The Fitness Triad: Nutrition, Exercise, Mental Health

Women and Exercise--It Takes More Than Spinach

Is that why Olive Oyl looked the way she did? Is it because Popeye hogged all of the spinach? Maybe not.

It's hard to cover a subject like women's health without combining the confluent subjects of both nutrition and exercise. Indeed, I tried writing about just nutrition and then just exercise and found it impossible. This is with good reason. The two are inseparable. Each enhances the other, and deficiencies in each cause deterioration in the other. We now know that actual fitness is a complex scheme and balance of good nutrition, physical exercise, and a third necessary ingredient--mental health. Additionally, tip-toeing along a woman's physique is the chemical network of hormonal pathways that can affect as well as be affected by nutrition and exercise. Pregnancy is the ultimate challenge, and a women's needs become different when she's living for two.

Many women equate nutrition with weight control. The simple truth is that with good nutrition, weight control is included without much extra effort. Supplementing good nutrition with the right amount of exercise, and suddenly weight control isn't much of an issue.

First, let's talk, about exercise. Overall physical fitness is best achieved by cardiovascular fitness, which should be the major goal of exercise. The best way to attain cardiovascular fitness is with a sustained program, at least three times a week, in which a woman achieves a target heart rate for a period of at least 20-30 minutes. A simple way to determine one's target heart rate for this goal is by the formula:

(220 - AGE) X 60-80 percent = Target Heart Rate.

Understanding Your Target Heartrate

For example, for a 36-year-old woman, 220 minus 36 equals 184. 60-80 percent of 184 gives a target range of 110-147 beats per minute. If weight loss is also desired, it is important that exercise be intertwined with a slow weight-reduction diet. But remember that I said that good nutrition may be the only thing needed to see weight slowly go down. But if dieting is also needed, I recommend a slow weight-reduction diet. One needs to lose it like she gained it--a couple of pounds a month. If one were to lose only a couple pounds a month, she will find that the actual decrease needed in calorie intake might be negligible, especially if low fat methods are used. And losing that little weight a month means that no one's suffering, adding to the chances of success. A slow weight-reduction also means that one is retraining the way she eats, further re-enforcing a combination of good nutrition, good exercise, and good dieting. Exercise, or better yet, cardiovascular fitness, tends to trim away more abdominal fat than fat in other areas, so the cosmetic results will be more rewarding.

The non-suffering aspect to dieting is important. If one were to lose only two pounds per month, for instance, she wouldn't be suffering. Upon reaching her ideal body weight a woman won't be inclined to feel, "Thank God that's over," and go back to any former dietary bad habits. And even though a dieter wants to lose tons of weight by yesterday, after a year of only two pounds per month she will have lost 24 pounds, and she will have KEPT it off by the end of that year. And retraining oneself to eat right--for the rest of her life--is a mindset a woman has to accept or she'll be through countless, fruitless cycles of binge dieting, binge exercising, and binge disappointments.

We're all changing. The food stays the same, but we're all different as we grow older. The fun's over. We can't eat like we did as adolescents, which is when we learned all of our bad eating habits. But throw in exercise, by all means. Suddenly a two-pound-a-month weight loss gets lost in the background. Now three to four pounds becomes easy, and additionally, cardiovascular fitness is included as well as trimming away abdominal fat to a greater extent when compared to the rest of the body.

But don't look to exercise as a crash diet adjunct. Weight loss from exercise is also slow, the value of exercise mainly coming from fitness and toning. Nutrition, the necessary fueling of the body, needs to be fine-tuned for best results. Countless studies have been conducted throughout recorded medical history, but presently we have reliable authorities, like the Food and Nutrition Board of the National Academy of Sciences, to rely on for information.

The best intake of calories seems to hover around 2000-2100 calories for a healthy non-pregnant woman. Pregnancy requires an additional 300 calories or so, usually in the form of high protein, low-fat, low-salt choices. Calcium needs are 800 mg, and pregnancy increases this need by an additional 400 mg. Post-menopausal women, besides taking estrogen as an essential condition for absorbing calcium, should increase calcium even more with pill supplements. This is to prevent progressive osteoporosis. Protein is adequate at 45 grams/day, or 75 grams if pregnant. Iron, at 18 mg. per day, should be at least tripled for pregnancy. Folic acid at 4/10 mg. per day for a non-pregnant woman, should be increased to a full milligram in pregnancy to decrease the risk of developmental abnormalities in the fetus. Prenatal vitamins have done a nice job in raising these amounts to the recommended levels for pregnant women.

Exercise in pregnancy is also beneficial to nutritional as well as mental well-being, as long as high-impact maneuvers or increases in core body temperature are avoided. In fact, the best labors occur in women who have achieved cardiovascular fitness before, and maintained it during, pregnancy.

I'll admit that it's hard to make interesting a topic most people find drudgery in practice, since we tend to lead our lives like Wimpy--gladly intending to pay Tuesday for that hamburger today. But it need not be drudgery; in fact, it should be exhilarating.

Mental health completes the triad of well-being. Even when things conspire to depress us, everyone finds that being in good physical condition, through good nutrition and cardiovascular fitness, lessens the blows that psychodynamics may deal us when we're confronted with the bad events that come periodically. We can't do anything to prevent all of them, but we can hedge our bets by maintaining the other two aspects of the triad, nutrition and exercise. And as any health "enthusiast" will tell you, one feels better emotionally and mentally when regular exercise and good nutrition are one's major lifestyle choices.

Are Diet Pills Still A Bad Idea?

I'm pretty dizzy by all of the about faces I've done regarding diet pills. My first position was that diet pills didn't work. This was because, at the time, diet pills meant amphetamine-like substances. Amphetamines are dangerous. They are addictive and can cause cardiac strain and psychoses. But then when the FDA-approved Redux came out, I was inclined to say they can play a very useful role when used in an integrated diet program that includes exercise and, most importantly, behavior modification.

At the time I was right in saying that most crash diets didn't work, because many people would say, "Thank goodness that's over with," and go on to eat like they used to. But now, changing one's ways of living and eating needs to go hand in hand with a permanent lifetime management of weight. Some might find this easy, but most would find it difficult.

Self-confidence, or the lack of it, was the doom of any well-intended plan. Before Redux and fen/phen, people didn't even want to try anymore, seeing the yoyo results. They found it difficult and embarrassing to go to the gym and exercise alongside the well-proportioned and sculpted bodies of the babes and hunks. This was where the temporary use of anti-obesity pills began to play a secondary, but important role. The new anti-obesity medicine Redux (and fen/phen) promised to jump-start a feeling of self-confidence. If a patient were to lose some weight at all, fairly quickly, then he or she might feel "qualified" to be seen at the gym, because the fact that the patient would notice any difference in the mirror would then have an enormous positive effect on feelings of well-being and self-respect.

So these newer pills gave that initial result sooner so that exercise could be added to the regimen fairly quickly and then the pills phased out. The resulting positive snowballing effects, it was thought, would then reinforce techniques of behavior modification, the third crucial step.

It seemed that gone were the days when the only "diet" pills were amphetamines and therefore addictive. Now we had what seemed to be much safer medications that could be used for substantial periods of time without the dependence or undesired side effects. But in spite of the new safety assurances from the FDA for this type of medicinal help, we still had the pitfalls of the old diet pill days--we still had to deal with a patient's continuing bad habits.

We knew, even during the Redux debacle, that no weight loss regimen of decreased dietary intake, pills, or exercise would work forever unless the patient were willing to retrain the way he or she would eat. After the initial success of weight loss was realized, and after initiation of exercise, behavior modification would become the weight-bearing wall of continued weight control (pun intended).

We felt we had pretty much eliminated the dangers of the types of medicine used. These newest pills, Redux and the "fen/phen" (fenfluramine and phentermine) combination, were to see a greater role after the old prejudices of the previous amphetamine diet pills were gone.

Then the scare of pulmonary hypertension got so much press that Redux and fen/phen had to be defended as probably much less of a threat to someone's life than the hypertension, diabetes, and heart disease that obesity can cause. Under a physician's direction, it was argued, the duration of medicinal therapy could be responsibly monitored and any risks recognized.

Even with exercise much more available through the social advantages of using health clubs or the availability of simple machines that can be used in the privacy of the home, keeping the weight off was still the problem, and changing one's ways was the crucial new necessity. Although behavioral modification officially fell under the expertise of behavioral neuropsychiatrists, most legitimate weight-reduction clinics used the counseling of the nutritionist or dietician.

But Redux and fen/phen remained popular, because finally there was a prescription any M.D. could write with a good conscience, as long as exercise and behavioral changes were pledged as well to seek a lifetime of ideal body weight. Although only exercising and only changing the way one eats could have the same beneficial effects over the long term, it had to be a combination of the two, or a three-part regimen that also included these new diet pills.

Exercise and changing the way one would eat could be used alone or in combination with the pills successfully. But we still knew that using the pills alone would perpetuate the failures of the pills of the past. These were the pills of the present, however, and there seemed less urgency to discontinue them even when a patient did the other things and thereby began getting results. And then there was the report of heart valve damage with Redux and fen/phen.

We all had high-cholesterol egg on our faces. The pills became bad press.

Not to worry, the weight-loss clinics said. The legitimate ones, anyway, for they felt so strongly about exercise, diet, and behavior modification that they felt that the loss of only the jump-start of these pills would only mildly slow down results. They were so wrong. Not about exercise, diet, and behavior modification, but about business--it plunged. People wanted their pills, dammit! Physicians, nutritionists, registered dietitians--we all underestimated how self-indulgent the something-for-nothings were when it came to losing weight.

Left with only the hard work of exercise, diet, and behavior modification, business went down the wrong tubes and clinics closed...awaiting a new pill.

That new pill is now out. Called Meridia, it boasts a designer serotonin alteration property that does NOT cause pulmonary hypertension and does NOT affect heart valves. Derived from anti-depressants (related to Prozac and Zoloft), it is felt that a patient may possibly stay on it for extended periods of time.

The Redux Debacle

Since a lot of what happens in the field of medicine involves pumping into us foreign substances such as penicillin, blood pressure pills, or decongestants, there are sometimes undesired effects. This is because the pristine system, Homo sapiens, was designed to run pretty much on its own. Of course we've been able to raise the life expectancy from 35 to 80 with these foreign substances, and so the battle to create good with a minimum of evil wages in research labs of pharmaceutical companies throughout the world.

One of the "consumers' advocates," if you will, is the FDA. They apply strict guidelines to assure the safety of medications flaunted to the public as safe and effective. Back in the olden days of diet pills, I proudly had refused to write any prescriptions for diet pills. First of all, they were all amphetamine-like substances--speed--with an array of side effects that ranged from feeling hyper to mood swings to outright psychoses. They messed with REM sleep. They were abused. But they sure worked. I felt at that time that one doesn't take diet pills to just lose the weight without changing the way one eats--forever. I knew that most dieters that used these drugs were doomed to failure, the patient almost without exception weighing more a year later than when he or she began this drug-diet. I was absolutely right.

Then came the new diet pills, Redux, "fen/phen" (fenfluramine and phentermine). FDA approved, seemingly safe, tested, and based on a version of anti-depressants that have been declared safe enough to use even in pregnancy, I was no longer able to hide behind the serious side effects of amphetamines in refusing to write prescriptions for these new "safe" pills. But realizing that doctors know much less about nutrition than a certified nutritionist, I decided to do it right. I still felt that even the miraculous new pills were not magic bullets--that the patient would still have to change the way she (I'm OB-GYN) ate for the rest of her life. I insisted on a program of behavior modification and exercise that would carry over well beyond the temporary jump-start that the pills would bring. So we did do it right.

With the newer pills, we followed FDA guidelines. We insisted on behavioral modification and exercise as well. We declared from the beginning that the pills were only a brief crutch to get them used to a new way of eating for the rest of their lives. In one of my articles, I wrote, "Where I once said that diet pills don't work, now I'm forced to say they can play a very useful role when used in an integrated program that includes exercise and, most importantly, behavior modification..."

Gone were the days when the only "diet" pills were amphetamines and therefore addictive. Now we had much safer medications that could be used for substantial periods of time without the dependence or undesired side effects. Even when the scare of fatal pulmonary hypertension was raised, doctors could still say that the risk from death was greater from obesity and justify the pills. But then there was this heart valve business.

Oops (medical slang)

I had a long discussion with Diana Davis-Kelly, the dietitian and nutritionist who directs nutrition and weight management in our practice. The final disposition was that we were not going to be devastated by the removal of these diet pills. In fact, we agreed that we wouldn't even be inconvenienced. Afer all, we had long ago decided that the standard of care for our dietetic and nutritional services would be comprised of behavior modification, including a change to a lifetime of correct diet and exercise. And the rest is consumer desertion history (see above).

So, O.K., we relied on the FDA and got blind-sided by the newer concerns. But it's the FDA that also alerted us to the dangers. Sometimes the initial studies that indicate safety when mixing chemicals with Homo sapiens can also start a marketing campaign which by its very success adds more volume to a study than originally recorded, resulting in the discovery of side effects never picked up initially. Thankfully, we only used these pills for what they were really meant to be--a temporary aid in getting someone used to a new way of eating. Also, although the evidence seems to point an evil finger at these medications, there are other studies in the works that may exonerate them in the future. Unless the new pill Meridia and future ones like it make Redux resurrection unnecessary.