The Transient State of the Nervous System: A Window of Opportunity, Not a Solution

The human body is governed by the nervous system. Thus, the state of the nervous system influences every function that we perform, consciously or unconsciously. For brevity and simplicity, lets consider the nervous system as a regulating network that is working behind the scenes, at all times, and is responsible for every action (i.e. output). Far from a physiology lecture on the nervous system, but for context, it is important to know that outputs are influenced by inputs.

Given that the nervous system is constantly interpreting input and reacting with outputs, transient changes occur often. In the world of rehab and training, the transient nature of the nervous system can often be misleading.

For example, doing some breathing exercises may relieve a patient’s back pain. A baseball player may increase internal rotation with a stretch. Ankle mobilizations may increase a basketball player’s dorsiflexion and a shot putter may increase throwing distance after a potentiating throw.

And the list goes on.

In the examples presented, an output was improved by an input. This is simply an acute response resulting from the transient state of the nervous system.

Importantly, this acute response is, by definition, short lasting. Too often, clinicians consider an immediate response from an intervention as a solution. This interpretation is short sighted and may lead to a missed opportunity for meaningful, lasting changes.

Andreo Spina entertainingly demonstrates this idea here (h/t to Matthew Danziger for showing me this video earlier this year):

 

The takeaway here should not be that making acute changes to the nervous system is a worthless practice. On the contrary, the transient state of the nervous system should be utilized as a window of opportunity to accomplish the desired goal.

This of course assumes no harm done, which includes indirect nocebo effects.

Lets get back to some examples to give this context.

Two basketball players with limited ankle range of motion get some ankle mobilizations via manual therapy from an athletic trainer. After spending a few short moments on the table, the basketball players have increased ankle range.

Player 1 gets taped up and heads on to the court to start practice. The acute change in ankle range doesn’t last long. This is repeated over the course of a season and the player’s ankle range remains limited all season.

Player 2 utilizes this window and instead of heading onto the court, he heads into the weight room to perform some active ankle mobility exercises and some exercises to train the new range of motion. This is repeated over the course of the season and the player’s ankle range and function improve.

Player 1 settled for the simple, less effective approach. Player 2 opted to capitalize on the window and train the acute passive ROM increases to transfer over to functional capacity.

Another example could be the use of isometrics to decrease tendon pain which allows a window of opportunity perform more work and increase capacity of the tendon.

While another example could be the use of acute low back pain relief to encourage graded movement exposure to decrease fear and anxiety, which has implications for chronic pain rehab.

Ultimately, interventions that create acute positive improvements should be used as a means to a greater end; increase the capacity of the athlete or patient to handle the demands placed upon them. This is true in rehab and training.

The takeaway here is twofold: (1) Single inputs do not create long lasting, meaningful changes, and (2) the acute improvement in the outcome of interest should not be interpreted as a solution, rather a transient window of opportunity to create a chronic adaptations.

I like to refer to this process as big picture rehab or training. Don’t stop at the short sighted and single factor approach. Rather, think big picture and capitalize on the window of opportunity to make a lasting improvement in the outcome of interest.

The key is to not fool yourself by misinterpreting the transient state of the nervous system. It is a window, not a solution.

“The first principle is that you must not fool yourself and you are the easiest person to fool.” Richard P. Feynman

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-42

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health 

Ramsey

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Core Stability: Winning Popularity, Losing Science

Got back pain? Core stability will fix it. At least that’s what it feels like if you spend enough time in the human performance and rehab world.

Core stability is certainly winning the popularity contest, but what does science say about it?

Ill be the first to admit that I was a proponent of the core stability parade. I prescribed core stability exercises to my clients and athletes and when they got better I attributed success to the intervention (i.e. core stability training).

In short, I settled for the convenient and misleading “I’ve seen it work” rationale (see here:  http://wp.me/p4TIPB-2P ).

As is often the case when I start sciencing (science is a verb, duh) for answers, my thinking was flipped on its head.

The popularity of core stability training is based on the following assumptions (taken directly from Lederman 1):

  • That certain muscles are more important for stabilisation of the spine, in particular transverses abdominis (TrA).
  • That weak abdominal muscles lead to back pain.
  • That strengthening abdominal or trunk muscles can reduce back pain.
  • That there is a unique group of “core” muscles working independently of other 
trunk muscles.
  • That a strong core will prevent injury.
  • That there is a relationship between stability and back pain.

Admittedly, these assumptions pass the “it sounds right” test for someone who isn’t up to date with the pain literature. But “it sounds right” is far from a scientific basis and as a proponent of evidence based practice, I prefer to make clinical decisions based on the best available evidence. In the case of low back pain and core stability, we have a good deal of scientific evidence that we can consult for answers. The literature suggests the following (taken directly from Lederman 1):

  • Weak trunk muscles, weak abdominals and imbalances between trunk muscles groups are not pathological, just a normal variation.
  • The division of the trunk into core and global muscle system is a reductionist fantasy, which serves only to promote CS.
  • Weak or dysfunctional abdominal muscles will not lead to back pain.
  • Tensing the trunk muscles is unlikely to provide any protection against back pain or reduce the recurrence of back pain.
  • Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise.
  • Core stability exercises are no better than other forms of exercise in reducing chronic lower back pain.
  • Any therapeutic influence is related to the exercise effects rather than CS issues.
  • There may be potential danger of damaging the spine with continuous tensing of the trunk muscles during daily and sports activities.
  • Patients who have been trained to use complex abdominal hollowing and bracing maneuvers should be discouraged from using them.

In short, the assumptions that core stability reasoning are built upon are no longer tenable. The evidence clearly demonstrates that core stability as a single solution to low back pain is no more than a reductionist fantasy. If a thorough review of the literature on the topic is desired, the reader is encouraged to read Lederman’s well referenced paper The Myth of Core Stability 1.

To support the argument that there is nothing “special” about core stability training, consider a recent systematic review and meta-analysis comparing the effectiveness of core stability exercises to other forms of exercise for the treatment of non-specific low back pain (NSLBP). The review 4 concluded, “There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term. The low levels of heterogeneity and large number of high methodological quality of available studies, at long term follow-up, strengthen our current findings, and further research is unlikely to considerably alter this conclusion.”

To be fair, core stability training has been shown to help with low back pain, albeit treatment effects are small and not clinically meaningful. However, it is important that a positive outcome is not confused as support for treatment rational. Improvements in back pain after core stability training are not attributed to improvements in core function 5, and thus positive outcomes should be attributed to core stability training as a mode of general exercise.

Interestingly, patients with low back pain may actually have more core stability through the neuromuscular protection of co-contraction 2. Thus, core stability training may in fact be feeding into this protective mechanism, which can be counter productive and reinforce both the state of the CNS and the beliefs of the patient, which further influence the state of the CNS and exacerbate pain.

To explain the consequences of this, here is a comment I made recently when discussing core stability with a fellow pain science enthusiast (note: not an expert):

Do we really need to reinforce the CNS excitement around the core? Couple that with the rationale of “your core is unstable thus we need core stability training” and you have a recipe for nocebo effects, negative shaping of beliefs, etc. I have seen positive outcomes with such exercises, but those same clients who I helped may eventually (or already have) back pain return and believe that their weak or unstable core is the cause. I shaped their beliefs of their back as a weak and easily damaged structure which will likely do more harm than good in the long term. I owe them an apology.

The problem with core stability training, in my opinion, isn’t in the training itself. I think the bigger issue at hand is the rationale that clinicians use (assumptions above) and the language they use to explain the patients pain. By framing pain in the biomedical view, clinicians paint the spine and the human body in general as a weak and easily injurious structure. Indeed, patients view the back as easy to harm, hard to heal 3 and these views are at least partially iatrogenic (i.e. induced by the clinician). 6

The reductionist fantasy of core stability is largely a result of single factor thinking derived from the biomedical model of pain; a model that is outdated and does not appreciate the complexity of pain. In short, the biomechanical model is an insufficient framework to work from when managing pain and should be abandoned for a less wrong biopsychosocial (BPS) model, which sufficiently address the many influences that guide a pain experience.

As Lars Avemarie, a pain science educator and current physical therapy student puts it, “The biopsychosocial model of pain is not perfect, any model our minds can conceive of, is potential flawed and bias towards what we currently know. But it is the best explanatory model of pain, that we have thought of, with our current and potentially flawed knowledge base.”

The transition from a biomedical model to a BPS model involves, as Dr. Jason Silvernail, DPT, DSC, FAOOMPT has coined it, Crossing the Chasm.

As Dr. Silvernail explains, embracing the modern pain science approach of managing pain does not mean clinicians have to throw out their current practices that they find success with. Rather, clinicians should have a rationale for treatment that is in agreement with the evidence.

Its time we all cross the chasm, the patients and athletes we work with deserve it.

If you want to hear more about why core stability’s popularity isn’t justified by the evidence and why it can actually be doing harm, then I encourage you to watch the following video of Dr. Peter O’Sullivan, world-renowned physiotherapist, pain researchers, and professor discussing the topic.

Although a discussion of the etiology and treatment of low back pain is beyond the scope or aim of this article, its pertinent to note that NSLBP symptoms improve in a similar fashion, regardless of treatment. In clinical trials of NSLBP 7 , the common trend in symptom improvement is “represented by a rapid early reduction in mean outcome scores within the first 6 weeks followed by a slower reduction thereafter proceeding to a plateau at 6 months.”  The similar response regardless of treatment highlight the importance of factors other than the treatment that can influence symptom improvements (e.g. natural history of low back pain, regression to the mean, non-specific treatment effects, etc.). Notably of these factors are the patients beliefs, which are influenced by the healthcare practitioner, supporting a move away from core stability training rationales and biomedical reasoning.

Lastly, its important to note that I am not saying “core stability exercises should never be used!” I am instead saying that the assumptions clinicians make are not evidence based and that the reasoning and explanations practitioners are giving to their clients can be harmful. There is a fun discussion to be had on why core stability can be helpful as a means of general exercise and CNS desensitization (hint: its effectiveness is not specific to core stability training).

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-3x

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health 

Ramsey

Acknowledgements: Thank you to Lars Avemarie for editing and contributing and Ben Cormack for reviewing.

References:

  1. http://www.ncbi.nlm.nih.gov/pubmed/20006294
  2. http://www.ncbi.nlm.nih.gov/pubmed/11725237
  3. http://www.ncbi.nlm.nih.gov/pubmed/25811262
  4. http://www.ncbi.nlm.nih.gov/pubmed/25488399
  5. http://www.ncbi.nlm.nih.gov/pubmed/22270245
  6. http://www.ncbi.nlm.nih.gov/pubmed/23575999
  7. http://www.ncbi.nlm.nih.gov/pubmed/20713495
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GMOs and Aspartame: Chipotle and Pepsi Cater To Ill-Informed Consumers

This week Chipotle announced they are no longer serving genetically modified organisms (GMO), while Pepsi announced they are getting rid of aspartame in their diet sodas.

Screen Shot 2015-04-30 at 1.22.53 PM

Pop quiz time: Are these decisions based on the science or are these business decisions?

A. Business

B. Business

C. Business

D. Business

If you chose business then you are correct. It doesn’t take an economics PhD to know that businesses make decisions to ultimately make more money. Really no problem there; that’s the essence of capitalism.

Capitalism: An economic and political system in which a country’s trade and industry are controlled by private owners for profit, rather than by the state.

The issue is the ill-informed and illogical loop of consumer confirmation that results from such decisions.

Screen Shot 2015-04-30 at 1.04.13 PM

Consumers are ill-informed and are worried about genetically modified (GM) foods and aspartame so they don’t buy them. Businesses take these things out of their products so consumers will buy. Consumers think they must have been “bad for their health” since the businesses took them out and use this as confirmation for their beliefs. See the problem?

Business decision made independent of science is of course nothing new. Look at food packaging.

  • All Natural.
  • Gluten Free.
  • GMO Free.
  • MSG Free.
  • 100% Organic.
  • No Artificial Sweeteners.
  • And The List Goes On.

These are all ways for businesses to get us, the consumers, to buy. Consumers think these things matter, which they often don’t, so businesses address them to, you guessed it, earn more profit.

This is economics 101: supply and demand.

But if you are inclined to question, seek truth, and not blindly accept the messages from the media or so called nutrition experts, then you may have asked:

What does the science say about GM foods and aspartame?

The answer to both is quite clear: they are safe!

Genetically Modified Food

Lets start with GM foods. Instead of talking about studies, such as the 2013 review, which looked at nearly 2000 studies and concluded GM foods safe for humans 1, or the 2014 study which represented over 100 billion (with a B) animals and found no unfavorable effects in livestock health or productivity 2, I’ll reference 10 leading health and science organization position statements:

http://www.geneticliteracyproject.org/wp-content/uploads/2013/08/GLP-Science-and-GMOs.pdf

And if 10 agreeing statements on safety isn’t enough, here are 23:

https://ramseynijemfitness.files.wordpress.com/2015/04/a5e51-gmauthoritiesnew1.jpg

Whether something is natural or not says absolutely nothing about its safety or healthiness; and how long it has been around says the same – nothing. Both are common fallacious arguments (appeals to nature and antiquity or tradition) that the anti-GMO crowd echo as if when they all scream together the claims become more valid (another fallacy – appeal to popularity).

All foods we have available have been changed through thousands of years of cultivation. Genetic modification is modern technologically advanced cultivation (simplified).

For reference, here is an image showing what some popular foods would look like without genetic modification:

Screen Shot 2015-04-30 at 12.54.09 AM

Most anti-GMO claims are made because the claim maker has a problem with Big Agriculture, namely Monsanto. This is yet another weak and fallacious argument (genetic fallacy) and beyond the scope of this article or the scope of my care. This is about the science not public relations. But I will say that I was quite surprised to learn how much Monsanto pulls in relative to other big companies:

Screen Shot 2015-04-30 at 12.36.41 AM

Far from the big bad wolf that people make them out to be.

Before I move on, lets get back to Chipotle for a second. First, although I understand that they are making business decisions, its important to note that they are perpetuating pseudoscientific “GMO” fear messaging. Lastly, their meats and dairy come from animals fed genetically modified livestock and their beverages contain genetically modified ingredients. This is hidden behind their “G-M-Over It” slogan.

Aspartame

To start, I appreciate that Pepsi cited consumer opinion as the reason they decided to take aspartame out of their diet sodas and not pseudoscientific reasoning, with their VP saying “Aspartame is the number one reason consumers are dropping diet soda.” Diet soda sales have decreased because people fear aspartame so Pepsi takes it out. Again, that’s business.

Screen Shot 2015-04-30 at 1.28.11 PM

Similar to GMOs, aspartame is controversial to the public. But controversy does not indicate a disagreement between scientists. On the contrary, and similar to GM food consensus, aspartame is the most studied food additive over the past 30 years and there is a compelling consensus among scientist and regulatory agencies that it is safe.

Before we get into the science, consider this for context. The FDA has set the acceptable daily intake level for aspartame at 50mg per kg of bodyweight per day. If we take someone that weighs 150 pounds (68kg), they would have an acceptable daily limit of 3,400mg. An 8oz diet Pepsi has approximately 118mg of Aspartame. That would come out to 28 diet sodas a day before reaching the FDA acceptable daily intake level.

If that’s not reason enough to stop worrying about Aspartame, then perhaps the science is:

This review 3 by the Council on Scientific Affairs concluded, “Available evidence suggests that consumption of aspartame by normal humans is safe and is not associated with serious adverse health effects.”

This review 4 concluded, “When all the research on aspartame, including evaluations in both the premarketing and postmarketing periods, is examined as a whole, it is clear that aspartame is safe, and there are no unresolved questions regarding its safety under conditions of intended use.”

This review 5 concluded, “Evidence does not support links between aspartame and cancer, hair loss, depression, dementia, behavioural disturbances, or any of the other conditions appearing in websites.”

This review 6 concluded, “Thus, the weight of scientific evidence confirms that, even in amounts many times what people typically consume, aspartame is safe for its intended uses as a sweetener and flavor enhancer.”

This experiment 7 investigated cognitive function in kids and concluded, “Even when intake exceeds typical dietary levels, neither dietary sucrose nor aspartame affects children’s behavior or cognitive function.”

What about cancer? Aspartame is not related as this review 8 concluded, “Epidemiological studies on aspartame include several case-control studies and one well-conducted prospective epidemiological study with a large cohort, in which the consumption of aspartame was measured. The studies provide no evidence to support an association between aspartame and cancer in any tissue. The weight of existing evidence is that aspartame is safe at current levels of consumption as a nonnutritive sweetener.”

This experiment 9 disputes the neuropsychologic and neurophysiologic claims with the conclusion that “Large daily doses of aspartame had no effect on neuropsychologic, neurophysiologic, or behavioral functioning in healthy young adults.”

And finally, this review 10 concluded that aspartame does not appear to have specific hormonal effects on insulin, cortisol, glucose, GH and prolactin.

Conclusion

The data is clear on the safety of GMOs and aspartame.

Of course science rarely drives public opinion (vaccines anyone?). Rather, consumers often form their opinions based on the best framed messaging. The media fear messaging plays to the consumer’s emotions, which ultimately drives buying decisions.

The scientific consensus isn’t buying Chipotle bowls or stocking up on diet Pepsi so it should be no surprise that these companies are catering to an ill-informed consumer market.

Unfortunately the public gauges claim validity based on the response of these businesses. For example, they might think “aspartame must be bad because Pepsi took it out,” or “GMOs are unsafe otherwise Chipotle wouldn’t be trying to get rid of it.” These conclusions are a result of the ill-informed and illogical loop of consumer confirmation.

Chipotle and Pepsi are not the only companies that have made changes to their products due to public opinion. Kraft, Nestle, General Mills, Subway, and McDonalds have all made similar changes recently as a result of growing concerns from their consumers.

Image is everything in business and these companies would rather accommodate a concern than risk declining sales.

In my opinion, the growing public concern over such things as GMOs, Aspartame, artificial sweeteners, Gluten (see here: http://wp.me/p4TIPB-P), and other food additives, highlights America’s missing of the bigger picture.

America’s waistline continues to expand and instead of consumers placing their time, effort, and concern into food amount, they’d rather worry about harmless food additives or modification. Instead of worrying about increasing fruit and vegetable consumption, they’d rather worry whether their doughnut is gluten free. Well I got news America, that burrito with sour cream, guacamole (yes you paid extra) and chips and salsa is 2,000 calories, whether it’s GMO free or not (which its not because you got meat in it).

Then again, it will all be justified with an Aspartame free diet soda.

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-3j

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health 

Ramsey

 

References

  1. http://www.ncbi.nlm.nih.gov/pubmed/24041244
  2. http://www.ncbi.nlm.nih.gov/pubmed/25184846
  3. http://www.ncbi.nlm.nih.gov/pubmed/2861297
  4. http://www.ncbi.nlm.nih.gov/pubmed/12180494
  5. http://www.bmj.com/content/329/7469/755
  6. http://www.ncbi.nlm.nih.gov/pubmed/11754527
  7. http://www.ncbi.nlm.nih.gov/pubmed/8277950
  8. http://www.ncbi.nlm.nih.gov/pubmed/17828671
  9. http://www.ncbi.nlm.nih.gov/pubmed/9734727
  10. http://www.ncbi.nlm.nih.gov/pubmed/2923074
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Sugar Myths: Instilling Fear, Ignoring Science

Sugar is the new cocaine. Period. This shit kills you. The adverse health effects of a cookie are equivalent to a cigarette. Obesity is rising. Diabetes is rising. Sugar is responsible for all of it and private profit is being placed above public health.

At least that’s what it feels like with all of the anti-sugar messages going on. Look no further than the Fed-Up documentary, which I admittedly did not watch.

 

With all of this fear messaging, it appears to be clear: Sugar is to blame.

But is that fair? Lets review some of the data to debunk some of the myths that are emphatically purported by the media.

Sugar is not causing obesity or diabetes.

For sugar to be causing increases in obesity and diabetes, we would at minimum need sugar to positively correlate with obesity and diabetes. In other words, sugar consumption would have to rise as obesity and diabetes rise. This data alone could not demonstrate cause, but without a positive relationship, where variable X (e.g. sugar) increases with variable Y (e.g. obesity or obesity), then cause cannot be inferred.

Is obesity increasing? Yes.1

Here is a prevalence table for obesity levels from 2000 to 2010 in America.

Screen Shot 2015-04-28 at 2.51.28 PM

Is diabetes increasing? Yes.2

Here is a prevalence table for diabetes from 2000 to 2010 in America.

Screen Shot 2015-04-28 at 2.49.22 PM

This data is unsurprising of course. But here is the kicker; what I like to call black swan data. It’s the one piece of data that single handedly debunks the entire premise that sugar is the culprit of the increases in obesity and diabetes.

Sugar consumption is decreasing.3

Here is a graph of sugar consumption in America from 1999 to 2008.

Screen Shot 2015-04-28 at 12.50.44 PM

From 1999 to 2008, consumption of added sugar decreased by 25% on a grams consumed basis (from approximately 100g to 75g) and 4% on a total energy basis (from 18% to 14% approximately), with a decrease in soda consumption accounting for two thirds of the total decrease.

Screen Shot 2015-04-28 at 12.59.19 PM

 

Its important and fair to note that even at the lower consumption rates, sugar intake by many Americans exceeds the upper recommended limit of the Dietary Guidelines.

The data demonstrates that sugar is not solely responsible for obesity and diabetes as the media suggests. This is not to say that sugar cannot negatively influence the energy balance equation and ultimately play a role in obesity and diabetes; it obviously can. This data, in my opinion demonstrates what most of us in the health industry already know: Obesity is a complex issue that cannot be explained by a single variable. For reference on how complex, take a look at this diagram:

Obesity Diagram

(See here for interactive version: http://www.shiftn.com/obesity/Full-Map.html)

Sugar is not addictive.

After blaming sugar for the obesity epidemic and increases in diabetes rates, media fear mongering goes on to explain how sugar is addictive. This is simply not true.

People will often reference some rat studies to “show” that sugar is addictive. For example, college undergrads performed an unpublished research project where they gave hungry rats oreos or rice cakes on one side of a maze. Then they gave the rats the option to hang out on the either side of the maze and found that the rats spent more time on the side where they were given an oreo. The researchers then compared the results of this test to a similar one with cocaine or morphine used instead of oreos and saline used instead of rice cakes. Oreo fed rats spent similar amounts of time on the oreo side of the maze as the rats given drugs spent on the drug side of the maze.4

Low and behold, sugar is addicting!

So because rats like oreos more than rice cakes, sugar is now addicting to humans?

That makes sense. Not.

I never understood why people love to reference animal data when we have human data. We are humans; therefore we should default to human data when available. Duh.

Fortunately we have a review of such human studies and guess what? Sugar is not addicting.5

If not sugar, then what?

So if sugar is not addicting and its not to blame for obesity and diabetes, then what is all the fuss about sugar? In short, people like to simplify complex issues, which results in massive oversimplification. The process of simplification looks like this: America is obese, junk food is bad for you, junk food has sugar, sugar is the devil.

Lets look beyond such a reductionist fantasy and appreciate how complex this stuff is.

First, its important to acknowledge that body weight is ultimately determined by the energy balance (calories in versus calories out); the first law of thermodynamics is immutable. Hence why it is possible to lose weight on any diet that creates a caloric deficit. Yes, even a Twinkie diet.6

With that said, there are important considerations for such things as:

  • Excess calories of any kind will promote weight gain.
  • Eating, as a behavior, may be addicting rather than sugar or a specific macronutrient.7
  • Hyperpalatable foods (processed foods that taste really good, often full of fat and sugar) make people want to continue eating them.
  • Reward seeking behavior and food (often “junk food”) conditioning to pleasure centers in the brain.
  • Food environments that predispose people to bad nutrition choices.
  • Lifestyle, especially nutrition habits that fuel weight gain, obesity, and diabetes.
  • Marketing of “junk food” is extremely powerful and ubiquitous.
  • Will power is easily exhausted.
  • This list can go on and on.

The point being this: Sugar is not the one bad bandit and scaring people into sugar avoidance wont do much but result in public fear. Avoiding any food is not advised, unless done so for personal or medical reasons, and will only make it harder for someone to have success.

Is putting down the bag of chips and opting for some vegetables good advice? Yes. Is telling people that the same bag of chips is going to kill them the right approach? No. In fact, I would argue that favorite foods such as ice cream, cookies, chips, etc. have a healthy place in someone’s diet. Without planning these foods into a diet, people will undoubtedly fail. Cravings turn into binges when not dealt with appropriately.

So should you avoid sugar? Sort of. Excess sugar should be avoided, but eat your favorite foods in moderation. If not, you’ll go crazy. A scoop of ice cream won’t slow weight loss progress if you plan for it.

On top of planning your favorite foods in moderation into your diet, avoid drinking your calories, eat fruits and vegetables, focus on nutrient dense choices, opt for lean protein sources, avoid making food choices in the hungry state, and ultimately accept that health is a journey that cannot be fast tracked by depriving yourself of every tasteful food you love to eat.

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link:http://wp.me/p4TIPB-36

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health,

Ramsey

 

References

  1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527647/
  2. http://www.cdc.gov/diabetes/statistics/prev/national/figage.htm
  3. http://ajcn.nutrition.org/content/94/3/726.full
  4. http://www.conncoll.edu/news/news-archive/2013/student-faculty-research-suggests-oreos-can-be-compared-to-drugs-of-abuse-in-lab-rats.htm#.VT_rssa1pD4
  5. http://www.clinicalnutritionjournal.com/article/S0261-5614%2809%2900239-8/abstract
  6. http://www.cnn.com/2010/HEALTH/11/08/twinkie.diet.professor/
  7. http://www.sciencedirect.com/science/article/pii/S0149763414002140
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Cleanse and Detox: Marketing Pseudoscience

Screen Shot 2015-04-24 at 12.05.42 AM

Last week I posted the image above on Facebook with a reminder that cleanses and detoxes are BS. Since I acknowledge that my opinion is easily defeated by the admittedly persuasive marketing behind these pseudoscientific attempts at improving health, lets review why cleanses and detoxes are complete nonsense with no scientific basis.

Cleanses and detoxes (used interchangeable here) are purported to rid the body of toxins through some variation of juicing and limited food intake, often allowing only fruits and vegetable consumption, or some random concoction of harmful substance fighting ingredients. Once the body is cleared of the toxins, a host of health benefits will be redeemed such as weight loss, improved energy and cognitive function, and prevent or eliminate various diseases.

Sounds good. But is there any truth to the claims?

For cleanses or detoxes to be effective (i.e. do what they are purported to do), the following would have to be true:

  1. Your body would have to collect toxins.
  2. Your body would need help removing toxins.
  3. The cleanse or detox would have to help remove the toxins.
  4. Health benefits would have to result from these removal of the toxins.

Does your body collect toxins? Yes.

For example, your body can accumulate dangerous levels of heavy metals and other toxicants.

Does your body need help removing said toxins? No

Your body is working 24/7 to remove undesired substances and waste products. The liver, kidneys, and colon, as well as other organs play a pivotal role in the ongoing natural cleansing and detoxing. The proof of such processes are evident every time you head into the restroom. An easy example to consider is when urine turns darker after taking vitamins and minerals; the darker color is the excretion of excess vitamins and minerals your body doesn’t need.

Do cleanses or detoxes help remove toxins? No.

Not even close. This is highlighted by a 2009 investigation, which asked 15 companies to to provide evidence for their claims and found that companies could not specify a targeted toxin, provide evidence for their claims, nor did the companies even agree on a definition for “detox.”

The authors conclude: “In fact, no one we contacted was able to provide any evidence for their claims, or give a comprehensive definition of what they meant by ‘detox’. We concluded that ‘detox’ as used in product marketing is a myth. Many of the claims about how the body works were wrong and some were even dangerous.”

So are there any benefits to cleanses or detoxes? A resounding NO.

Typically cleanses involve liquid only or liquid plus fruit and vegetable diets. Done for a few days, or worse, a few weeks, and these cleanses or detoxes will result in some weight loss. But this is mostly water weight that will quickly return once a normal, more reasonable and nutritious diet is returned to.

Is there any downside of cleanses or detoxes? Yes.

The most obvious downside is the fact that these cleverly marketed schemes are a waste of money. Without a single meaningful health benefit, these often expensive magic in a bottle regiments are doing nothing more than lightening your wallet. Done for short periods of time, cleanses or detoxes will likely only result in some low energy levels, irritability, unpleasant stomachs, or other insignificant side effects. Done for long periods of time and these side effects can become really harmful. Anecdotal reports of undernourishment, kidney failure and various other medical issues are available online.

Bottom Line:

Ultimately, cleanses and detoxes only feed the grand illusion that health can be found in a bottle or some type of quick fix. Trust me, this is not true. If it was I would know and would gladly share such information. But that’s now how health works. Instead of tossing your money away into nonsensical “master 3 day cleanses,” invest in long-term meaningful interventions such as changing your nutrition habits and food environment.

Stop searching for the miracle in a bottle. Contrary to what Dr. Oz claims, there is no such thing. Good nutrition habits and exercise are the “miracles” available and we know they work for improving health. Spend your time and money investing in your health and not in ridiculous health scams.

If you insist on giving your money away, then I encourage you to email me because my doctorate tuition bills that can use your help (only partly kidding).

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-2Z

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health,

Ramsey

References:

1) http://www.senseaboutscience.org/data/files/resources/48/Detox-Dossier-Embargoed-until-0001-5th-jan-2009.pdf

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The Clinical Paradox Of Experience

Clinical experience, defined here as the number of years a clinician has been practicing, is often discussed as if it has some inherent credibility. This is unfortunate given that a number alone lacks context. The value of experience is dependent on the knowledge gained throughout the years. If little knowledge has been gained then little value is possessed. Thus, more experienced clinicians aren’t necessarily better and less experienced clinicians aren’t necessarily worse.

In fact, more experienced clinicians may be at risk of providing care that is not technically appropriate or optimal. For example, consider the strength and conditioning coach who relies solely on the BIG 3 (squat, bench, dead) to develop athletes or the athletic trainer who uses ice bags and passive modalities for all injury treatment. Not to mention the physical therapist that prescribes core stability exercises for all back pain patients.

The “wash, rinse, and repeat” cyclical model of health care certainly has its downfalls, which only increase as years in practice does. This, in my opinion, demonstrates one benefit of lacking many years of experience; rooks or newbies do not have models of practice that they are married to. In short, the inexperienced clinician can’t default to the troubling “I’ve seen it work” rationale of treatment (see here: http://wp.me/p4TIPB-2P) and is forced (ideally) to look to the literature for answers. (Of course rooks or newbies are not immune to low quality care delivery and inexperience has its own limitations.)

The potential for more experienced clinicians to provide lower levels of quality of health care was highlighted by a 2005 systematic review published in the reputable Annals of Internal Medicine1 which assessed the robustness of the relationship between clinical experience and quality of care. 1

The authors looked at 62 empirical studies that described a physician’s time since medical school graduation or age and measured physician knowledge or quality of care. Of these studies, more than half suggested a decrease in performance over time, while only 1 paper showed improved performance for the outcomes measured.

  • 12 studies assessed the knowledge of practicing physicians and reported a negative association between knowledge and experience.
  • 24 studies assessed the appropriateness of physician use of diagnostic and screening tests, as well as preventive health care, 15 of which demonstrated a negative association between experience and adherence to standards of practice in this domain.
  • 19 studies assessed the influence of experience and adherence to standards of therapy, 14 of which demonstrated a negative association between experience and adherence to standards of appropriate use of therapy.
  • 7 studies assessed the relationship between experience and actual health outcomes, the strongest of which was “conducted by Norcini and colleagues (14) who analyzed mortality for 39 007 hospitalized patients with acute myocardial infarction managed by 4546 cardiologists, internists, and family practitioners. After controlling for a patient’s probability of death, hospital location and practice environment, physician specialty, board certification, and the volume of patients seen, these researchers observed a 0.5% (SE, 0.27%) increase in mortality for every year since the treating physician had graduated from medical school.”

The implications of these studies are clear and summarized by the researchers:

“Physicians who have been in practice for more years may also be less likely to deliver high-quality care (11-12). Medical advances occur frequently, and the explicit knowledge that physicians possess may easily become out of date. Therefore, although it is generally assumed that the tacit knowledge and skills accumulated by physicians during years of practice lead to superior clinical abilities (13), it is also plausible that physicians with more experience may paradoxically be less likely to provide technically appropriate care.”

The researchers go on to discuss potential explanations for their findings:

“Our findings have many possible explanations. Perhaps most plausible is that physicians’ ‘toolkits’ are created during training and may not be updated regularly (70). Older physicians seem less likely to adopt newly proven therapies (71–72) and may be less receptive to new standards of care (73). In addition, practice innovations that involve theoretical shifts, such as the use of less aggressive surgical therapy for early-stage breast cancer or protocols for reducing length of stay, may be harder to incorporate into the practice of physicians who have trained long ago than innovations that add a procedure or technique consistent with a physician’s preexisting knowledge (74).

“Our findings may also reflect the substantial environmental changes that have occurred in medicine over the past several decades; evidence-based medicine has been widely adopted, and quality assurance techniques, such as disease management and performance evaluation, are frequently used. More experienced physicians may have less familiarity with these strategies and may be less accepting of them. Given this, our results may represent a cohort effect; that is, when the current generation of more recently trained physicians has been in practice for a longer time, there may be smaller differences between their practice and those of their younger colleagues than our data would suggest.”

The results of this systematic review indicate that clinicians with more years of experience may paradoxically be at risk for providing lower quality care. This may be due to:

  • Outdated toolkits (i.e. knowledge base that can be drawn upon for clinical decision making).
  • An inability to accept practice innovations that compete with our experience and biases, calling for a theoretical shift.
  • An unfamiliarity and lack of acceptance of EBM.

Thus, to avoid providing lower quality of care, experienced clinicians should constantly consult the scientific literature to update their toolkits, acknowledge bias and embrace clinical evidence that invalidates currently accepted practices and replaces them with more accurate, efficacious, and safer ones. Ultimately, clinicians should enthusiastically welcome EBM given that it is an approach that will optimize care because without best available evidence practice risks becoming out of date to the detriment of patients.

These same rules apply to younger, less experienced clinicians who have an opportunity for a cohort effect, ideally neutralizing the current negative relationship between experience and quality of care provided. In fact, the recently trained relatively inexperienced clinician has no excuse not to continually update their toolkits given that modern technology has made it much easier to access the literature.

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The evidence base is a means to a goal for me: To become the best clinician I can be. Although experience will undoubtedly help me get there, without constantly consulting the literature my toolkits are at risk of becoming out of date and my care at risk of becoming technically inappropriate and low quality.

Because I acknowledge I may be biased toward the EBM model and I am a voice speaking from the younger cohort of relatively inexperienced clinicians, I have invited commentary from an experienced clinician, my colleague and friend, Manny Romero. Manny is a head Athletic Trainer in the NBA with 20 years of experience, who is currently in the dissertation phase of his PhD. He’s also an NBA champion and one of the wittiest people I know. Without further adieu, here are his responses (cue audience clapping):

Manny, why do you frequently consult the scientific literature?

To validate or refute my clinical practice.

Why do you think experienced clinicians are hesitant to accept an evidence based practice approach to health care and what do you think can be done to overcome the push back?

The biggest obstacle to overcome is the lack of understanding of an evidence based approach. While there are certain principles to learn, practicing evidence-based medicine should not be a daunting or time consuming task. In fact, by learning to read, appraise and apply what is grounded in the literature, you can become a much more efficient clinician. I think all clinicians leave school with a common knowledge base, grounded on foundational principles. Practicing based on these principles should provide satisfactory outcomes. Practicing based on foundational principles substantiated by current evidence should only enhance these outcomes.

Are there any additional thoughts you care to share on evidence based practice and the relationship of experience and quality of care?

I think we are all searching for the “absolute or truth,” that is what is the most definitive way to treat our patients. There are so many confounding factors for each patient that defining this “absolute” may be unattainable. Pursuit of the “absolute,” however, should be non-negotiable. I think practicing evidence-based medicine moves our practices closer to the “truth.”

Thank you for your time and insight Manny.

In summary:

  • Increasing experience does not mean improved quality of care.
  • Clinicians, old and young, should continually update their toolkits and embrace EBM to optimize care.
  • Check egos and biases at the door (admittedly a hard thing to do) and accept theoretical shifts when the evidence base demands it.
  • EMB is not a threat to you current practice, rather a tool to ultimately improve on the care you deliver.

Note: The systematic review that this article is based upon reviewed studies on physicians1. It is of my opinion that the inverse relationship found in physicians would be found in all health care professions given that physicians require the most extensive training. Thus, physical therapist, athletic trainers, strength and conditioning coaches, personal trainers, dietitians,  nutritionist (whatever that means) and all other health care clinicians are at risk of lower quality of care if they do not continually consult the literature to update their toolkits.

If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-2V

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health,

Ramsey

References:

  1. http://annals.org/article.aspx?articleid=718215#t1-8

 

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The Problem With “I’ve Seen It Work”

Have you ever had the uncomfortable position of explaining to someone that the intervention they are proposing may not do what they think it does?

Tell someone that the low carb diet they’re on isn’t the reason they lost weight.

Tell someone that the supplement they’re taking isn’t the reason they gained muscle.

Tell someone the medicine they’re taking isn’t the reason they got better.

Tell someone that the treatment for his or her pain isn’t the reason they’re pain free.

And the list goes on.

Whenever you try to explain to someone that what he or she is doing may not be doing what he or she thinks it is doing, they inevitably respond with “I’ve seen it work.” This is a common response when delivering the message that a treatment is not well supported by the evidence base and that alternative interventions may be better given the current state of the literature.

Although I do not doubt that these respondents sincerely believe that they’ve seen “it work,” there are 3 key problems with this popular justification:

1) Post Hoc Ergo Proptor Hoc

Post Hoc Ergo Proptor Hoc, often referred to as the Post Hoc Fallacy, is the belief that because Y happened after X, X therefore caused Y. In other words, because something happened, a previous intervention is responsible for it. While this may sometimes be true, without control of confounding variables, it is impossible to know whether X caused Y or a host of other things are responsible. This is why anecdotal evidence holds little value for determining causality. This faulty or fallacious reasoning often leads people confidently astray. It is important to remain cautious when assigning responsibility to intervention when change, positive or negative, seems to occur following said intervention.

2) Outcomes Measure Outcomes

Outcomes measure outcomes, not treatment effects. Further, outcome measures do not justify a diagnosis-treatment-improvement link nor do they confirm treatment rationales. Re-testing with improvement tells us that an improvement occurred; we cannot be certain, in the clinical setting, whether or not our intervention is necessarily responsible. It is certainly possible that what we did had a positive, negative, or neutral influence on the outcome. For example, a positive outcome could have occurred naturally. It is even possible that a positive outcome could have been better if it wasn’t for our intervention. Likewise, if an outcome is negative, its possible that the outcome would have been worse if it wasn’t for our intervention. Thus, in the clinical setting it is hard to determine the effectiveness of a treatment with outcome measures. Given that outcomes cannot necessarily be assigned solely to treatment effects, clinicians are often stuck in the uncertainty zone (i.e. cannot be certain why changes occurred in the condition). This should not be discouraging given that positive outcomes are the ultimate goal of the clinician. Improvements are likely a complex interplay of many things, including treatment effects and alternative explanations.

3) Alternative Explanations Are Plenty

Unlike the lab setting, clinical settings offer little control of confounds. Thus, it is always possible that outcomes are a result of something other than the treatment. Here are a few examples of alternative explanations that may be responsible for the outcome:

  • Change didn’t actually occur but seemed “to work” due to confirmation bias or post hoc reasoning.
  • The condition was going to get better due to the natural course of the condition.
  • The symptoms improved due to the statistical regression to the mean.
  • Changes in condition were due to the placebo effect, which is influenced by just about every part of the clinical interaction.
  • Signs and symptoms often improve with or without treatment.

Summary:

Although “I’ve seen it work” is a compelling justification for treatment decisions, clinicians must avoid the temptation to award credit to therapeutic interventions that are not supported by high-level randomized control trials. Even when such evidence does support treatments, remain cautious of assigning responsibility of positive outcomes solely to intervention and appreciate the complex interplay of the clinical interaction and confounding explanations.

Being uncertain does not make a clinician naïve, rather it makes them honest and open to the likelihood of outcomes being influenced by many things, including but not limited to treatment effects. It is important to acknowledge confirmation bias of both the clinician and the patient to avoid imagined symptom improvements. It is also important to consider that positive outcomes, even when they are truly treatment effects, do not mean that the treatment was optimal; it is certainly possible that a different intervention would have resulted in even better or quicker improvement.

Lastly, outcome measures do not justify a clinical rationale for treatment. This is why randomized control trials are not enough to optimize care across a patient load; what works for one patient may not work for the next. For this reason, critical thinking and a fundamental understanding of the science of the condition are imperative for tailoring individualized care and optimizing treatment.

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If you found this article to be helpful or insightful then I encourage you to share it with others who may find it helpful. Simply copy and share the link: http://wp.me/p4TIPB-2P

Thanks for reading. Feel free to drop me a line below or on my Facebook or Instagram (“Follow” top right). Also, don’t forget to sign up for email updates to stay current with me. As always, I thank you for your support.

Sincerely,

Yours in fitness and health,

Ramsey

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