying you exercise only got you a 15% decrease in mortality, after all. These results only apply if you get fitness results, and let’s face it, working hard at exercise is not the default setting in the developed world. By comparison eating better is a breeze.

Studies such as this one are mint, man. Especially to people like me, people who follow the CrossFit Rx and other programs that ask you to work hard. It’s exercise AND nutrition. Says so in the study. Sure, we can pick at this one if we want, like I did above, but my bid is that we use studies such as this one as talking points to prove that our worldview is the gold standard by which all public health initiatives ought to be compared. We can turn the cynical “exercise is medicine” campaign of “BS” on its head and use their own data against them. Eat like a CrossFitter (protein, nuts and seeds, little starch, no sugar). Exercise like a CrossFitter (functional movements performed at relatively high intensity). Seek ever-higher levels of fitness (work capacity across broad time and modal domains) like we do.

“Exercise is medicine” is just fine as long as we continue to call BS on “BS”. Health requires both exercise AND nutrition. People who are fit, especially physicians, are just the right people to tell that story.

 

“Lift”, Fitness, and the CrossFit Games

Here we are, a couple of weeks away from the CrossFit Games. Getting pretty exciting, huh? Sadly, once again, due to an illness in my extended family, I will not be able to attend the Games in person this year. Last year turned out to be our last with my Dad. This year we are spending as much time as we can with Beth’s Dad. No need to feel sorry for me, though. I think I’ve made it to 8 of the Games, each time as a guest of Greg Glassman who is a most gracious host. I’ll  surf over to the Games site and check out all the different ways to watch our annual extravaganza from home. Maybe this is the event that finally pushes me to get that new, “big ass” TV I’ve been planning to buy for…oh…3 years now.

Tuesday’s Wall Street Journal has a book review on “Lift” by Daniel Kunitz, a history of fitness. According to the review, Kunitz is very complimentary of CrossFit and Coach Glassman. Interestingly, the author of the review is a gentleman named Michael Shermer. His personal fitness journey sounds remarkably like that of so many of us in the CrossFit community. Indeed, he even references both “What is Fitness?” and the Ten Essential Characteristics of Fitness. Shermer’s discussion of fitness, sport, and training brought me back to thoughts I have had about fitness as sport.

There is a tension that exists between CrossFit, the strength and conditioning program and CrossFit, the Sport of Fitness.This tension is usually expressed in the guise of criticism of various versions of CrossFit programming. What’s very interesting is the lack of tension on this topic among the truly elite CrossFit athletes. If you look at their programming it looks like they are training to become…wait for it…really good at CrossFit.

Weird, huh?

What does that mean, anyway? Good at CrossFit? Follow Mr. Kunitz’s lead. This is a perfect time for you to both re-read the seminal article “What is Fitness” in CFJ #2 and to recommend it to anyone who is either curious or unsure as to what constitutes CrossFit, and for the sake of this musings, CrossFit programming.

CrossFit is the pursuit of a broad, inclusive general fitness where fitness is defined as work capacity across broad time and modal domains. In the vernacular, CrossFit trains and tests us to move larger loads further over a longer period of time. In order to do this Coach Glassman has identified 10 Essential characteristics of Fitness as so defined and noted in the book review, each of which needs to be equally expressed. Cardiovascular/Respiratory endurance; stamina; strength; flexibility; power; speed; coordination; agility; balance; accuracy.

Fitness as defined by CrossFit and Greg Glassman includes a precisely balanced degree of each of these 10 elements, with no one element being more of less important than any other. The CrossFit Games, and the athletes who take part, are simply an expression of the farthest right side reaches of the fitness Bell Curve. Look carefully and you will see that the events ask for equal competence in all 10 Elements; the athletes are simply better than the rest of us across the board. They get there because they do more work on all of the 10 Essential Elements.

While we here, and most folks in CrossFit Affiliate gyms, can assume agreement on the benefits of seeking Fitness as defined by CrossFit, this is not to say that either our definition of fitness or our particular way of seeking it (expressed through our CrossFit programming) is appropriate for every individual. Some people just like to run really long distances, while others are happiest when they lift really heavy stuff. Still others are interested only in the appearance of their body, and their entire fitness program is geared toward achieving a particular vision or visual. There is nothing inherently wrong with any of these desires, nor anything inherently wrong with the programming necessary to achieve these outcomes.

It just may not be CrossFit.

Because of this, the issue of programming is always on the table, especially during the Crossfit Games season that starts with the CrossFit Open and culminates in the spectacle in Carson, CA. Is there an optimal version of CrossFit programming? People take turns at supporting and denigrating the programming on the Main Page and in various CrossFit Affiliate gyms. Countless efforts are made to “improve” on the model you see on what we call “.com”. Some of these alternatives make sense, while others IMO are not really alternative CrossFit programming but alternatives to CrossFit itself. Most of these, indeed most of the conversations in general, have to do with strength and strength training. Are you (is anyone) strong enough? Will CrossFit.com or another version of CrossFit make you strong enough?

The 10 Essential Elements found in CFJ #2, “What is Fitness”, are also posted on Workout  030530 ( ironically on a day when heavy Deadlifts were prescribed). Pretty much all of the conversations noted about programming revolve around the premise that strength is somehow more important than other elements of fitness. Reasonable people can disagree on this point, but as a premise in discussing CrossFit the notion that strength is a, or the, primary element of fitness has no standing. There are 10 elements of Fitness, each no more and no less important than any other if we are seeking a broad, inclusive general physical preparedness that we call “fitness”. Full stop.

Whoa, wait a minute there pal, aren’t you the guy who co-wrote an article called “Strong Medicine” introducing a programming alternative called “CrossFit Strength Bias”? Hasn’t your home gym programming had supplemental strength training per CFSB principals since it opened? Isn’t that statement there just a bit, oh, duplicitous? Forked-typing?

Nope. Not at all. You see, if you read the original article you will see that CFSB is one way to address a DEFICIT in strength relative to the other 9 Essential Elements, not a program meant to gain strength at the EXPENSE of the other 9. As such it, like some others, is a program for the masses, a CrossFitter who perceives a hole in his/her fitness that needs to be addressed, not at all unlike a CrossFitter who does supplemental work on balance or flexibility. Additional Element-specific work, be it strength or agility or whatnot, that drives continued balance and improvement in all 10 Elements is very much CrossFit. All versions of CFSB (I am now using v3.2) are designed to be one way to address this imbalance. There are others that you may enjoy more (Wendler, Westside, Conjugate, etc.), and just like having personal goals, there is nothing inherently wrong with another supplemental strength program as long as it works without the need to sacrifice other competencies.

Whether you are looking at members of a CrossFit Box or competitors at the CrossFit Games, CrossFit is outcome based. The outcome desired is a broad-based fitness comprised of equal quantities of each of the 10 Essential Elements. What goes into the left side of the hypothetical Black Box should produce Work Capacity Across Broad Time and Modal Domains if the Black Box is a CrossFit athlete of any type. An increase in your Deadlift brought about by concentrating on strength training at the expense of cardiovascular/respiratory endurance will be accompanied by a decrease in your 5K run time and vice versa. This may be precisely in line with your goals, but it is not CrossFit as defined by Coach Glassman and expressed at its limits by Games athletes.

Programming for CrossFit should be aimed first and foremost at CrossFit outcomes. For most people, ever increasing fitness as described and defined by CrossFit results in increased health. What you find on CrossFit.com, and what you should probably expect to find as the primary goal in a CrossFit Affiliate gym, is programming that seeks to balance all 10 of the Essential Elements of Fitness, doing extra work in a lagging domain, and increasing all of them in an effort to produce increased work capacity across broad time and modal domains.

A demonstration of CrossFit programming will be available in a couple of weeks online and on ESPN. We call it the CrossFit Games. While I won’t be able to accept my invitation to visit my CrossFit friends and see it in person, rest assured that I will be glued to my (hopefully big ass) TV and watching nonetheless.

 

–bingo

Measuring Health Part 4: Fitness ‘F’

Health should be defined along the lines of individual human potential. An actionable definition would go something like “the ability to live at the limits of your fullest potential without any encumbrance now or in a foreseeable future”. Fitness as defined by Greg Glassman and CrossFit–work capacity across broad time and modal domains–should therefore be seen as “applied health”. As such, since fitness at any given time is an accurate measurement of one’s functional ability, our variable ‘F’ should have the heaviest weighting in our Health Index.

Let us begin our discussion of Fitness by reviewing and dispelling several myths and misconceptions about the interrelation between health and fitness. First, is it really necessary to review all of the date which now stares us in the face as far as the importance of exercise in health? By the same token, it should be clear to any sentient being that not only is what we eat important (although we must concede that this may differ across populations) but how much?  Simple carbohydrates, manufactured substances meant to cheaply replace real food, harmful (trans-) fats–it doesn’t matter what KIND of nutrition plan you follow, these are all BAD. As I write this I am recovering from surgery and I am not able to exercise. Does anyone believe that I will NOT gain useless weight if I maintain my pre-operative food intake? This part isn’t rocket science, folks. Coach Glassman says it as well as anyone: “Eat [protein] and vegetables, nuts and seeds, some fruit, little starch, and no sugar. Keep intake to levels that will support exercise but not body fat.”

Next up is the canard that fitness is simply being able to do something for a very long time. This view, promulgated and propagated by the likes of Outside Magazine and others, is not only insufficient but has been shown to be false as well. In the last couple of years there have been a number of very important studies showing a degradation of heart function in so-called “Ultra” athletes in any area. Decreased cardiac output and an increase in cardiac arrhythmias such as atrial fibrillation have been shown to be caused by excess endurance training. Endurance as the sole defining characteristic of fitness is as incomplete as would be strength. One need only look at the life expectancy of the strongest humans on record to see that strength in and of itself is not sufficient to produce health.

The question of what constitutes fitness is one that has been answered, at least insofar as health is concerned. It is not enough to be able to run or bike or swim long distances if you cannot also lift heavy things, including your own body. In the same vein one is not truly fit if one can deadlift or squat 3X his or her own bodyweight but cannot run a mile in under 15:00. One must have some measure of BOTH. As such the inescapable conclusion is that Greg Glassman is correct when he says that fitness equals work capacity across broad time and modal domains. You must be able to lift heavy things over a short distance when necessary, but also possess the ability to carry lighter things a longer way for a longer time as well. While I am not naive enough to expect that this will be accepted without spirited debate, when it comes to any measurements of health now available, all arguments to the contrary are not supportable. Glassman has won this battle.

As an aside, this should once and for all put to rest the myth of the “healthy obese”. What good is it to be happy, ‘W’ off the charts, with a stratospheric ‘M’ because all of your bloodwork is perfect, to go with your BP of 120/70, if your joints will cave under pressure decades sooner than they need to? You simply cannot escape the reality that health requires physical fitness.

If fitness can be described as “applied health”, it stands to reason that it will have the greatest contribution to our eventual Health Index. As such it is especially important that our chosen tests meet the criteria outlined in Part 1, that the measurement be as broadly accessible in all ways as possible. In the purest sense we would be able to measure an individual’s “work capacity”, the totality of his or her expression of fitness as measured by many tests covering different loads, distances traveled, and time. In CrossFit we talk of this as the “area under the curve” of a graph that records Power (lbs-ft. per second) on the X axis and Time (in minutes) on the Y. In a perfect world this would be part of every individuals ongoing pursuit of health, but alas, even in the CrossFit world where a very committed everyone records everything, this has proven to be problematic. In designing a series of tests to be applied to the broadest possible swath of humanity this ideal must yield to a more pragmatic approach.

What, then, should we measure, and how? Let us first propose a couple of general characteristics of the tasks in our test and then see what fits the bill. We should test an individual’s ability to move from one place to another under their own power–running is a fundamental human trait and should be part of our evaluation. Likewise, the ability to pick something up off the ground is a pretty basic, everyday movement and would qualify as our test of strength. Lastly, in the U.S. we have a storied heritage from the 1960′s, The Presidential Council Fitness Challenge (PCFC), in which candidates are tested on their ability to perform calisthenic exercises for both speed and endurance. It would be fitting to include something that evokes this historical element.

Once again I anticipate a vigorous debate about the particular elements we include. I’ll go first. We can reward both speed and endurance by starting with a timed run in which the result is distance traveled. The most common example of this comes from athletic programs and the military: a 12:00 timed run for distance. We live in the U.S.; the unit is yards. Pick up something heavy? Sure sounds like a deadlift to me. Any deadlift you wish, standard or sumo, will do. My bias is that a lifting belt is just fine, but except in very special circumstances (e.g. one-armed subject) I would say that straps to help you grip the bar are not a good idea, especially for the very inexperienced subject.

After giving considerable thought to the exercises and format in the original PCFC I think we should simplify the test while at the same time bringing it into the modern fitness world. In the PCFC one sought a maximum number of reps in 2:00 of pull-ups, 2:00 of sit-ups, and 2:00 of push-ups. What exactly are we testing with sit-ups that reflects true fitness? I would favor swapping out sit-ups for air squats. With a nod to CrossFit and Greg Glassman’s outsized contributions to this discussion, let’s use the format made famous by the CrossFit WOD “Cindy” with a small adjustment. To test our subject’s ability to perform bodyweight movements and move quickly, repeats of the triplet of 5 pull-ups, 10 push-ups, and 15 air squats in 6:00, counting as our result the total number of repitions achieved.

There you have it. A definition of “Health” and “Healthy”. The introduction of the three variables that go into the measurement of “Health”: traditional medical values ‘M’, emotional well-being ‘W’, and Fitness ‘F’. Next I will address how we will value each of these measures, and then ultimately how they will be combined to give us a meaningful, actionable health measurement ‘H’.

 

Measuring Health Part 3: Emotional Well-Being “W”

2016 is an Olympic year. We will hear stories, as we do in every Olympic cycle, of the extraordinary physical accomplishments of Olympians in sports which require otherworldly amounts of what we in the CrossFit world would consider “Fitness”. Strength, speed, and agility. Uncanny feats of coordination and accuracy, some performed over distances and times that are so far beyond the reach of the average human as to defy credulity. Many of these athletes, certainly the ones we will meet through the intercession of NBC, will match our expectations of the happiness that must certainly accompany such outsized achievements. Mary Lou Retton, anyone? Indeed, what we will see on our screens will fairly scream “Healthy”.

But there will be others, too. And for all of their physical fitness, expressed so dramatically for our viewing pleasure and patriotic zeal, the lack of emotional health will make it obvious to anyone that they are not healthy. Bruce Jenner, anyone?

Remember our proposed definition of “Healthy”: Able to perform in all ways at the farthest limits of one’s potential capabilities. Health is therefore the state in which no infirmity is, or can in the future, impede this ability to fulfill a potential. It takes but a moment to think of how mental illnesses such as depression, bi-polar disease, and schizophrenia can be hidden from view when examining only physical metrics. There are examples all around us. The woman who partners with a 1400 pound horse in the rigorous, physical tasks required to compete in the three-part test that is eventing, so poised and accomplished in the arena, who retreats to solitude outside the barn because she is incapable of overcoming her anxiety around people. The outdoorsman who in his manic phase performs feats of strength and endurance others can only marvel at, and then plunges into the depths of depression from which he cannot see the noon-day sun. Much more prosaic and much more common is the individual who continually increases his or her fitness by any and all measurements due to a deeply held sense of low self-worth, perhaps even self-loathing, pursuing an unreachable ideal and always falling short.

A truly universal measurement of health must include some element of emotional well-being. Let’s call it “W”. You could certainly call it the “Happiness Factor”, and some undoubtedly will. I imagine criticism directed toward this to take the form of “Happy Face” mockery. No matter. Well-Being is a better term for this part of our equation because it encompasses more than whether or not you are happy, whatever happy may mean to you, when you are measured. Are you content with your circumstances at the moment? Do you have the ability to persevere under duress?  What is the state of your relationships? A recent study of Harvard men carried out over decades found that both happiness and longevity were tied quite closely to the quantity and quality of your relationships with family and friends. Where are you in your pursuit of your goals, your dreams, and how do you feel about that? How much stress do you perceive in your life and how are you managing that? All of these make up what one might think of when we consider Well-Being.

How, then, should we go about measuring ‘W’? Remember, all of our tests should meet the dual imperatives of being accessible to pretty much everyone, and as inexpensive as possible. We could certainly use something like the classic anesthesia “smily face” pain scale, relabeling the figures, but this feels too simplistic and too momentary to be truly applicable. Our measurement should require a bit more thought than that. I have to admit here to countless hours of internet crawling trying to find a validated test of emotional well-being that has a track record in a heterogenous group that mirrors our population; most have been utilized in very specialized populations (e.g. soldiers) with a very specific research interest. Those that might apply must typically be purchased.

John Pinto is a well-regarded consultant in the world of my day job, ophthalmology. He has long had a list of clients that spans the gamut of pretty much every measurement you could think of in a group of doctors. Men and women. Young and old. Fantastically successful doctors and those that could only be described as spectacular (if unexpected) failures. As part of his quest to better understand his clients in order to better serve them, John used a questionnaire that measured emotional well-being. He found that external measurements of success such as volume of surgeries, income, and professional acclaim did not always coincide with his clients sense of success, their emotional valuation of their professional lives. These were certainly variables that mattered, but his happiest clients were not always his wealthiest, and his least happy not always those who had less. The assessment he used is the best one that I’ve been able to find, notwithstanding the fact that it is not free.

(http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ).

I am not wedded to the Psychcorp assessment and would happily review any alternatives. Especially if they are free! As is the case with ‘M’, our traditional health metrics like blood pressure and serum lipids, I expect a vigorous debate as to the relative weight of ‘W’ in our final Health Index. My bias is that ‘W’ is a current factor with a greater impact on health, and it should have a correspondingly greater weight in our formula. Let me start the “bidding” with double; however the final formula shakes out ‘W’ should have twice the value of ‘M’.

Mental health is an inextricable part of health. It must be included in any serious definition and measurement of health. Our variable is “Well-Being” or ‘W’.

 

CrossFit and Routine

“Constantly varied…” So, routine is the enemy, right? Well, yes and no. Routine is one of those multi-layered words that applies in many ways in many situations.

Routine is the enemy when we train, and I think this is true for almost all athletes, almost everyone who trains. We risk acclimation to the stimulus if we have a strict routine in the gym, if our workouts are substantially the same day after day. We further risk the numbing effects of boredom, a slow ebbing of our enthusiasm and our resolve. Routine is the major building block, the cornerstone in the brick wall that often stands between athlete/trainee and training.

Routine is our ally when “routine” is synonymous with “consistency”. Remember “Form, then consistency, and only then intensity.” The establishment of a routine, a schedule, a commitment of time and spirit to the quest for fitness, health, and athletic achievement is the first paving stone on the highway of living.

Routine, the yin and yang, push and pull, up and down, enemy and ally.