Wednesday, July 23, 2014

Staying Fit in Medical School

Medical school can be a busy time. The first two years can be managed fairly well if you play your cards right, but as you add things on top of the basic goal of passing your classes (e.g. volunteer activities, research, family, or whatever hobbies you might have), you’ll quickly find your time becomes a precious commodity. To make time for other (often good) pursuits, we sometimes take shortcuts when it comes to our health – we sleep less, eat more, and move less.
Don't do this. Please.

I’ve lifted weights for a few years now, but before medical school I usually worked jobs that kept me pretty physically active on top of just lifting. That translated into not really having to worry much about, for example, what I ate – I could pretty much down whatever I wanted and top it off with two large bowls of ice cream lathered in chocolate syrup and be fine. While that was a blessing (obviously – ice cream is delicious), it also turned out to be a somewhat of a curse. When I got to medical school and suddenly became quite a bit more sedentary, I started to put on a bit of weight. Nothing outrageous, and it wasn’t all of the sudden. I continued to regularly lift, and for a while I told myself that I was just getting “bigger.” But my lack of attention to my food intake caught up with me, and my waistline started to grow. Suddenly, I wasn’t fitting into my clothes quite as well as I used to.  Before long, I was over 190 lb. at about 5 ft. 9 in. and around 22% body fat. Not good.

Time for Change

Before I go any further, I want to take a second and say a couple of things. First, if you are looking to get healthier, that’s great. I personally want to be around for a lot of years so I can spend a lot of time with my wife and family, and want to be able to not get tired out after just a few minutes of wrestling with my son when he is older. Additionally, something like strength training just has a lot of carryover to real life – things that run the gamut from being able to lift heavy things to help friends move, carry in the groceries, or protect my family if the need ever arises. The desire to lose weight, on the other hand, might stem from wanting to improve your various lab profiles, reduce your risk for cardiovascular disease (a big one for me, since I’ve got a pretty strong family history for it), or reduce your risk for all of the other diseases that come hand-in-hand with an expanding waist line.

So if something along those lines is providing you with the intrinsic drive you need to eat less and move more, that’s awesome. However, some people take this whole fitness thing way too far. Being “fit” should not become your identity or sole purpose in life – it’s a means, not an end. Also, don’t be ridiculous about things. Sometimes you might miss a session to hang out with family, or will eat “bad” food when you are out with friends. Whatever. Don’t freak out about it. Enjoy it. While you obviously don’t want to eat crap all of the time, every once in a while (and probably more often than you think), it’s perfectly fine. So relax, and enjoy life a bit. And whatever you do, do NOT go around telling people how they can be healthier, or what they should and shouldn’t eat. I know people like that, and it’s not helpful or pleasant at all. Changing your lifestyle is a personal decision, and if someone actively wants your help, then by all means help them – but don’t force anything on anyone.

Ok. So Now What?

Alright, so back to my waistline. I knew things needed to change. So I started doing a little research. Here is a brief summary of what I found.

Losing the Chub

First off, you have to get something straight – the most important determinant of how lean you are, or even how muscular you are, is not how much “cardio” you do, how much weight you lift (although lifting is important – more on that later), whether or not you eat gluten free, paleo, your micronutrient profile, or whatever. The single most important determinant of your body composition is simply your energy balance – in other words, the calories you take in vs. the calories you expend.

If you want to lose fat, then you have to eat less.

If you want to gain muscle, then you have to eat more and provide the proper stimulus (e.g. weight training).

You can stop reading now if you want. That’s really how important that concept is.

All of the common diets out there – low carb, paleo, Zone, Atkins, Weight Watchers, or whatever – all work. At least for a while. Why? Because in one form or another, they get you to eat less. That is really the crux of the issue when it comes to losing weight. Cutting out carbs, for most people, cuts out a significant food group and thus removes a lot of calories from their daily intake. Eating only so many “points” worth of food each day does the same thing. And so on. Where some of these diets fail, in my opinion, is by failing to hammer home some basic nutritional concepts that help people keep the weight off in the long run. When they add carbs back in, the weight comes back. Or they might start increasing their intake of low-carb foods to the point that they are once again eating a caloric surplus. Once the meal replacements are replaced with real foods, people haven’t learned about portion size, so they just go back to doing what they were doing that made them gain weight in the first place.

So paying attention to the amount of calories you eat is important – that should be clear. Problem is, most people are terrible at estimating how many calories they are eating. They might think they are eating less and are confused as to why they are not losing weight or even still gaining it, but they don’t realize that they are still eating at a surplus, or perhaps have just reduced their intake down to maintenance levels.

So how best to keep track? I started using a free app on my phone called MyFitnessPal. It’s an awesome, easy-to-use way to keep track of things. They have a huge food data base and you can typically just type in whatever you are eating and find it. They have pretty much every major restaurant’s food and a lot of smaller restaurants as well, which makes it convenient when you are eating out. You can also build common meals and save them to use them again later. It remembers what you typically eat, which makes it easier to use the longer you use it. It also can keep track of your weight and other markers as well. For someone like me who likes data points and keeping track of things, it’s awesome. Additionally, it only takes maybe 3-5 minutes a day – tops – to use once you have things down. So it takes minimal time, but it allows you fairly fine control over your caloric intake – which is THE MOST IMPORTANT STEP when it comes to losing fat or gaining muscle.

Of course, as with any data, if your data is trash then your conclusions are useless. Be honest about what you enter. When in doubt, I try to overestimate what I’m eating (because most people usually underestimate).

That said, I’m not a huge fan of weighing or measuring everything you eat. My guess is most people aren’t. It’s just inconvenient. For some who are trying to get into peak condition, it might be necessary. For most of us, though, it’s probably not. You might find it helpful to weigh something once or measure something once just to get an idea of what a cup of this or 12 oz. of that actually looks like, but don’t get too crazy.

Once you’ve downloaded the app (you can just use it on the computer as well, but the app is way more convenient), track your intake for a few days. Be honest. You have to figure out where you are to figure out why you got there and where you are going to go.

Finding Your Numbers

So you have the tools to keep track of your calories, which, if you haven’t caught on by now, is IMPORTANT. Now what?

The next step is to figure out what your goal is. For most people, this will be something like, “Well, I want to lose fat and gain muscle.” That’s great, but with the exception of rank beginners, it’s unlikely to occur. It’s possible, of course, but progress will be exceedingly slow and you are really working at counter-purposes with yourself. Remember, to lose fat you have to eat less, and to gain muscle you have to eat more. You can’t really do that at the same time – you cannot serve two masters. So pick your goal, and go with it.

But getting back to the topic of this section. You need to establish your caloric maintenance requirements – the amount you need to eat to stay the way you are. The calculator I like (which has lots of features, which we’ll talk about later) can be found here. Plug in your numbers, be honest about your activity level, and select which formula you want to use to calculate your caloric needs (I would just choose the one with the most conservative values for starters – it’s easier to add in calories later if needed than it is to remove them). That’s your maintenance caloric requirement.

If your goal is to lose fat, you need to eat less than that number to achieve that. The typical recommendation is to eat 500 calories under your maintenance each day – over a week, these leaves you with a caloric deficient of about 3500 calories. Traditionally, this is the amount that is touted as necessary to lose a pound of fat a week. You can also set your deficit by using a percentage of your maintenance - so, for example, you might decide to eat 20% less calories than your maintenance level each day. If you want more information on choosing the correct deficit, I would recommend reading this article. This one is also a good read on the topic. 

That’s one way to do it. Problem is, over time, as you eat a deficit your metabolism does slow a bit. Additionally, traditional dieting like this tends to lower the levels of a number of important hormones in your body (you can read more about this effect here). All bad things.

Enter the Cycle

One way around this is calorie cycling – eating less one day and more on another such that you still eat at the deficit you need to lose fat, but while sort of “tricking” your body into thinking that you’re not actually starving it – this helps keep it from hanging on to stubborn fat and generally making you feel like crap.

So how do you do this? There are a couple of ways. First, start looking at your calorie requirements over a week rather than just over a day. So, for example, say Person A needs 2500 calories a day. Over a week, that’s 2500 calories x 7 days = 17,500 calories/week. If you wanted to eat at a deficit of 3,500 calories, then that means you need 17,500 calories – 3,500 calories = 14,000 calories over the course of the week. You can then choose to divvy up those calories across the days as you see fit – you might want to eat more on days you work out and less on rest days, or save some calories for that meal out with some friends. You can wave your calories throughout the week to avoid the pitfalls of straight dieting however you choose. That said, I personally just like to use the old rule of thumb that says eat 10 times your bodyweight in calories on rest days and 12 times your bodyweight in calories on work out days to lose fat. I’ve had the most success with this method, and have so far lost about 20 pounds. You can work out the numbers, but when training 3x a week, this puts me at the perfect deficit.

Alternatively, you can go back to the calculator I gave you earlier and select one of the fat loss options. It will run the numbers for you and show you how much you can expect to lose per week (these are only estimates, of course) and how much you should eat per day on both work out and rest days.

An important note: as you lose weight, you will need to account for this. Recalculate your caloric requirements every 5-10 lb. Otherwise, your deficit will over time become your maintenance.

One More Important Tool

One final thing I will say here is that, for weight loss in particular, one tool that I’ve found particularly helpful is something called Intermittent Fasting (IF). This isn’t a diet – it’s more of a pattern of eating. The basic idea is that you set up an “eating window” – typically something like 4-9 hours – and then fast until your next eating window. It may have some health benefits in terms of reducing risks for various diseases and improving lipid profiles and speeding up fat loss, but more than anything it’s just darn convenient. A typical way to go about it is to eat from, for example, noon to 8 pm and then fast for 16 hours until noon the next day. It takes a little getting used to at first, but after a while some people report increased mental clarity and focus, as well as a feeling of well-being, during the morning part of the fast. I’ve found that to be true, as well.

But what about breakfast? Isn’t that the most important meal of the day? And don’t I need to eat every 2-3 hours to keep my metabolism speeding along? My body will consume itself!!!

Slow down. All are valid concerns, but have been addressed elsewhere. I recommend reading this for a great overview of IF and answers to many common questions. This is a good overview too. Another great read can be found here - it discusses some of the common myths surrounding fasting. Also here. This is a great overview and analysis of different ways to go about fasting. If you're going to do IF, I'd recommend taking a few minutes to read through those links. (Update 2/18/15: A comprehensive guide about how to "do" intermittent fasting can also be found here. In the interest of full disclosure, I'll note that the owner of the site contacted me about listing his link here, but it seems like a solid website that's definitely worth looking over if you are interested.)

One of the things I like about IF, especially while eating at a deficit, is simply that it allows me to “save” a lot of calories for later so that, when I do eat, I get to eat a couple of larger meals instead of eating like a bird throughout the day. Also, it’s a lot easier to get out of the door in the morning not having to worry about making and eating breakfast.

A brief note about weight lifting while using IF – there are several ways to go about this, most of which are addressed in the links above (which you should read if you are going to do this). I personally tend to usually only fast on rest days, since I tend to lift weights in the mornings (which means a whey protein shake beforehand and then a meal after working out) and am not a fan of stopping eating at 3 pm in the afternoon to keep my “eating window” intact. And it’s ok. Do what you can. If you work out in the evenings anyway, then this won’t be an issue.

Keeping Track

So you have the tools for fat loss. I’ll talk a bit about weight training here in a bit, but first let’s talk about tracking your progress.

The first thing I’ll say is that changing your body composition takes time. Weeks, months, even years. So don’t be discouraged if you don’t see changes right away. When you make a change, give it at least three weeks or so – preferably more – to see if something happens.

But how do you know if something is happening? By seeing if your metrics are changing. Personally, I use the scale, calipers, and the mirror. The scale is great for keeping track of weight changes, but doesn’t tell you if you are losing or gaining fat or muscle. That’s where calipers come in. Get a cheap pair of reliable calipers (I use the Accu-Measure Fitness 3000 Calipers - they are about six bucks and well-regarded), and learn how to use them (this website is great for both learning how to use them and calculating your body fat percentage). Note that the body fat percentage might not be spot on accurate, but it’s more important that you are consistent so that you can track changes. I’d recommend weighing and taking caliper measurements once a week under the same conditions – I do this Saturday mornings, after getting up and using the restroom and before eating or drinking anything. Once again, be patient. It takes time for your body to change.

Note for females: you might find that you retain water differently throughout your monthly cycle, so your weight may vary from week to week. Thus, it might be more helpful to compare weights/body fat measurements from week 1 of cycle 1 to week 1 of cycle 2, week 2 of cycle 1 to week 2 of cycle 2, and so on.
One More Word about Diet

Image courtesy of Home Fitness Life
So you know how important calories are, how to keep track of them, a bit about intermittent fasting, and how to keep track of changes in your body composition. I haven’t discussed much yet though about what to actually eat. I won’t say much about this except that I really just make sure my protein intake is on par (at least 1.5 g/kg body weight) and let the rest (carbs, fat, etc.) fall where they may while generally eating quality foods. Also, drink plenty of water – you want at least five clear/light yellow pees a day. That’s the easiest way of doing it, in my opinion. You can get a little more crazy with this if you want to – see this website for more information.

I will say that I typically still eat ice cream, albeit in smaller portions, fairly regularly. Remember, at the end of the day, your goal is to meet your calorie requirements for whatever you are trying to do. If you can squeeze in a cup or two of ice cream into your calorie log, so much the better. Like I said before, you don’t want to eat crap all of time, but life is too short to go too crazy with this stuff and you can change your body composition successfully while still enjoying yourself.

To Gain or to Lose?

If you aren’t sure where to go from here, figure out where you are at first. For guys, a healthy body fat percentage is about 10-15%. For gals, that can be more like 18-25%. If you are a guy who wants to gain muscle, but are at 19%, then you need to lose some weight first. This is for a variety of reasons, but for now I’ll just say that first, fat is not functional tissue. It does not make you stronger; it just slows you down. Second, the fatter you are, the more likely your body is to just gain more fat. The leaner you are, the more like your body is to gain muscle (see here for more). Conversely, the fatter you are, the easier it will be to lose fat. The leaner you are, the harder it is to lose fat (unfortunately). So, getting down to a leaner you will, on a lot of levels, be better for your overall progress. I would recommend getting down to at least 10% or so before starting to gain weight again. Hold your diet there at maintenance levels for about two weeks to allow your body to “settle.” When you decide to gain, try to only gain about one pound per week (will be some fat and some muscle) until you get up to around 15% body fat or so. Again, hold there for two weeks before starting to cut weight again. Repeat until satisfied.  

As far as eating for weight gain goes, just eat more. I would recommend calorie cycling still – use the calculator above to figure out what you need to eat on rest and work out days for weight gain. Keep track of your progress weekly, and don’t let things get out of hand.

A Brief Word on Weight Training

Weight training is an important component of any exercise program. Or, at the very least, it’s a very valuable addition. Obviously, be realistic and consult with your physician if you have any question about whether weights, or any exercise for that matter, is right for you.

I also want to make a note that weight training is for both men and women. Women sometimes fear that it will make them bulky, but short of using exogenous hormones, they just don’t have the hormone profile for this to be even remotely true. Guys, similarly, sometimes don’t want to get too big. Don’t worry – you won’t just wake up huge. These things take time. That said getting stronger has multiple benefits for life in general and can be just darn helpful.

I’m a big believer in safely performing basic compound exercises – squats, deadlifts, bench press, overhead press, rows, dips, and chins. Do those, increase your weight over time, and you will get stronger. If you are just starting out, I would recommend something like Starting Strength (can be found here; I like the Practical Programming version) or Stronglifts (can be found here). After you’ve progressed as far as you can on those, check out Jim Wendler’s 5/3/1 (the basic program can be found in various places online, but you should buy and read the book Beyond 5/3/1: Simple Training for Extraordinary Results and pick your variation) or some of Paul Carter’s programs. I wish I had progressed like that when I first started.

(Edit: Since I wrote this, some excellent resources have been put out by Greg Nuckols - a very strong and very smart guy. Head on over to his website (a good place to start is here) and enter your email [don't worry - this guy is legit. The worst he'll do is send you some awesome information that you can unsubscribe from at any time] to get his free training programs. He'll send you an excel file with a bunch of programs that can be used at essentially any level and that you can progress through as you get stronger. That is probably one of the best ways that anyone could get started on their strength-training journey.)

Note that I said that I’m a believer in SAFELY performing these exercises. Spend some time learning and refining your technique before adding much weight. These exercises are not inherently dangerous or bad for you – unless you are doing them wrong. Check out ExRx for pointers. Also, I really like these articles for technique:

Squat: read this.
Deadlift: read this and this.
Bench Press: READ THIS – Part 1, Part 2, this, and this.

Check out ExRx for form instructions for the other exercises.

A Brief Word on Cardio

“Cardio” is what people typically first think of when they think of trying to lose weight. By now you should know that that is not necessarily the case – calories are most important. That said, you can use cardio to help create your deficit, and it’s also useful for increasing your overall work capacity. It’s useless to be strong but unable to walk down the block without doubling over or finish a fight. I try to lift three times a week, and fit in at least two cardio sessions. What you do isn’t really that important. Swim, ride a bike, do bag work, sprint, go for a walk. Just be active and do something you enjoy. Set a goal and achieve it. I used to be a lifeguard, and at least once a week we had to swim a 500 (20 laps in a 25 meter pool). I used to be able to knock that out without a second thought – now I can barely get 10 continuous laps. So that’s my goal. I try and hit the pool twice a week, and am working towards getting better every time.


So that’s that. Medical school is busy, but it’s entirely possible to set up a routine that has you lifting two to three times a week and doing some form of cardio at least twice a week. Controlling your food intake is made much easier by using the tools that I discussed above, and after a while won’t take much thought at all. Getting started is the hardest part, but once you’ve overcome that initial inertia, it will begin to work in your favor. Good luck.

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