Archive for May, 2012

Vitality Does Not Demand Exercise Nor Super-Healthy Eating

May 25, 2012

Andrew Siegel, M.D.   Blog # 60


“Hey, how are you doing?”

“Not bad.”
“Anything good going on?”
“Nah, not really…same old.”


In many circumstances—as above—the absence of bad is as favorable as the presence of good, and that, dear reader, is the premise for the ensuing discussion.

As ridiculous, simplistic and absurd as it may sound, you do not need to eat a super-healthy diet and exercise regularly to have a vital existence.  Rather, what you do need to do is to avoid eating harmful foods and abstain from a sedentary existence.

The Hippocratic oath teaches us Primum non nocere, a Latin phrase meaning “First, do no harm.”  It is a useful doctrine that physicians practice on a daily basis.  In many situations, avoiding mistakes and errors is the key to success.  This is also applicable to sports—for example, tennis—where a match can be won without hitting many clean winners by simply not making many errors.

The aforementioned is totally relevant to our eating and exercising habits.  You don’t need to eat a vegan diet, a Paleolithic diet or a Weight Watcher’s diet to be healthy, nor do you need to be a gym rat to be fit.  What you do need to do is to try to avoid processed and junk foods and stay active, energetic and kinetic. Don’t get me wrong—there is a difference between the intensity, duration and type of exercise necessary to improve sports performance versus that needed for health and vitality. Staying active is not the same as sport-specific training, in which we work on discrete exercise skills, accompanied by endurance and weight training that culminates in adeptness, conditioning, efficiency and adaptation.

Our bodies will always adapt to the stresses placed upon it, whether the stresses are strenuous exercise, staying active, or being sedentary.  The changes in terms of insulin resistance, blood glucose, fat-fighting enzymes, metabolism and energy level resulting from strenuous exercise and staying active are quite positive, but those resulting from a sedentary existence are quite negative.  If you want bulging biceps and pectorals or a ripped six-pack or to train for a triathlon, you’re going to have to earn that with healthy eating and lots of “formal” exercise; however, if your endpoint is optimal health and not glamour nor excelling in sports, you just need to do some moving.  Many health benefits can be derived without doing “formal” exercise—the physical activity does not need to be particularly exertional, but does need to involve locomotion.  The problem is that two-thirds of us get absolutely no exercise whatsoever; being a couch potato not only is unnatural, but also has grave health consequences in terms of the maladaptive response of our bodies to this sedentary existence.

Integrational exercise is a means of incorporating exercise and movement into your daily activities. You don’t need special equipment, gym clothes, a fitness center, a heart rate monitor or a personal trainer. The key to integrating exercise into your daily routine is keep moving—it has even been shown that being fidgety is a form of exercise that burns calories in the form of nervous energy.  Take the stairs instead of the elevator; when at an airport, climb the stairs instead of using the escalator and walk to the gates instead of using the conveyor; at the mall, instead of circling around looking for that close-to-the-entrance spot, park the car as far away from the shops as possible and walk the distance; “power” vacuum your rugs; mix batter for a cake by hand as opposed to using an electric mixer; use hand tools instead of power tools; garden; shovel snow; mow the lawn; saw tree branches; walk the dog; carry a heavy laundry basket; take out the recycling; carry your child on your back; dance; stand upright while talking on the telephone, etc. These integrational exercises may not result in weight loss, but they will keep you active and moving, making you healthier and enjoying a longer life.

Non-Exercise Activity Thermogenesis (NEAT) is the term applied to how we reap major benefits through thousands of minor movements each day.  NEAT is the body’s means of fighting inertia.  Interestingly, some of us do not gain weight despite increased caloric intake because of compensation via subconscious movements including taking the stairs; trotting down the hall to the water cooler; bustling about with chores; even fidgeting in one’s seat.  Standing has been shown to cause us to reap substantial benefits as opposed to sitting.

A few days ago, I played doubles tennis for two hours and then played a round of golf in which I walked the course.  This really was not much in the way of aerobic, resistance, or core exercise—my lungs weren’t heaving, my heart wasn’t racing, I wasn’t sweating much, my muscles were not sore—but nonetheless, it was six hours or so of energetic movement.

Another way in which one can reap the health benefits of the “good” by essentially avoiding the “bad” is in the food arena.  In our modern society, if you want to stay on track regarding a healthy diet and weight, it is not so much what you choose to eat that counts, but what you elect not to eat.  Making a concerted effort to avoid unhealthy, unwholesome and unnatural foods as much as possible will ensure the intake of an abundance of natural and wholesome foods. There are a great variety of quality foods that can nourish us, and it is not important what your specific choices are as long as there is balance, sufficient intake of macro-nutrients (protein, fats and carbohydrates) and micro-nutrients (vitamins and minerals), and avoidance of excessive calories. The key is to stay away from processed, reconstituted, unhealthy, mystery, faux foods.

Humans are remarkably omnivorous, meaning that there are a great variety of different foods—plant and animal in origin—that can both provide energy for our metabolic processes and sustain us in terms of tissue replenishment. I borrow Michael Pollan’s maxim and reverse it in an effort to summarize what not to eat: Imitation food, a lot of it, mostly animal-based…and there we have the Western diet—processed foods, lots of meats, refined carbohydrates, fats and sugar—the eating style that has contributed to two-thirds of Americans being overweight or obese and responsible for the scourges of Western civilization, namely hypertension, diabetes, cardiovascular disease and some cancers.

Bottom line: The active pursuit of a healthy diet and regular exercise certainly go a long way in terms of shaping our health destiny, but are not essential for our vitality and longevity.  What is essential is the avoidance of an unhealthy diet and refraining from a sedentary existence, simple actions that can be transformative.  The science is crystal clear that powering ourselves with poor-quality fuels and sitting motionless on a chair or couch for prolonged periods of time are unhealthy and disease-promoting behaviors.

A few years ago, I wrote a book entitled Finding Your Own Fountain of Youth: The Essential Guide to Health, Wellness, Fitness & Longevity.  Through the process of interviewing many youthful elderly persons (referred to as “YEPpies”) I concluded that the cornerstones of vitality were the following:

  • Having a sense of purpose
  • Staying physically active
  • Passions and hobbies
  • A healthy diet
  • Avoiding self-abuse: junk food, obesity, tobacco, immoderate alcohol, excessive sun exposure, etc.
  • Close relationships
  • Optimism and the ability to adapt to life’s changes
  • Preventative maintenance
  • Respecting yourself and living well

Always remember:

Food and lifestyle have the power to prevent, reverse, and even cure
most chronic illness, the cause of endless personal suffering and an

unsustainable burden to our global economies and social fabric.

(Mark Hyman, M.D.)

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Available on Amazon Kindle


Pelvic Floor Muscle Exercises: Becoming the Master of Your Pelvic Domain

May 18, 2012

Andrew Siegel, M.D.  Blog # 59

The pelvic floor muscles (PFM)—first described by Dr. Arnold Kegel—are key muscles that are essential to the health and well being of both women and men.  These muscles do not get a great deal of respect, as do the glamour muscles of the body including the pectorals, biceps and triceps. The PFM should garner such respect because, although hidden from view, they are responsible for some very powerful and beneficial functions, particularly when trained.

The PFM compose the floor of our “core” muscles.  Our core is a cylinder of muscles of our torso that function as an internal corset.  They surround the inner surface of the abdomen, providing stability.  These muscles are referred to in Pilates as the “powerhouse”; Tony Horton, guru of the P90x exercises series, uses the term “cage.”  The major muscle groups in this core are the following: in the front the transversus abdominis and rectus abdominis; on the sides the obliques; in the back the erector spinae; the roof is the diaphragm; the base are the PFM.  These muscles stabilize the torso during dynamic movements and provide the wherewithal for body functions including childbirth; coughing; blowing our noses; equalizing the pressure in our ears when we are exposed to a change in air pressure as when we travel on airplanes; passing gas; moving our bowels; etc.  If you want to be able to expectorate like Gaston in Beauty and the Beast, you need a good core!


Core strength provides us with good posture, balance, support of the back and stabilization and alignment of the spine, ribs and pelvis. The core muscles are a “missing link” when it comes to fitness, often neglected at the expense of the limb muscles.   Tremendous core strength is evident in dancers, swimmers, and practitioners of yoga, Pilates and martial arts.  The core stabilizes the trunk while the limbs are active, enabling us to put great effort into limb movements—it is impossible to use the arms and legs effectively in any athletic endeavor without a solid core to act as a platform to push off.   An example of static core function is standing upright in gale force winds—the core helps stabilize the body so that the winds do not cause a loss of balance or posture. An example of dynamic core function is running up flight of stairs, resisting gravity while maintaining balance and posture.


The PFM form the base of the pelvis and represent the floor of the core muscles.  They provide support to the urinary, genital and intestinal tracts.  There are openings within the PFM that allow the urethra, vagina, and rectum to pass through the pelvis to their external openings.  There are two layers of muscles: the deep layer is the levator ani (literally, “lift the anus”) and coccygeus muscle.   The levator ani consists of the iliococcygeus, pubococcygeus, and puborectalis.  The superficial layer is the perineal muscles. These consist of the transverse perineal muscles, the bulbocavernosus and ischiocavernous muscles, and anal sphincter muscle.


The PFM have a resting muscle tone and can be voluntarily and involuntarily contracted and relaxed.  A voluntary contraction of the PFM will enable interruption of the urinary stream and tightening of the vagina and anus.  An involuntary (reflex) contraction of the PFM occurs, for example, at the time of a cough to help prevent urinary leakage.  Voluntary relaxation of the PFM occurs during childbirth when a female voluntarily increases the abdominal pressure at the same time the PFM are relaxed.

The PFM have three main functions: supportive, sphincter, and sexual. Supportive refers to their important role in securing our pelvic organs in proper position. Sphincter function allows us to interrupt our urinary stream, tense the vagina, and pucker the anus and rectum upon contraction of the PFM.  In terms of female sexual function, the PFM tightens the vagina, helps maintain and support engorgement and erection of the clitoris, and contracts rhythmically at the time of orgasm.  With respect to male sexual function, the PFM helps maintain penile erection and contracts rhythmically at the time of orgasm, facilitating ejaculation by propelling semen through urethra.

In men, the bulbocavernosus muscle surrounds the inner urethra. During urination, contraction of this muscle expels the last drops of urine; at the time of ejaculation, this muscle is responsible for expelling semen by strong rhythmic contractions.  In women, the bulbocavernosus muscle is divided into halves that extend from the clitoris to the perineum and covers the erectile tissue that is part of the clitoris.  The ischiocavernosus muscle stabilizes the erect penis or clitoris, retarding return of blood to help maintain engorgement.

The PFM can get weakened with aging, obesity, pregnancy, chronic increases in abdominal pressure (due to straining with bowel movements, chronic cough, etc.), and a sedentary lifestyle.

In women suffering with urinary incontinence or pelvic relaxation, the strength of the PFM can be assessed by inserting an examining finger in the vagina, after which the patient is asked to contract her PFM tightly.  (A similar assessment can be performed by placing a finger in the rectum, after which the patient is asked to contract the PFM.)

The Oxford grading scale is used, with a scale ranging from 0-5:

0—complete lack of response

1—minor fluttering

2—weak muscle activity without a circular contraction or inward and upward     movement

3—a moderate contraction with inner and upward movement

4/5—a strong contraction and significant inner and upward movement

PFM exercises are used to improve urinary urgency, urinary incontinence, pelvic relaxation, and sexual function. The initial course of action is to achieve awareness of the presence, location, and nature of these muscles.  The PFMs are not the muscles of the abdomen, thighs or buttocks, but are the saddle of muscles that run from the pubic bone in front to the tailbone in back. To gain awareness of the PFM, interrupt your urinary stream and be cognizant of the muscles that allow you to do so.  Alternatively, a female can place a finger inside the vagina and try to tighten the muscles so that they cinch down around the finger. When contracting the PFMs, the feeling will be of your “seat” moving in an inner and upward direction, the very opposite feeling of bearing down to move your bowels.  A helpful image is movement of the pubic bone and tailbone towards each other. Another helpful mental picture is thinking of the PFMs as an elevator—when PFMs are engaged, the elevator rises to the first floor from the ground floor; with continuing training, you can get to the second floor.

Once full awareness of the PFM is attained, they can be exercised to increase their strength and tone.  The good news is that you do not need to go to a gym, wear any special athletic clothing, or dedicate a great deal of time to this.  As a test, perform as many contractions of your PFM as possible, with the objective of a few second contraction followed by a few second relaxation, doing as many repetitions until fatigue occurs.  The goal is to gradually increase the length of time of contraction of the PFMs and the number of repetitions performed. Working your way up to 3 sets of up to 25 repetitions, 5 seconds duration of contraction/5 seconds relaxation, is ideal.  These exercises can be done anywhere, at any time, and in any position—lying down, sitting, or standing.  Down time—traffic lights, standing in check-out lines, during commercials while watching television, etc.—are all good times to integrate the PFM exercises.  Expect some soreness as the target muscles will be overloaded at first, as in any strength-training regimen.  It may take 6-12 weeks to notice a meaningful difference, and the exercises must be maintained because a “use it or lose it” phenomenon will occur if the muscles are not exercised consistently, just as it will for any exercise.

With respect to incontinence and urgency, recognize what the specific triggers are that induce the symptoms.   Once there is a clear understanding of what brings on the urgency or incontinence, immediately prior to or at the time of exposure to the trigger, rhythmically and powerfully contract the PFM—“snapping” or “pulsing” the pelvic floor muscles repeatedly—this can often be a means of pre-empting or terminating both urgency and leakage.   This benefit capitalizes on a reflex that involves the PFMs and the bladder muscle—when the bladder muscle contracts, the PFM relaxes and when the PFM contracts, the bladder muscle relaxes. So, in order to relax a contracting bladder (overactive bladder), snap the PFM a few times and the bladder contraction dissipates.  Stress incontinence can improve as well, because of increased resistance to the outflow of urine that occurs as a result of increased PFM tone and strength.

By improving the strength and conditioning of the PFM, one may expect to reap numerous benefits. Urinary control will improve, whether the problem is stress incontinence, urgency, or urgency incontinence. Post-void dribbling (leaking small amounts of urine after completing the act of voiding) will also be aided. Furthermore, improvement or prevention of bowel control issues will accrue.  Some improvement in pelvic organ prolapse may result, and PFM exercises can certainly help stabilize the situation to help prevent worsening.  PFM toning can also improve sexual performance in both genders.  When a female masters her pelvic floor, she acquires the ability to “snap” the vagina like a shutter of a camera, potentially improving sexual function for herself and her partner.  Similarly, when a man becomes adept at PFM exercises, erectile rigidity and durability as well as ejaculatory control and function can improve. For both sexes, PFM mastery can improve the intensity and quality of orgasms. In terms of quality of life, PFM exercises are really as important—if not more so—than the typical resistance exercises that one does in a gym.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Available on Amazon Kindle

ANSWER TO QUESTION: Can you name an animal that has tremendous core strength?

Dolphins—essentially all core with rudimentary limbs.

To access my video on PFM exercises:


May 12, 2012

Andrew Siegel, M.D.    Blog # 58


Why is a blog on gout relevant to “promiscuous eating”?   Simply because gout can often be precipitated by dietary indiscretion (promiscuous eating), although it is often multi-factorial, with the most common underlying factor being an impairment of the kidneys’ ability to excrete uric acid.  This subject touches both health/wellness and urology, subjects that are dear to my heart.

I once had a “wicked” gout attack, which pretty much ruined my wilderness medicine meeting/vacation in beautiful Big Sky, Montana.  I never imagined that gout was in the cards for me, assuming naively that gout was a problem of portly and sedentary Dickens-like characters that enjoyed their Porterhouse steaks, red wine and cigars.  However, the day my family arrived in Big Sky I became aware of throbbing in my left big toe.  It progressed dramatically and when I examined myself, I noticed that the toe was red, swollen and painful.  A few days before, I had stubbed it walking up the stairs in my home, so my immediate assumption was that I had unknowingly broken it.  The situation rapidly progressed to the point where the entire foot became extremely swollen, red, hot-to-the-touch, and literally grotesque; I had trouble bearing weight on the foot and it was so tender that even the contact of a bed sheet on the foot caused severe pain.  I phoned my buddy Frank Alberta, a sports orthopedist, to ask some advice for management of a broken toe.  When I explained the scenario to him, he replied that I was having a classic case of gout and I would need to obtain some anti-inflammatory medication and ride it out.  I suffered through that week, limping meekly through Yellowstone Park with the support of my daughter on one side and my wife on the other.  Eventually it resolved, but left me with some limitation of mobility of that toe.  After the resolution of the acute attack, I had my uric acid levels checked and they were found to be elevated.  Subsequently, I went on Allopurinol, which has knocked my uric acid down to an acceptable level.  Between the Allopurinol and being attentive to my diet, I have never had another attack. 

 In retrospect, I believe that a number of factors triggered my attack.  There was the injury factor—not a broken toe, but certainly an injured one.  Then, what I later found to be my high serum uric acid levels, likely inherited as my grandfather suffered with gout.  There was the dehydration factor from several vigorous and lengthy tennis matches played a few days prior in the heat of August.  Finally, my dinner at home before leaving for Montana can be described as very gout inducing—crab cakes, sushi, asparagus and beer—all items high in purines, those chemicals that are broken down into uric acid.

Uric acid is the end product of the breakdown of proteins known as purines.  If there is too much uric acid production or not enough excretion, the result is high levels of uric acid in the blood. Gout occurs almost exclusively in those with elevated uric acid, although only a minority of those with elevated uric acid levels actually develops gout.

Gout is a chronic inflammatory arthritis most often caused by a deficit in the kidneys’ ability to excrete uric acid, resulting in elevated levels of uric acid in the blood. When uric crystals get deposited in joints and tendons, there is an inflammatory response resulting in intense pain, redness and swelling of the affected area.  It most often involves the big toe, but can affect any joint.

Tophi—deposits of crystalline uric acid at the surface of joints or in skin or cartilage—can be a feature of gout.  Risk factors for gout are genetics, a diet high in purines, aging, declining estrogen levels in women and obesity.  High levels of uric acid are correlated with chronic kidney disease, high blood pressure, heart failure, diabetes, and high cholesterol.

If the uric acid crystals precipitate in the joints, a gout attack occurs; if the uric acid crystals precipitate in the kidney, kidney stones occur.  Increased uric acid levels are associated with red meats and poultry; organ meats (liver and kidney); many forms of seafood including anchovies, mussels, scallops, crab, shrimp, lobster, oysters and a variety of fish; certain vegetables including asparagus, spinach, mushrooms, lima beans, kidney beans, and lentils; fructose-sweetened beverages; and alcohol, particularly beer.

The good news is that gout is very treatable—in fact, it is the only form of chronic arthritis that is indeed curable.  When uric acid levels are reduced over the long-term, uric acid crystals in joints, soft tissues, and tophi dissolve, and acute attacks diminish. Proper management of gout is aimed at treating the elevated blood levels of uric acid.  Uric acid levels of < 6.0 mg/dL are desirable.

Acute flares of gout are typically managed with non-steroidal anti-inflammatory medications to treat the pain and inflammation.  At times, alternatives such as colchicine or corticosteroids need to be employed for an acute attack.  Long-term management usually begins with allopurinol to reduce uric acid levels.  An alternative is febuxostat.  Sometimes probenecid, a medication to increase the kidneys’ excretion of uric acid is used.  For refractory gout, an intravenous medication known as pegloticase is sometimes called for—it is relatively new and can literally dissolve tophi.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Now available on Amazon Kindle