Weight loss or Health?

Forget Weight loss- Focus on Your Health First!

Forget Weight loss- Focus on Your Health First!



Each month, there are an estimated 4 million google searches about weight loss. 4 million!


On the one hand, that is an astounding number. On the other hand, considering more than one-third of U.S. Adults are obese with two-thirds overweight, along with alarming rates of growing obesity within our youth, suddenly 4 million searches seems just about right.


Of even greater concern, this growing obesity epidemic has coincided with increasing occurrences of heart disease, strokes, type 2 diabetes, and other chronic diseases.


It appears as if Google has yet to solve our obesity crisis. Why not?


One study suggests that Less than 3% of Americans are living a generally healthy lifestyle. Less than 3%! That means less then 3% of Americans are:

  • Performing moderate exercise for at least 150 minutes a week
  • Following a healthy diet as defined by the healthy eating index
  • Maintaining a body fat percentage of under 20 percent for men or 30 percent for women
  • Not smoking


It’s not lack of information that is most likely the issue. It’s the lack of attention to our behaviors and habits, and our mindset regarding a healthy lifestyle.


We live in an impatient world that is addicted to convenience. We expect everything, from our food to our information, to be packed in a neat and convenient package for immediate consumption.


It is this attitude that has led many who are suffering from obesity to resort to weight loss drugs or dramatic interventions popularized by T.V. shows such as The Biggest Loser.


Unfortunately, neither of these options are making our society healthier.




Because weight loss by itself does not equate to better health. And because our health can’t be solved with convenience.


Weight loss drugs: Wrong Goal- Wrong Approach


Over the course of the last few years, weight loss drugs such as Qnexa, Contrave, & Lorcaserin have hit the market and have seemingly become the solution for many people’s weight loss problem.


But, if you dig deeper, these drugs are anything but a solution. Significant side effects, not to mention exorbitant costs, limit their efficacy.


Contrave (ranging from $55 to $200 depending on the plan) demonstrated 9% weight loss after 56-weeks with the most common side effect being nausea (did it work by making people feel sick so they ate less? One has to wonder).


Lorcaserin, also known as Belviq (starting at $213), also showed modest results. In its main study, only half of the subjects taking the drug lost more than 5% of their body weight. Once the drug was stopped, most regained the weight. The main side effect again was nausea, along with headache and dizziness. Are you seeing a pattern?


Lastly, a panel of FDA advisors recently voted against the approval of Qnexa. It showed a modest 5% weight loss, and showed increased depression, trouble concentrating and suicidal thoughts. Hardly a path to health.


One of the biggest problems is that these drugs aren’t changing anyone’s behavior toward food. They aren’t changing habits or mindsets. Instead, they’re applying a band aid to the problem, creating a reliance on the drug, and ultimately helping the drug company shareholders more than your health.


What else can we do if drugs aren’t the answer? Unfortunately, some have taken it even further to create a surgical form of bulimia. The AspireAssist is a pump that is surgically implanted into the stomach so that you can drain out what you just ate. The studies show that it can help you lose weight. No question about it. But what about your nutrition, vitamins, energy, and quality of life? Apparently, those are less important for some.


These weight loss drugs and surgeries are a direct contradiction to the development of healthy habits. Habits that create and maintain our health. It may not be easy to adopt these habits, but easy rarely leads to the best results.


Where can America learn the healthy habits that will produce results?


The biggest loser? It’s society that loses


The T.V. show The Biggest Loser has caught the attention and hearts of the American public for years. Watching men and women shed pounds along with witnessing the emotional hurdles they overcome is a powerful representation of overcoming health struggles.


But there’s a lot of the story that isn’t displayed on the television screen.


Contestants are losing weight and following strategies that aren’t kind to their metabolism and aren’t likely to succeed in the future. A study done on contestants from season 8 of the biggest loser found the majority regained most or all of the weight, and they showed a significant slowing of their resting metabolism. A slower metabolism makes it that much harder to keep the weight off. In essence, their own bodies were fighting against their efforts to lose weight.


Here’s a more sustainable alternative


If weight loss drugs and rapid weight loss programs aren’t the answer, then what is?


  1. Focus on your entire lifestyle, not just one part


We frequently hear about nutrition and exercise, but paying attention to factors such as sleep and stress levels will pay huge dividends with your health and weight loss as well.


When your body does not respond well to stress, the increased cortisol and adrenaline hormones sabotage your weight loss efforts, and negatively impact your overall health.


A regular mindfulness or meditation practice is the first step in correcting your body’s reaction to stress. Overtime, your stress hormone response will diminish and your body will more efficiently lose weight and restore health.


The same applies to sleep. A poor night’s sleep is one of the best ways to sabotage our health or weight loss goals. It creates an imbalance in our leptin (I’m full hormone) and our Ghrelin (I’m hungry hormone), thus tricking our body into feeling hungry. That usually results in snacking on nutrient-poor, processed, high-carb foods. In short, a recipe for disaster.


  1. Commit to consistent activity


This doesn’t mean exhaustive boot camps or rigorous workouts for hours each day. Don’t get me wrong, those are great too. But they are not the only goal. Instead, focus on being active in your daily life.


In his book, Blue Zones, Dan Buettner identified the most common habits in societies where people live the longest. Guess what? They didn’t do triathlons or run marathons. Instead, they made regular physical activity a consistent part of their lifestyle.


If you can do that and still get your boot camp workouts done, fantastic! If not, don’t let perfect be the enemy of good. Develop the habits that will keep you moving. Start gardening, walk to do your errands, take the stairs. You have heard these before, now you just need to start doing them.


  1. Be okay with losing weight slowly


Slow and steady truly does win the race. Rapid, extreme weight loss disrupts our hormones and can create long-lasting metabolic changes that counteract our intentions in the future.


Focusing on healthy habits instead of weight loss ensures that your body does not react in a counterproductive way. Slow and steady is less likely to trigger deleterious hormonal and metabolic shifts within your body. And most importantly, slow and steady is more sustainable for the long term.


  1. Reframe your goal


If you want to lose 20, 50 or 100 pounds, this can be an overwhelming task.


To lessen the psychological toll of such a task, it’s better to break it up into mini goals and get small wins along the way.


Small victories can still have health benefits.  For example, 5% weight loss in obese individuals results in improved insulin sensitivity, an important factor for diabetes, heart disease, and dementia.


The small wins can add up to big wins, and the ultimate goal becomes less onerous and stressful.




If weight loss is your goal, stop and ask yourself why. Especially if you have considered weight loss drugs or intensive rapid weight loss programs. Take a moment to think about the difference between weight loss and health.


Being skinny but also stressed out and with a disturbed metabolism doesn’t sound like much of a victory.


Commit to healthy lifestyle habits, embrace them as part of who you are, and watch the weight steadily fall away. Slow and steady wins the race to your health.


Contact us today to learn how we can help you develop an individualized lifestyle intervention to take control of your health. No drugs. No surgeries. Just you, your life and your health.




Does Lifestyle Beat Drugs? It Just Might….


Drugs, Drugs, Drugs. Everywhere we turn we see new ads, new guidelines, and new marketing campaigns showing us how beneficial prescription medications can be for our lives. As we swim in the sea of medications, it is important to step back and realize we do have better options for maintaining our health and preventing chronic diseases.


Drugs Get All the Attention


Why do prescription drugs get most of the attention from medical science?

  • They are easier to study. It’s easy to measure compliance, it’s easy to isolate the intervention to one thing. Just take the pill. You either get the drug or the placebo. No grey zone there
  • It’s where the money is. A well-designed study that involves thousands of subjects over many years is expensive! Who’s going to pay for that research? Usually it’s someone who has something to gain. The pharmaceutical companies have the most to gain by studying their drugs, and they have the deep pockets to back it up.
  • It’s in our medical culture. Over the years, our medical culture has become medication focused. It’s almost an inherent assumption that medications are beneficial and should be used to “help” everyone. That doesn’t make it right. It just makes it common.


Fortunately, despite our pill-centric culture, we are starting to see a small increase in lifestyle focused studies in the medical literature.


A study recently published in the NEJM showed that maintaining 3 out of 4 healthy lifestyle habits (following a healthy diet, regular physical activity, not smoking and not being obese) reduces the risk of developing heart disease by almost 50%.


The media may be reporting this as if it’s a brand new revelation, but it turns out it’s not completely new.


Previous Studies


The INTERHART study published in 2004 showed that 5 risk factors (daily fruit and vegetable consumption, Apo B/Apo AI ratio, current smoking, abdominal obesity, diabetes) accounted for 80% of all heart attacks. All those factors can be controlled with lifestyle interventions.


In addition, A 2014 in JACC study showed that 80% of all first heart attacks are explained by 5 risk factors (smoking, waist circumference, healthy diet, regular physical activity, moderate alcohol consumption).


While these aren’t randomized controlled trials, they are still very powerful suggestions that we can be in control of our health. We can dramatically reduce or cardiovascular risk without the need for prescription drugs.


Bad News Persists


Despite this encouraging information, heart disease remains the leading cause of death in men and women. There are approximately 900,000 heart attacks annually in the U.S., one every 42 seconds, with 365,000 dying from their heart attack every year. Heart disease costs $207billion annually in the U.S. alone.


And for the first time in 20 years, the life expectancy in the U.S. has started to decline. This decline has occurred even though prescription drug use has increased consistently over time with 60% of adults taking at least one drug, and 15% taking more that 5 drugs!


How can this be happening?


2.7% Americans Lead a Healthy Lifestyle

There is a clear disconnect between knowing that lifestyle improves our health and the implementation of this knowledge. Knowledge by itself is not power. We need to put that knowledge into action to realize that power.


A study published in the Mayo Clinic Proceedings concluded that an only 2.7% of all Americans led a healthy lifestyle (defined as regular physical activity, healthy eating, not smoking, and having a recommended body fat level). Less than 3%! That is an astounding finding.


When it comes to our failures with maintaining a healthy lifestyle, the excuses are many and varied. Not enough time. Not enough motivation. Not enough knowledge. Not believing it really matters. Not enough “will-power.” And on and on.


Each reason may have its own unique solution. But fortunately, recent science can put to rest the question of if leading a healthy lifestyle really makes a difference.


We can control our genes


A November 2016 study in NEJM showed that even those with the highest genetic risk of cardiovascular disease can reduce their heart disease risk by almost 50%.


They retrospectively looked at four large trials totaling almost 55,000 subjects. They were able to quantify risk of coronary artery disease based on genetic polymorphisms, and they also could determine adherence to a healthy lifestyle (defined as getting regular physical activity, eating a healthy diet, not smoking, and not being obese).


In the group with the highest genetic risk for heart disease, they found that adhering to 3 of the 4 healthy lifestyle practices reduced the risk of heart disease by 46% (relative risk). In one of the studies, that corresponded to an absolute 5.6% reduction over 10 years.


For comparison sake, statin trials in general demonstrate a 1-3% reduction over 10 years.


(Disclaimer: It is not scientifically valid to compare statin trials with this trial and claim that lifestyle was “proven” to be more beneficial than statin. We would need a head-to-head trial to scientifically prove that. Given the amount of money such a trial would require, and the fact that pharmaceutical companies would never fund it, we are unlikely to see that trial completed in our lifetime).


Can Your Pill Do This?

The results showed that practically everything is improved in the “favorable lifestyle group.” LDL is better, HDL is better, Triglycerides are better. Diabetes is lower. Hypertension is lower. Body mass index is lower. And most importantly, the risk for heart disease is lower.


Do you have any idea how many pills someone would need to take to get those same effects? Two different pills for cholesterol. One for blood pressure. One for diabetes. One for weight loss.


Up to 5 pills! And after all that, it may still not significantly reduce the risk for heart disease.


Impressively, this study shows you can achieve those results with ZERO pills. And most importantly, you can significantly reduce your heart disease risk with ZERO pills. If that isn’t an empowering finding, then I’m not sure what is.


Time to Take Control


The time has come to understand that our health destiny is within our control. We don’t have to be dependent on prescription drugs. We don’t have to “accept our fate” that a heart attack is inevitable.


We can commit to healthy lifestyle practices and enjoy the benefits of improving our health and lowering our risk of heart disease. The science is there. It shows that lifestyle really does make a difference.


Now it’s our job to embrace it, break through our healthy lifestyle barriers and start making meaningful changes in our lives today. Our health depends on it.


Is Perfect The Enemy of Good?

Who are you? An “all-or-none” person? Or a “moderate approach” person?


During my years in clinical medicine, I have learned that there are two types of people when it comes to lifestyle intervention programs: Those who need an “all-or-none” approach and those who need a more moderate approach.


The all-or-none individuals prefer to limit their choices and therefore limit their opportunities to waver. They structure their lives with 100% commitment. They choose to be completely gluten free, completely sugar free, they prefer to count servings and measure serving sizes.


When they are able to commit in this manner, they tend to be wildly successful. The problems are having the drive to make the initial commitment, and then being able to maintain it long term.


The more moderate approach does not want to see things as black and white, good or bad. They realize they are not going to look like a supermodel or a movie superhero. But then again, they wouldn’t want that anyway! They want to find an approach that works within their lifestyle and still helps them on the path to health and success.


(As an aside, if you want an entertaining and instructive account of what it takes, good and bad, to “get ripped” like a super hero, you should read Joel Stein’s account of doing just that here.)


This approach fits in with people’s lifestyles better, but can create opportunities to “fall off the wagon” and allow too many exceptions to take over the norm.


Individualized Approach


There is no universal right or wrong approach. There is, however, a definite right or wrong approach for each individual. They key is finding out which individual you are.


My approach tends towards the later. Yet I see the benefit to the former. Here is an example:


I almost always suggest that my clients try a 2-week trial of going gluten, sugar and alcohol free. For that 2-week period they focus on high quality, real-food plant and animal based nutrition. I ask for 100% commitment.


After the 2-weeks, I ask them to try to extend it for another 2-weeks.


One particular client of mine felt so much better after the four weeks and found he didn’t miss the gluten or sugar at all. He did miss the alcohol a little, but he was able to change his life and keep the 100% commitment for the next 6-months and is still going strong. He lost weight, he had more energy, he slept better, and he felt much more productive at work and life in general.


He had never considered making this type of change before. Once he saw the power of an all-or-none approach, however, there was no other option for him. He found which camp he was in, he embraced it, and he succeeded beyond his imagination.


Another client was so desperate for her bread and dessert at the end of the 2-weeks that she wasn’t willing to even consider doing it for another 2-weeks. But when she went back to eating her normal pattern, she realized that she ate much less bread and much less sugar, and was able to continue with a high quality, predominately plant based nutrition pattern.


So even though she would never consider the all-or-none approach, she still enjoyed the majority of the initial benefits. She too, had more energy, lost weight, and felt more productive. Her health improved, and she was able to limit her temptations.


For her, perfect would have been the enemy of good. She is perfectly happy being “good,” which is a dramatic improvement from previously, and she is much healthier for it.


I have seen the same examples when it comes to regular exercise. My favorite is when I have someone try Orange Theory Fitness twice per week for 2 weeks. After the first week, they are usually pretty sore and beat down. But after the second week, they are usually hooked and in it for the long run.


The hard part is the initial step. Once you commit to that, the rest falls into place.


Everything in Moderation?


As Oscar Wilde once said, “Everything in moderation, including moderation.”


On the surface, it sounds like such a simple plan to follow. But does it work?


The answer, of course, is it depends. As in the examples above, some people will thrive in the all-or-none approach, and some will drown in it. For those, moderation may well be the way to go.


The science is split on the subject, but that is likely because peoples’ personalities are likewise split. Add to that the lack of a clear definition of “moderation,” and it is a recipe for scientific disaster.


Those in favor of moderation point out that restricting something can increase the craving for that item and counteract your intent. They prefer to not think in “good” and “bad” foods, and instead strive to reach a balance without too much of any one thing. That will fit much better into society and everyday life, and it requires less brain-power, less will-power, less obsession.


For some that may work great.


The problem is that there really ARE good foods and bad foods. Sugary soda is bad. No way to spin it. Processed, sugar laden foods full of additives and chemicals are bad. These are the foods that are destroying our health. For the sake of our health and our children’s health we NEED to adopt an all-or-none approach with these foods.


Where do we draw the line?  That is the hard question to answer. That is what we have to explore for ourselves and find where we do best. It may not be easy, and we may not find it right away. But by paying attention, and committing to our health, we can find our “sweet spot,” the perfect combination of moderation and all-or-none.


My Suggestion:


Commit to an all-or-none approach for 2-4 weeks in any endeavor.


It can be the nutrition pattern I described above.


It can be going to the gym or going for a walk every day before work.


It can be starting a meditation practice for 20-minutes every morning.


They key is to commit one hundred percent. No excuses, no variations. You can do this for 2-weeks. I know you can, and you know you can. It’s only two weeks.


Then see if you can extend it two more weeks. You may be able to and you may not.


Then take time to reflect and re-evaluate at the end of the 2 or 4 weeks. You will quickly learn if you thrive with the all-or-none approach, or if you are better suited for a more moderate approach.


Either way, you will reap the rewards from the brief intense commitment, and it will help you redefine what is your moderation. What do you “need” and what do you “want” as a rare treat.


This is a fantastic first step on your path to continued health and success. Give it a try. Your health will thank you for it!


Bret Scher, MD, FACC, CPT



Pasta or Fat? Why not both?

Here we go again. Two new studies came out recently that grabbed impressive headlines about what we should or should not eat. Unfortunately, once again the details may not warrant the high publicity. I have warned about the pitfalls of nutritional research before. Nutritional research is hard. Epidemiological studies require food recall, leave too many variables uncontrolled, and cannot prove causation. On the other end of the spectrum, if the study is overly controlled, it leaves little application to real world scenarios where life is not controlled. I do not mean to be overly critical of the scientists performing these studies, as they are doing their best with the scientific tools they have available. I do, however, mean to be critical of the news agencies and so called experts on social media who promote these studies as if they have definitively answered the questions we have all been asking. The reality is far from it.


The first study (Nutrition and Diabetes 2016,6,e218) examined over 23,000 people in two different epidemiological studies (Moli-sani and INHES trials) and concluded that eating pasta is not associated with increased body weight or abdominal obesity. This is the study we have all been waiting for, right? Now we can get the big heaping bowl of pasta and feel good about ourselves. Who doesn’t want that?


It did not take long for the headlines to roll in. “Eat Pasta to Lose weight!” Or, “Think Pasta is fattening? Think again! It may help you lose weight!” And may others. But my favorite is definitely from “food.mic” and their headline, “This study on how pasta can help you lose weight is easily the best science of 2016.” Gag. It could be nominated for the worst science of 2016. How they can be so far off base is beyond me.


For starters, this wasn’t actually one study. Instead, the report took data from two different studies and compared them. One study, the INHES group, reportedly only filled out a single survey of their food consumption in a 24-hour period, and the body weight and height measurements were self-reported (definitely subject to creative reporting by the subjects). That hardly seems like an accurate assessment of their health and dietary patterns. The other study, the Moli-Sani group, also had just one data point of dietary patterns and was very subject to recall bias.


The next problem is that the authors try to make adjustments for variables, but as we have seen before, there is no way to compensate for all the variables. For instance, those who ate pasta were also more likely to follow a Mediterranean diet (which has been proven to reduce cardiovascular outcomes, reduce weight, and improve biomarkers). So was it really the pasta that helped the subjects maintain a lower BMI? Or could it have been that they ate more in line with the Mediterranean diet? We do not know. This study does nothing to prove that point.


Other key points I enjoyed learning: 1- A “large” portion of pasta in Italy is 3 ounces. That is barely an appetizer in the U.S. Therefore this would not be applicable to anyone who thinks an overflowing bowl of pasta is a normal portion. 2- The study was funded by Barilla, the pasta company. Do you think they had an agenda going into the study?


Despite all that, no study is completely devoid of useful information. We can conclude that pasta is not inherently evil, and one bite will not cause you to gain weight and erode your health. When pasta is a small part of an otherwise balanced and healthy diet, it could be fine. The problem for many Americans is that we like extremes. If some pasta is good, then the endless bowl of pasta and Olive Garden must be great! For those of us who gravitate toward extremes or have difficulty with self-control, I would still suggest avoiding pasta. For those who are better at regulating portion sizes and balance (trust me, this is a skill that needs practice), pasta can be part of an enjoyable lifestyle.


As always, the main conclusion is: Don’t believe the hype! We need to take the time to understand what is behind the hype, understand the positives and negatives of the study, and understand how it may apply to us as individuals and as a society.


The second study (American Journal of Clinical Nutrition 2016 doi: 10.3945) investigated the hypothesis that a very low carbohydrate diet can increase calorie utilization and fat burning. The theory is that carbs increase insulin levels, which act as a fat storage hormone. Insulin will then cause an increase in fat stores, thus reducing the number of calories our bodies burn at rest, ultimately leading to weight gain. Switching carbs for fat should therefore have the opposite effect. A low-carb diet will lower insulin, increase fat utilization, increase resting metabolic rate, and aid in weight loss.


This trial enrolled only 17 overweight subjects. They were sequestered in a metabolic ward where their metabolic rate was accurately measured and they were monitored for their activity level and food intake. They ate only the food that was provided, and their every movement was observed.


This study is in direct contrast to the pasta study I mentioned earlier. The pasta study had no controls, no causative proof, and far too many variables. This study, on the other hand, probably went too far in controlling the environment. That level of control was necessary to isolate a single variable, a high fat compared to a high carb diet. In the end, they concluded the low-carb diet may have less of a metabolic effect than some have promoted. However, what I find fascinating, is that the low carb diet DID lead to weight loss, it DID increase resting energy expenditure, it DID reduce insulin, triglyceride and leptin levels. Yet the researchers claimed it proved a low-carb diet was not truly beneficial. To me, this highlights the importance of bias in interpreting the results. The authors seemed to have a bias against a low-carb diet, so they interpreted the findings by stating how the low-carb diet should have shown even greater effects than it did. Let me get this straight. It showed the exact effects you were testing it for, but you felt it should be a greater effect and therefore you call it a negative study? Sounds fishy to me.


In addition, as we explore the details of the study, we see even more reasons to be skeptical of the publicized conclusions. The subjects were followed for only 4 weeks on the low-carb high-fat diet. There is a well-described adaptation period to a high-fat diet, so this study barely got out side of that time frame. Also, one of the main reported benefits of higher fat diets is that even without purposefully calorie restricting the subjects, they still consume fewer calories then those on a calorie restricted low-fat diet. The higher fat diet is more filling, and therefore they can control their cravings and eat less. This is vitally important in the real world setting, but it is something this trial could not assess given the overly controlled environment.


Lastly, and this is my favorite, for the first 4 weeks the subjects were given a high carb diet that was supposed to match what they were eating prior to enrolling in the study. What happened? They lost weight right away! That tells me 1- The subjects were way off when they said how much and what they ate at baseline. 2- The “high carb” diet given to the subjects wasn’t representative of the standard American diet that most people eat. They did specify in the trial that the high-carb diet they provided was low in processed foods and added sugar. So even though this diet was supposed to be the high carb, high sugar diet that most Americans eat, it was still a dramatic improvement over what they were really eating. Therefore, the study comparison should not have been the high fat diet with the high carb study diet, but rather the high-fat diet compared to the pre-enrolment diet. That likely would have shown the much more dramatic benefits the authors were looking for.


Regardless, the study does raise the potential that the physiological effect of a very low-carbohydrate diet may not be as great as promoted by it’s most vigilant supporters. One big problem, however, is that this trial is so far outside the realm of the real world that it has little application to our lives. Once again, however, there is still useful information to be gained from this study. The take home messages should be:

  • Eliminating processed food and added sugar resulted in weight loss and health improvements even when they were still eating a high-carb diet.
  • Switching to a low-carb, high-fat diet resulted in additional weight loss, reduced insulin levels, reduced leptin levels, reduced triglycerides, and an increase in the resting energy expenditure.


Clearly a low-carb, high fat diet could be a useful diet for some people to help with weight loss, satiety and reduce cravings. Is it for everyone? Of course not. The key is finding a nutritional pattern that we can follow long term that helps promote a healthy weight, supplies adequate nutrition, and is enjoyable. That may or may not include appropriate portions of pasta. It may or may not be a high-fat low-carb diet. But it definitely should be a low-processed foods and low-added sugar diet. At least on that we can all agree.


Thanks for reading.


The “Skinny” on our Metabolism

Does our metabolism slow as we age, and what can we do about it?

Getting older (and wiser) can come with plenty of benefits and positive experiences. By creating a healthy and vibrant lifestyle for ourselves, there is no question that we can age with grace. But is its inevitable that no matter what we do our metabolism will decrease with age? I have heard it many times before, “Doc, I just can’t lose the weight. I have always had a slow metabolism and it has just gotten worse with age.” This is a loaded statement, with some truth and some fiction. Hopefully this blog will help separate partial fact from partial fiction, but first, let’s start with definitions.

“Metabolism” is basically the process by which our bodies convert what we eat and drink into energy. Ingested calories are combined with oxygen to release the energy that our bodies need to function. When someone uses the term “metabolism,” they are usually referring to the Basal Metabolic Rate (BMR). The BMR accounts for 60-70% off all calories that we burn during the day (the others are thermogenesis and daily activity, more on this later). It is also referred to as the Basal Energy Expenditure (BEE). It is meticulously measured after 8 hours of sleep, a 12 hour fast, and the while lying still in a dark room where the oxygen you consume and the CO2 you expel is precisely measured. This is a true basal rate as you are not permitted to MOVE!

The resting metabolic rate (RMR) or resting energy expenditure (REE), is a less restrictive measurement that allows normal simple activities and will almost always be higher than the BMR. They are frequently used interchangeably even though there are some small but important differences as I mentioned.

Now let’s get into the main questions surrounding our metabolism:

Does BMR decrease with age? Yes and no. Basically yes, but there is a healthy debate about whether it is truly age related or if it is due to the decreased lean body mass (LBM) and increased fat mass that normally occurs as we age. There are plenty of studies out there about how the metabolic rate decreases by 2% every decade after age 25, or 5% every decade after age 40. A small proportion of that is likely due to age itself, but the greater association has been linked to loss of LBM. This is obviously important when it comes to treatment. We can’t reverse our age, but we can try to increase out LBM.

Does a lower BMR lead to weight gain? Yes it can. It does not by definition lead to weight gain. But it does make it more difficult to avoid weight gain. All it really means is that your body does not burn as many calories at rest as it once did. This is likely true also for burning calories with activity. To counter act this, you would need to burn more calories by exercising more and eating less, two things that are very difficult for the majority of the population.

What else can slow BMR?

1-There is certainly a genetic component. Some people are just born with a higher metabolic rate, and we are usually jealous of these people. But again, is it all in their BMR? Or are they also more energetic, exercising more and maintaining a higher LBM? Again, both genetics and activity level likely contribute equally.

2-Endocrine dysfunction- Hypothyroidism is the most often cited medical cause of decreased BMR. There is some debate in the literature, without a clear answer, if it is the cause or the effect. Are hypothyroid patients less active because they feel fatigued and lousy, and therefore exercise less, have lower LBM and lower BMR? Or does the hypothyroid condition itself directly lower the BMR? Chicken or the egg? Either way, the treatment is virtually the same. Treat the hypothyroidism, get them moving and exercising, and educate them on proper nutritional choices.

3- Weight and body composition. This is a particularly cruel problem. People with higher body fat have a lower BMR. People with higher body fat also on average tend to have more difficulty maintaining a regular exercise program, and need to work “harder” than someone with a lower body fat to reach the same BMR. It does seem a little unfair that a gym rat with high LBM burns more calories per unit of work than someone with a higher fat mass. Fair or not, that is the way our bodies are wired, and we need to adapt and put in the necessary work to take control of it.

What can we do to “treat” a low BMR?

  • Exercise, exercise, exercise. Increasing LBM is the best and most established way to improve the BMR. That means not just doing cardio, but also doing RESISTANCE training to increase muscle mass. This can be challenging if you are not very comfortable in the gym or if you have pre-existing orthopedic problems. That makes it crucial to start slow, work with a qualified professional, do it safely, and progress only with supervision.
  • High Intensity Interval Training (HIIT). HIIT has been proposed as a great form of exercise to improve BMR (please see my pervious post on HIIT here http://www.myboundlesshealth.com/hiit-right/ ). Specifically, people cite the EPOC, or essentially the body’s increased burning of calories even after you have completed the exercise. While this is true, HIIT does burn more calories after you exercise when compared to cardio exercise, the absolute number is small. In addition, when comparing 20min of HIIT to 45 minutes of moderate cardio exercise, the total calories burned tends to favor the moderate exercise. That does not mean you should avoid HIIT. Absolutely not! It is a fantastic form of exercise for improved fitness and increased LBM. However it is also easy to overstate its effect on BMR.
  • Green tea and Spicy foods- Technically these do improve your BMR. However, they only improve it by about 4%, and only for 30-60 minutes after ingesting the food. Not much bang for your buck.
  • Testosterone- Even in people without “low T.” testosterone supplementation can increase BMR by approximately 10%. This is felt to mostly be due to the increased LBM, and less due to some intrinsic effect of testosterone itself. I don’t want to get into the whole topic of testosterone supplementation (that is a whole blog or two in itself), but increasing LBM and BMR does seem to provide two more reasons for making sure if you have low T you should be evaluated, treated and monitored.
  • Definitely fallen out of favor due to side effects and complications.

What are other strategies?

  • Increase the percentage of active metabolism. Remember in the beginning I mentioned that BMR accounts for 60-70% of our daily energy expenditure. Thermogenesis is roughly 10% and active metabolism is the rest. One of the best things we can do is increase the time we are doing active metabolism! That obviously includes regular exercise, but also simple things like taking the stairs instead of the elevator, parking far away from your office or the shopping mall, getting up and walking around the office every 30-60 minutes. As our society becomes more of a sitting society, this needs to be more of a constant reminder.
  • Make sure weight loss strategies also include LBM maintenance strategies. Many “crash diets” work well for weight loss, but at the expense of losing muscle mass. Guess what that does to the BMR….lowers it further! So even though you lost weight, you also lost LBM, lowered your BMR, and you made it that much more likely that you will gain the weight back with your newly reduced BMR.

What about eating 6 small meals every day? This is one of the most popular beliefs about improving your BMR. The problem is that the science does not support it. The theory is that by providing a relatively constant supply of food for your body to break down, you are keeping the metabolic rate going and preventing it from shutting down. However, the work to digest 3000kcal is actually the same whether you ingest it as 500 kcal 6 times per day or 1500 kcal twice per day. That is not to say that frequent small meals are not a good weight loss technique. It works great for some people. But it does not work by increasing your BMR. It works because for some people it helps cut down on feeling hungry and the inevitable cravings that can lead to binge eating, usually on simple carbohydrate snacks. So if that works for you, Great! But be warry of the “calorie creep.” Sometimes as people get used to eating frequent small meals, the meals start to become not-so-small and the calories increase. Also, it forces people to think about food more, search for food more, and plan ahead to make sure you are surrounded by good food choices. If you need to eat every 3 hours, you better be good at avoiding the chips, cookies, muffins, and other poor choices that are far too plentiful in most work settings.

But doesn’t eating less frequently cause your body to shut down metabolism to preserve energy? This is likely only the case if you fast for 72hours or more. If you remember my previous post I talked about intermittent fasting with a 7hr feeding cycle and 17hour fasting cycle (http://www.myboundlesshealth.com/intermittent-fasting/) . This works well for weight loss in most people and does not slow BMR. It doesn’t work for everyone, but if you can stick to the schedule, it can be very effective. Please see that post for more details.

In summary, our metabolism does slow as we age. But the good news is that we can control it! There is no magic bullet to fix it, but by making healthy nutritional choices, increasing our resistance training, and being more active during the day, we can increase our daily energy expenditures. So when someone says to me, “Doc, I just can’t lose the weight. I have always had a slow metabolism and it has just gotten worse with age.” I know that part of his statement may be true, but I also know that most of it is still under your control. At Boundless Health, it is our priority to educate you about the facts, and develop an individualized program that will give you the highest chance of succeeding. Therein lies the art of individualized medicine that we make a priority at Boundless Health. Contact us today to learn more!


“Bacon and Hot Dogs Can Cause Cancer!!”

“Bacon and Hot Dogs Can Cause Cancer!!” This was the dire warning sent out by the World Health Organization last Monday, essentially rocking the world of millions of processed meat eaters everywhere. They also labeled red meat as “possibly carcinogenic.” Who knew? Well it turns out, we pretty much all did, or at least we should have. None of this is new. The WHO made their decision based on decades worth of nutritional studies. In fact, a similar statement was made in 2007 by other institutions. There was no new trial that just came out showing this to be true. Instead, it was an expert opinion that happened because they had a scheduled meeting and reviewed the old data. Don’t get me wrong. I applaud any reminder that some of our nutritional choices may have adverse consequences for us. What bothers me about the report, however, is the lack of clarity in the rating system and the “breaking release.”


Processed meats (bacon, hot dogs, sausages) was labeled as a Group 1 carcinogen, which is the highest rating they have and states that something has strong evidence to support that it has the POTENTIAL to cause cancer. Not that it WILL cause cancer, but has the potential to do so. This is the same classification as smoking, alcohol and asbestos exposure. However it does NOT mean they are equal in how often they cause cancer. It simply reflects the research strength, NOT the degree of risk. I feel this is worth repeating. It does not mean that smoking cigarettes is equivalent to eating hot dogs. It just means they both have a strong level of evidence behind them regarding the correlation.


Even more confusing is the 2B classification of red meat, which is “possibly carcinogenic to humans.” To put it into context, some have quoted the fact that group 4, “probably not carcinogenic to humans,” has just one substance listed despite hundreds that have been evaluated. So the 2B category of red meat is where pretty much everything else is deposited that can’t be proven yes and cant be proven no. I don’t know about you, but I do not find that helpful at all.


You know what else causes cancer? THE SUN! Does that mean we should all stay out of the sun forever? No. But it does mean we need to be aware of our cumulative sun exposure. We shouldn’t lie out in the desert sun at noon bathed in suntan oil for hours at a time. We need to limit our sun exposure, not eliminate it. Alcohol is also a class 1. How has that affected Budweiser sales? That should give you an idea of the classification.


What is the quick summary? If hot dogs and bacon are part of your every meal, then this report was another good wakeup call that it is time to reevaluate your nutritional choices. But if you have the occasional bacon as part of your Cobb salad, or you have a few slices of beef jerky during your round of golf on Saturdays, then you need not worry too much about the “new” report. Just be aware that some of your nutritional choices may have long term implications. As for red meat? This classification adds nothing new. There may be a real association between red meat and colon cancer. Or there may not. It is tough to say with scientific clarity.

The good news is that the report allows us another opportunity to emphasize that we should all focus on a real food, vegetable based, Mediterranean style diet. Anything to help support that is a welcome addition. But I think the WHO needs to be clearer in their classification system, and not unduly scare people into thinking their 4oz of grass fed steak on top of the salad packed with veggies is as evil as smoking a pack of cigarettes. That just does not compute.


The one take home that we can all hopefully agree upon is that the WHO needs a better classification system!





Golf and Low Back Pain part 2

“Ouch! Every time I swing I get this pain in my lower back . My back is messed up. I am a walking Motrin commercial. I must need an MRI, a low back massage, and strengthening of my lower back. Right?”


Sound familiar? I hope not. But if it does, please read on!


Low back pain is one of the most common golf-related injuries with up to 80% of golfers experiencing back pain at some point. The vast majority of the time, the lower back gets injured as an innocent bystander, caught in the crossfire between poor hip mobility, reduced thoracic spine mobility, and an underactive core. This is a dangerous combination that dramatically increases the strain and load on the lower back, and almost guarantees an eventual injury.


The problem is that working on the lower back won’t solve any of these issues! Without a thorough physical evaluation, it is highly unlikely that you will find the culprit. The key is to NOT focus all the attention on your back. Instead, you need a complete, thorough evaluation from a qualified professional to get to the root of the problem. Only then can you develop a program to safely address it.


It turns out, back pain can come from physical limitations as well as swing related causes. The swing causes are often a result of the physical causes, and thus it is vitally important to have your swing evaluated by a professional trained in the swing-body connection. The Titleist Performance Institute (TPI) has revolutionized the training of practitioners versed in both the golf swing and body mechanics. By finding someone who is TPI certified, you know you are staring in a good place.


At Boundless Health, we boast 3 highly trained, TPI certified practitioners to help identify the main issues and develop an individualized program to address them.


While an exhaustive discussion of back pain is beyond the scope of this blog post, lets look at some of the most common swing characteristics and related body factors that can lead to low back pain:



  1. Set Up Posture

An “S posture” is a very common cause for low back pain. This is where you have excessive curve in your lower back and your butt sticks out behind you. This automatically puts you in a position where you rotate more through your lower back and less through your thoracic spine and hips. You aren’t even giving your hips and upper back a chance to do their job! Correcting your set up posture to a neutral posture will quickly alleviate this issue. But can you reliably maintain a neutral posture? That is when we have to look at how your body works.


Can you do a slight pelvic tilt and glute contraction while keeping your shoulder blades pulled back, all without thinking about it or forcing yourself into the position? If you sit at a desk or work on a computer all day, the answer is likely NO! With the proper training, however, I guarantee you that you will be able to. And that will go a long way to protecting your back.



  1. Backswing

Remember, it all starts with proper set up posture. Once you have achieved that, then you are ready for your backswing. But what if your backswing causes you to have a “reverse spine angle?” This is where your weight doesn’t properly transfer to your trail leg, you don’t rotate much over your trail hip, and thus end up leaning towards the target with an arch in your lower back. OUCH! You will feel this one in your back swing and then it will get you again in the compensation needed in your downswing. Twice the risk for injury!


This swing characteristic is commonly caused from limited hip mobility in your trail leg, a weak gluteus muscle, or reduced thoracic spine rotation. With a more thorough screen, we can tell the difference, attack your weakness, and get you moving much better to shift the weight off your lead leg, allow your trail hip to rotate in, thus keeping your spine neutral, and feeling that stored power in your coil. All without asking your lower back to do any of the work. Notice that none of this has to do with weakness in your lower back! Your lower back was an innocent bystander asked to compensate for improper movements.


  1. Downswing

On the downswing, we need to transfer our weight back to our lead leg so we can rotate around the lead hip. But what if we “hang back” and don’t efficiently get our weight to our lead leg? You still need to deliver the club to the ball, so our lower back will quickly try to take over and shoot your hips forward (toward the ball, not the target), thus causing you to bend through your back again and dramatically increase the pressure and load on your lower back.


To tackle this issue, we need to see if your lead hip can rotate efficiently, and if your core can act as a rotary motor rather than forcing you to move laterally or forward. Since we do not tend to do these motions in our daily life, the necessary muscles are frequently underdeveloped. With directed training, we can help you strengthen properly, and more importantly, develop the needed neuromuscular connections to easily and reliably fire those muscles in the time of need.



This is a brief introduction to the complex topic of golf and low back pain. Remember, the lower back is rarely the cause of the problem, but it is frequently the path of least resistance in the chain that ends up getting injured. With a thorough screen of both your swing and your body’s movement patterns, we can help identify the cause of the increased strain on your back, and help formulate a plan to fix it. Contact us today to learn more how we can help you play better, and help you play pain free!


Bret Scher, MD, FACC

Lead Physician, Boundless Health





Introduction to Golf Posture

Proper golf posture is a critical element to our swing, yet it is often overlooked. Proper posture requires an intricate balance between multiple body parts and movements. Here is a brief introduction to golf posture. This is such a complex topic, and this introduction barely does it justice. At Boundless Health, we welcome the opportunity to work with you to develop an individualized program to get your body primed for your optimal golf posture.


Golf Posture

Here is our brief introduction to posture and an initial exercise to get you started. This is obviously just scratching the surface, and we welcome the opportunity to work with you on an individualized program to improve your posture and your function in everyday life and on the golf course.


Grab Your Salt Shaker!!!

It appears another devil has been found to be not so evil, and that the real devil is once again in the details. Conventional medical wisdom has preached for years that salt is evil and should be avoided at all costs. The US government perpetuated this by making it part of their dietary recommendations to limit salt below 2.3g/day.

It is becoming an all too common occurrence, but was once again we should be shocked to find out how the government based its strong recommendation on extremely suspect data (see the previous blog on fat intake). Their decision to firmly recommend low salt intake for the general population came from a single trial that followed people for only 30 days. It is true that the DASH trial showed a reduction in systolic blood pressure by reducing salt to less than 2.3 g per day (NEJM 2001;344:3-10). However, it turns out that the absolute BP reduction was only 5mmHg/2mmHg. Hardly earth shattering. In addition, since the trial was so short there was no data on clinical outcomes (i.e. reduced heart attacks, strokes etc.). Once again, a government guideline that shaped medical dogma came from very limited data.

We now know that the data was not only limited, but also clinically misleading. Since 2001 there have been no trials showing a correlation with low sodium intake and reduction of heart attack, death or stroke. So although it may mildly reduce BP, it doesn’t help people clinically. Does this sound familiar? To me it sounds awfully similar to some type of fat increasing an LDL level but not having a direct increase on heart attack, stroke, or cardiovascular death. Clearly one measure does not tell the whole story.

Why is this an issue now? There was a recent article in the San Diego Union Tribune talking about a study that showed how salt may be potentially beneficial for wound healing (it was a small study in mice so I am not convinced it will apply to humans yet), and in addition, the WSJ had a recent “point and counterpoint” article about the benefit or risk of a low salt diet. Both articles highlighted the evidence that has come out over the past few years showing salt intake to not be as dangerous as once thought, and that salt restriction may actually be where the danger lies.

What is the evidence? A 2014 paper looked at data from 23 different studies and showed there was a U-shaped outcome for salt intake. U shaped meaning there was an INCREASE in harmful outcomes at both low (less than 3 g per day) and high (greater than 7 g per day) levels of sodium intake. Specifically, they looked at the risks of heart attack, stroke or cardiovascular death (Am J HTN 2014 Apr 26). This confirmed the findings of a 2011 study (JAMA 2011;306(20):2229) showing the same conclusion. In fact, in 2013, a committee at The Institute of Medicine officially said there was no scientific reason to recommend less than 2.3g of daily sodium intake (the AHA has yet to change its position despite the preponderance of evidence).

How can this be? Is there any potential scientific rationale as to why low sodium intake could increase a patient’s risk? The proposed mechanism of low-sodium causing adverse cardiovascular outcomes is that decreased blood flow to the kidneys can trigger a harmful hormonal response with associated downstream clinical effects. This is not a proven mechanism, but it is always nice to know that there is at least a plausible hypothesis for our scientific findings.

Once again we are confronted with the reality that the medical community and population as a whole need to continuously question the rationale for guidelines and official recommendations. We need to rely on outcome-based studies and use those preferentially to frame our recommendations.

(Keep in mind; however, avoiding sodium restriction would not apply to individuals with poorly controlled hypertension, or patients with a weakened heart muscle and congestive heart failure. And on the other side, avoiding high sodium intake would not necessarily apply to high performance athletes at risk for excessive sweat loss.)

We can rest assured that we no longer need to enforce a restrictive low-salt diet in the general population. So if you are so inclined, dust off the old salt shaker with a smile.

However, we also have to remember that medicine, health and wellness is not a one size fits all treatment program. We are each different and unique in our own way, and that applies to our sodium sensitivity as well. At Boundless Health we evaluate every client as an individual. We work closely with you to develop an individualized health and wellness program that works specifically for you. Together, we can start on your path to optimal health and wellness.

Please contact us today to find out more about what Boundless Health has to offer, and how we can help you achieve your health and wellness goals!

Bret Scher MD FACC

President, Boundless Health

Titleist Level 1 Certified

NASM Certified Personal Trainer



Best Evidence Summary

1-     Sodium intake above 2.3g/d can modestly increase BP2-     There have been no proven adverse clinical effects of sodium intake between 3-7gm/d

3-     Sodium intake below 3gm/d or above 7gm/d have both been associated with increased risk of heart attack, heart failure or death

4-     In the absence of poorly controlled hypertension or heart failure, there is no clinical need for sodium restriction aside from excessive intakes above 7gm/day

5-     Previous recommendation for low salt diet was based on a small trial over 30 days showing a modest increase in BP. No clinical outcomes were measured.


Approx. amount of sodium for a given amount of table salt

¼ teaspoon575mg
½ teaspoon1150mg
¾ teaspoon1725mg
1 teaspoon2300mg




Is HIIT Right For You?

Is High Intensity Interval Training (HIIT) a better way to exercise?


That is, of course, a leading question without a definite answer, and thus the question needs clarification. For starters, better for what? Weight loss? Fat burning? Muscle building? Explosive athletic performance?  Feeling good? There are too many options to give one simple answer. Yet based on popular news and marketing, we are frequently lead to believe that we should all be doing HIIT all the time. However, the most important part in that equation is defining what are your specific goals? To help guide you, it may be best to start with defining what HIIT is and what it isn’t.


By definition, HIIT (also called Sprint Interval Straining or SIT) consists of short bursts of high intensity, maximal performance exercise lasting less than 2 minutes in duration (frequently less than 1 minute) with equal or longer rest periods.  For generations HIIT has been used for sport and athletic performance. More recently, however, HIIT has has become popularized for the general exercising public with promises of better and more time efficient calorie burning, fat burning, weight loss and fun. Of course, the fun part is in the eye of the beholder, true for some and torture for others. You know who you are. But are the rest of these claims substantiated?


Looking at the following table, it becomes clear that HIIT is a better calorie burner than low intensity (3mph treadmill) exercise, but it is NOT better for burning calories than moderate (6mph treadmill) intensity cardio training. In fact, since HIIT can usually only be maintained for short periods of time and can’t be done for 60 minutes (usually 20 minutes max), the better choice for calorie burning is to do the longer, moderate exercise. (Of note, EPOC is Excess Post Exercise Oxygen Consumption, which has been linked to the improved metabolism from high intensity exercises that is not seen with moderate cardio exercise. However, while this is true, the absolute calorie yield is low at around 10% over 14 hours)


HIIT20minutes175 kcal burnedEPOC approx. 20kcal/14 hours
Treadmill 3mph20 min96 kcalMinimal EPOC
Treadmill 6mph20min195 kcalMinimal EPOC
Treadmill 6mpgh60min585 kcalMinimal EPOC


So if burning fat or calories is your only goal, HIIT is not “better”. But it certainly is a better exercise for developing lean body mass and also improving athletic performance. Some other benefits that have been described are its ability to improve insulin sensitivity (very important for diabetics and pre-diabetics), and improving VO2 Max, as well as aerobic and anaerobic thresholds.


Interestingly, weight loss may not be one of the benefits HIIT. There was a recent article in the Wall Street Journal about the popularity of cross fit, a prime example of HIIT. But the article wasn’t about the exercises, the calorie burning, or the time efficiency. It was about how participants can’t fit into their jeans anymore! The high intensity exercise is excellent for building muscle, predominately on the legs and glutes. Thus, the need for new jeans. In fact, one crossfit member saw it as a business opportunity and started his own jeans company specifically cut for the “crossfit body type”. You may not lose weight, but you will gain muscle. Is that better? Again, it depends on your goals and what other types of exercise you are doing during the week.


If we view traditional exercise as 30-60 minutes on the elliptical or treadmill, you can quickly see how the interval style training (frequently done in a group setting with like mined people) can be a fresh change and introduce diversity. And that is where I see its best effect, to break up or add to a routine, and to force you to push your limits and rediscover what your body can accomplish. It may even build a community to help with motivation and enjoyment.



ExerciseCalorie burnLean Body MassPerformanceFun
HIITGoodVery GoodVery GoodDepends
Moderate CardioBetterMinimalMinimalLess so



So at this point you may be wondering, “What are the downsides to doing HIIT?” First of all, because of the high intensity, HIIT is not an exercise that should be done every day or even every other day. This type of high-intensity exercise can produce significant initial muscle breakdown and stress hormone release, thus requiring a longer recovery period. Therefore, HIIT should only be done once or twice per week in the general population (this recommendation is different for athletic performance training). Secondly, because of the increased intensity, HIIT can increase the potential injury risk for those who do not have an adequate base level of strength, mobility and stability or knowledge of exercise technique. Thirdly, the high-intensity may be difficult to maintain over an entire workout leading to poor form and inadequate results near the end of the workout.


These potential downsides make it very important to consult with health coach or experienced trainer prior to initiating HIIT training. The first goal of exercise should always be to do no harm, thus the need to ensure you are doing HIIT in a proper, and safe manner


In summary, HIIT is a very popular method of exercise that can be fun to do, can build lean body mass and improve athletic performance, and can provide much needed variety to a training program. HIIT can take you out of your comfort zone and challenge you to learn what you can accomplish. However, do not expect it to be a superior exercise for weight loss, fat burning and calorie burning, and be cautious of the potential risk of injury, as well as your body’s need to properly recover from a HIIT workout. When monitored by a trained professional, HIIT is a valuable addition to any training program.


At Boundless Health we specialize in designing a personalized health and fitness program that works for you and your specific goals. Is HIIT right for you? Contact us today so we can help you determine how HIIT fits into your program for a lifetime of health and fitness.



Bret Scher, MD, FACC

President, Boundless Health

NASM Certified personal trainer

TPI level 1 certified