Motivation

It's hard to start an exercise habit.  Some people assume that regular exercisers wake up every morning eager to take on their workouts.

But that's not true.  More times than I can count, I wake up grumpy, wanting to roll over and go back to bed.  However, I still complete my planned workout, most of the time.  Why?

1) I know where I started.

That's me in 2005.  There have been many early mornings and long workouts between then and now that have gotten me to where I am today.

2) I know what I've accomplished.

Were it not for those 5 am wake-ups, or the cold evenings in the pool, I would not have accomplished what I have done.  I would not have earned a bronze medal at the Maccabiah Games in Israel last summer.  I would not have been able to complete Malibu 7 Canyons or Mulholland Challenge without the spin classes and long training rides.  Nor would I have had an awesome performance at Ironman St. George 70.3 a few weeks ago.

3) This guy will be pissed.

That's my coach, Gerardo Barrios of Fortius Racing.  He gives me a training schedule and helps me set goals.  If I don't do what's asked of me, I won't achieve those goals.

4) I won't see these guys.

These are my teammates, and my friends.  It's fun to see them.  If I sleep through a pool workout, they'll be asking me later where I was.

5) I feel awesome later.  My morning workout gives me energy for my day.  Without it, I just don't feel as good.

What's your motivation?  It's not always easy to go out and get in that workout.  But find what motivates you.

St George 70.3. Maybe I was ready after all?

I knew I had been doing lots of cycling since my foot fracture.  But I hadn't done much running.  I had about a half dozen runs longer than an hour over the past couple months, nothing longer than 9 miles.

My expectation for this race:  Normal swim, something in the 39-40 minute range, a good bike since that's what I've been doing so much of, and a lackluster at best run.  Also, I know there's going to be a high of 95 degrees, with no shade on the course.  So it's going to be a tough day.

 Some of my teammates before the start of the race.

Swim -- Was THAT The Gun?
With three minutes until the start, we amble into the lake and start to swim toward the start line, which is several hundred feet away.  It's cold by my standards, at 60 degrees, but with a steady supply of nervousness, that coldness isn't noticeable.  We're a few hundred feet from the start line when we hear a gun go off.  The woman next to me and I look at each other puzzled, and then we hear, "The 35-39 year-old women are off!", and we frantically realize we missed our start gun and start swimming.
I was hoping to finish in 38 minutes, but with the late start, it turned out to be more like 41 minutes.

Bike -- let's do this!!!
Now here's my strength at this point.  I've done three insanely hilly rides, the Malibu 7 Canyons Century, L'Etaupe with four loops of the Rock Store climb, and the Mulholland Challenge 120.  So I knew that this would be my strongest leg, and my running isn't up to where it was before my fracture, so I knew to go hard on the bike.  But, I knew not to go too hard, because I needed to have some gas left in me for the run portion of the race.  I passed people while climbing hills, maybe about 60 or so people going up Snow Canyon, the long climb of the bike course, but on flats and downhills plenty of people passed me.  I projected that  I would finish the 56-mile bike ride in 3 hours 30 minutes.  My actual time:  3:09.  Disbelief.  Wow.

Run
So there in the picture above, at the start of the run, I'm yelling to my coach, I can't believe how fast I just did that bike?!  Given my lack of recent run training, and the 90+ degree heat and lack of shade, I started conservatively.  I knew I would run the course, walking the length of the aid stations, and if truly necessary on an uphill, I would walk.  But, I didn't need to walk.  I reminded myself, what I lacked in running over the past few months, I had in my years of endurance training.  I am an endurance mule.  Drink, stay hydrated, keep jogging.

The out-and-back nature of the course was pretty awesome for seeing teammates and cheering them on.

A funny thing happened on the run -- I felt good.  I was keeping pace, felt no need to walk other than the aid stations.  And at no point did I feel that awful exhausted when will this horrible thing end feeling?  Did I not push hard enough?

That run that I projected would take me 2 hours and 30 minutes?  2:08.

Overall time -- 6:09.  Oddly, my fastest 70.3 time ever, on the toughest course and the hottest day.  I'm elated.

That means that Vineman 70.3 and Silverman 70.3 will hopefully be under 6 hours.  That's going to be my goal.

Pass the Fried Chicken, I'm on Lipitor!

It is true that statins have been shown in randomized controlled trials to reduce the risk of a first cardiovascular event.  The number of patients needed to treat to prevent one event is relatively high, as I have previously discussed, but it is true that there can be a role for statins in primary prevention.

The problem is that the real world doesn't function like a clinical trial.  People who are on a statin know that they are taking a medication with the purpose of lowering their cholesterol.  An important question that I've wondered is, how much does knowing that one is taking a statin affect behavior?

Anecdotally, I can tell you I've had conversations with patients in which they have rationalized less than ideal diet choices by stating that they are taking a cholesterol-lowering statin.  Or more blatantly, the person who goes out for a decadent dinner and then doubles up on his statin dose.

Source:  kevinmd.com

There is a study that was published in JAMA Internal Medicine this week on that subject.  This was a retrospective study looking at the caloric intake of statin users and statin non-users.  The study found that statin users increased their caloric intake by 9.6% and fat intake by 14.4% over the course of the ten year period studied, while non-users had no significant change in caloric or fat intake over that time.  Further, the statin users' body mass index (BMI) increased by 1.2 kg/m2 during that time, while the non-users BMI increased by only 0.4.

So, the increased calorie and fat intake and weight gain of a statin user may negate much of the beneficial effect of the statin medication.

What's a clinician to do?  I think it's important that we make sure our patients realize that a statin medication is not a carte blanche to eat whatever and however much they want.  But I think we also need to be judicious in choosing who we put on a statin as well, and make sure that their risk is appropriate to justify the statin prescription.

Passover Seder 2014

I hosted my fourth annual seder at my home with nearly 30 guests, including my four nieces.  This is why I open my home to family and friends for the holiday.

This year I used a different hagaddah, 30 Minute Seder -- The Hagaddah that Blends Brevity with Tradition.  The author of this hagaddah is a genius -- everything you need in a seder, including some songs, and a minimal amount of Hebrew, is included.  The story of Passover is told in a clear manner, unlike those archaic Manischewitz hagaddahs that many of us grew up with.

We ate well.  Hors d'oeuvres consisted of mock chopped liver and a Sabra eggplant spread and a beet salad with cut-up veggies for dipping.

I served a matzo ball soup from Nava Atlas.  The matzo balls were kitniyot-free, made from matzo meal and quinoa flakes, and were baked instead of boiled in water.  I would love to find nice fluffy matzo ball recipe that is kitniyot-free.  These were smaller, perhaps a bit more solid than a traditional matzo ball, but nonetheless good.

My newest dish for the holiday was a spinach, leek, and potato matzo gratin from Nava Atlas.  I added in some kale in addition to the spinach, and I did not add the Daiya vegan cheese since I thought the dish was already creamy enough.

From previous years, I also served a quinoa with pine nuts and dried cranberries, eggplant casserole, and a carrot apple sweet potato kugel. 

We had a chocolate matzo loaf and some delicious fruit and an apple-date mousse for dessert.

Here's an index of previous years of Passover seders and recipes.

Adventures in Cycling - A DOUBLE Race Report

When I fractured my foot back in December, I knew I wouldn't be able to do the marathons I had been training for.  So my goals had to change. 

I always looked in awe upon my teammates, particularly my female teammates, who were participating in challenging bike rides, things like the Mulholland Challenge and Furnace Creek 508.  And, I've always been a slightly weaker cyclist compared to my abilities in swimming and running, with the excuse that I have long legs and they're just not very good levers.

So, in those six weeks in an orthopedic boot, I'd go to spin classes 3-4 times a week, and sometimes two spin classes back-to-back.  I'd put my good foot in a stirrup and the booted foot on top of the other pedal.  I got some interesting reactions, a few double takes, a few spin instructors who thought I was "badass", and one who thought I was simply out of my mind and threw me out of her class out of fear that my spinning in an orthopedic boot was unsafe.

As I spun, and swam, I decided on a new goal -- complete some of those challenging rides that my fearless teammates had accomplished.  I signed up for Malibu 7 Canyons Century on March 15 and Mulholland Challenge 120 on April 12.

When the orthopedic boot came off, and I was riding with my teammates, I realized that I've become a stronger climber on the bike.  And I continued training, but now outdoors, with up to six hour training rides scheduled.  Some of the long rides were done while on call, hours of loops around Griffith Park, or up and down Laurel Canyon and Rinaldi Street by Holy Cross Hospital.  But the training rides got done, for the most part.

Malibu 7 Canyons
Imagine this -- come up with a hundred mile ride with the steepest climbs in the Santa Monica Mountains -- Decker Canyon, Deer Creek, Latigo, Portrero, Westlake Blvd.  Then add in the gnarliest descent with the worst condition roads (Yerba Buena), and have riders come down that descent TWICE.  Add in unstocked and unprepared aid stations on an 80+ degree day, no refreshments at the end, and no t-shirts as promised with entry.  That was the Malibu 7 Canyons Century.

That was the hardest ride of my life.  I was barely turning my legs toward the top of Deer Creek, and on parts of Portrero (mile 70) and Westlake Blvd (mile 85), I got off my bike and walked some of the 17-21% grade climbs.  Highlights of the ride included meeting other local cyclists around mile 55 and joining a pace line of about ten strangers on flat roads as we headed down PCH and Las Posas to our next climb.  Nine hours and forty-nine minutes later, I finished, sore, exhausted, and tired out.

L'Etape du California
I hadn't planned on doing this ride, as it falls a week before the Mulholland Challenge 120 ride.  But, as part of my weekend training before the race, I had done four trips up the Rock Store climb, and seeing several of my teammates sign up, I thought I'd give in to peer pressure and give this race a try.

L'Etape is the eighth stage of the Tour Of California cycling race.  The pro cyclists will be doing this same course in May, so this was an awesome opportunity to ride what the pros will ride.  The race consists of four loops, starting at the Hyatt in Westlake Village, heading east on Agoura Road, south on Cornell, then west on Mulholland, including the Rock Store climb, and then north on Westlake Blvd.

The Rock Store climb is a famous climb for cyclists.  It's about 2.5 miles with an average incline of about 7%, with plenty of twists and turns and beautiful views.  The climb gets its name from the Rock Store restaurant and bar which is at the base of the climb, a joint frequented by motorcyclists.

Results for the ride were based on combined times on all four Rock Store climbs.  I had no plan to win, just to see how fast I could get up that hill.

That's my team -- Fortius Racing!

Climb #1 up Rock Store felt pretty good.  I pushed a little harder on the second climb.  On the third climb, I felt a little bit more challenged.  And somewhere halfway through the fourth climb up Rock Store, I just wanted it to be over, my legs were tired.

That's me at the beginning of the second loop, having only been up Rock Store once.  My fuel for this ride consisted of coconut water mixed with equal parts tap water, bananas, orange slices, dates, a baked sweet potato, and peanut butter and jelly.  I've noticed I feel better fueling with real food as opposed to the more artificial gels, bars, blocks, and the like.

I enjoyed seeing my teammates on this ride, including my boyfriend Joel, who I did much of this ride with, though he sped away from me on the flats and I caught him on the climbs.

Obligatory selfie at the top of the Rock Store climb.

This was a challenging ride, certainly not as painful as M7C.  While my fingers were frozen and numb in the first eight miles of the ride, by the third loop I needed ice in my water bottles to keep from overheating.  The last half of this ride was easily 80+ degrees, and I was mindful to keep drinking water and consuming fruit for electrolytes once my coconut water was done (the H3O drink on the course simply wasn't palatable to me). 

Eighty-two miles later, it felt good to be done.

And the shocker -- I won my age group, women 30-39, for the fastest combined time for climbing Rock Store!

I couldn't be happier.  It's good to see my efforts on the bike over the past few months pay off.  And I feel confident heading into Mulholland Challenge 120.

Passover is Coming!!!

Often a holiday of culinary decadence with eggs, meat, cream, butter, matzah and constipation, I like to take a healthy spin on Pesach.  Here are several years of Passover seders, dishes, and exploration.  The older posts are some of my more rudimentary attempts at vegan Pesach dishes.  The more recent posts, particularly my three seders 2011-2013, represent a far more polished effort.

Seder 2013

Seder 2012

Seder 2011

2009

2008

2007

2006 - Passover as a new vegan and Eggplant and Matzo Meal Pancakes and Matza Pasta

Gold the Greyhound likes matzah!

Stuff Vegans Ask Me

One day last week, I had three plant-based vegan patients on my schedule.  As a managed-care employed cardiologist, that's a lot!!

And, my vegan patients tend to have very interesting questions.  So in my next few posts, I'm going to address a few of them.

First question:  "Caldwell Esselstyn doesn't permit nuts in his diet.  Do you eat nuts?"

source: nutstop.com

Short answer: Yes.

Longer answer:  Dr. Caldwell Esselstyn, in his book Prevent and Reverse Heart Disease, put his patients on plant-based diets with no oil and no nuts.  Through that diet, he demonstrated reversal of coronary disease and a lack of cardiovascular events over the course of five years.

I tell my patients, "I don't tell you to do anything I don't do.  When I tell you to exercise, I am exercising almost every day.  And a plant-based diet, I follow that."  But, I do eat nuts, in moderation.  As a young woman who exercises 10-15 hours per week, and does not have coronary artery disease, I don't need to restrict my consumption of nuts, other than to make sure that I don't consume too many calories.  Nuts are an excellent source of protein, fiber, and many different vitamins and minerals.  But they also have a lot of calories and fat, so in any diet, they should not be consumed in large quantities.

Rethink Food

I wrote a chapter for this book, Rethink Food.  It is available on Amazon for purchase!

"
Featuring over 100 doctors, 8 renowned nutritionists, and 8 elite athletes from around the world, Rethink Food empowers you with a tastefully simple solution for a healthier, stronger, and smarter you! The misinformation regarding our health is one of today’s greatest injustices. We have been led to believe that meat and dairy are the foundation of good health. This is a myth and the science can no longer be ignored. From the Ivy Leagues of Harvard, Princeton, Yale, and Cornell to the UK, India, Germany, Italy, Brazil, Mexico, and New Zealand, ReThink Food’s experts explain how we can reverse heart disease and diabetes, eliminate food allergens and autoimmune diseases, live pain- free from arthritis, prevent Alzheimer’s, even bring cancer into remission and much more by completely removing all animal products from our plates. In the history of disease we have never before faced such rampant levels of illnesses. We are turning to prescriptions for answers, but they do not address the root cause of diseases. The truth is our health is not completely dictated by our genes. Our meat and dairy diets are the primary cause of our alarming rise in chronic health problems and disease. Rethink Food’s doctors conclusively prove that we have the power to reverse and prevent today’s leading health problems simply by choosing a whole food plant-based diet! Plus as Rethink Food’s top professional athletes show, achieving peak performance and winning gold depends on being powered by plants. We were inspired to write ReThink Food after watching family and friends struggle with today’s most common diseases for years and then completely rid themselves of the debilitating symptoms and re-gain their health and vitality within months by fully adopting a whole foods plant-based diet. As these doctors attest, there is a powerful connection between disease and wellness that is strongly associated with our dietary choices. Changing what we eat has the power to change our lives. It all begins with the courage to rethink food. Join us!"

Running again... and a return to Barry's

It's been three months since my right foot 5th metatarsal fracture.

My fracture is almost, but not completely, healed.  The orthopedic surgeon has cleared me to do "light running," which apparently means I can run on dirt, trails, and treadmills, but not on pavement. 

So, for the past 3 weeks, I've been running a few days a week.  At first my right foot would practically slap down on the ground and I feared flexing the foot, so my running gait was pretty awkward.  But gradually it's gotten better.  Physical therapy, as well as gaining some confidence as I continued running, helped.  In fact, I was just discharged from physical therapy, in that I'm recovering well on my own, with the caveat that I need to try to "duplicate" with my right foot what my left foot is doing.

On Sunday I ran nearly six miles of trails over the course of an hour and I felt fabulous. 

Today I decided on the real test -- Barry's Boot Camp.  Now, Barry's is one of my favorite workouts.  30 minutes treadmill and 30 minutes fast-paced weights.  And, being the competitive person I am, I try to get on a treadmill next to someone who I think will be pretty fast to inspire me to run fast.  And I look around and see how fast people around me are running. 

It's not only my speed that I've lost.  As I changed out of my work scrubs and into my workout clothes, I thought to myself, the last time I was here at Barry's, I had better shaped legs, and a little less padding around my abs.  So I was a little self-conscious too.

Today, I knew I had to put the competitive me aside.  After three months of recovery from a fractured foot, just getting to Barry's today is a victory.  I warmed up and decided I would just stick with the "beginner" speeds; before my fracture, I would do the intermediate speeds, which would put me faster than most girls in the class and up there and faster than several of the guys.  But today, getting back into things, I would be a beginner.

Then our instructor Erik started calling out the speeds:  "4.0 beginner, 5.0 intermediate, 6.0 advanced" to start.  And something came over me.  I wasn't a beginner.  Maybe I'm not an intermediate, but let me push this a bit.  So I ran at speeds exactly between beginner and intermediate.  When beginners ran at 9.0, I ran at 9.5.

I accomplished some cool feats.  I ran at 9.5 miles per hour for 90 seconds, and then sprinted at 10.1 miles per hour for 45 seconds.  I didn't think I would be able to do that today.

I surprised myself.  I could have pushed harder, but since I haven't sprinted on a treadmill in 3 months, I didn't want to go all out.  I looked around at the end of class, and again, I was running faster than most of the girls, and the guy to my left, even on my first trip back to Barry's.

I feel pretty awesome. Maybe I haven't lost as much fitness as I thought.  And my shape, I'll get that back.

Do patients really *do* this?

I'll be the first to admit, the majority of my patients aren't vegans.  And, I'm okay with that.

My goal as a cardiologist is to provide my patients with the best information on how to improve their heart health and reduce their risk of cardiovascular events.  What they do with that information is up to them.

On one end of the spectrum, one of my long-term patients with coronary artery disease and a history of bypass surgery followed up earlier this week.  We have our usual conversation, where I tell him that he would be well served to eat better, exercise, and lose weight.  And as usual, he laughs and smiles, and says that he's not about to change.  He has remained otherwise stable on his medicines for blood pressure and his statin, and I'll see him again in six months.

On the other hand, I have patients who take on lifestyle change with vigor.  They adopt a plant-based and start exercising.  And without much effort, excess weight seems to come off.  They tend to feel better as well.  Of those motivated patients, I have not seen a single one of them have a recurrent cardiac event -- not one has needed another stent or another bypass surgery. 

After the Boot

I fractured my fifth metatarsal of my right foot about 6 1/2 weeks ago.  I wore an orthopedic boot for nearly six weeks, and now I am back in two shoes.

I thought a lot about what I would do for six weeks in the boot.  And I feel like I was successful -- I stayed active within my limits, remained fit, and did not gain weight.  In fact, I dropped a couple of pounds.

For some reason, I thought the boot would come off, my fracture would be magically healed, and after a couple days of walking, I would be back to running.  Such is not the case. 

My foot in all its x-rayed glory.  And proof that a car window can indeed serve as an x-ray light box.

Unfortunately, the fracture hasn't fully healed.  It's definitely better, but the two pieces of my fifth metatarsal bone have not completely fused.  My orthopedist has told me that there is no running permitted for the next four weeks, at which point we will perform another x-ray to evaluate.  In response to my shock, he responded that running prematurely could lead to nonunion of the fracture, which would then require surgery.

I hadn't truly thought out the consequences of my foot being immobilized in a boot for six weeks either.  My calf muscle and the muscles at the ball of my foot are all tight from not being used, and in fact there's probably some muscle atrophy as well.  I have been walking this week with quite an interesting limp.

This is what happens when one leg is immobilized in an orthopedic boot for six weeks.  The muscle atrophy on the right is pretty apparent.

With all my difficulty walking, it is ironic that the only place where I have felt like a normal person is on a spin bike or in a pool, because the mechanics of stationary cycling and swimming are not much affected by the condition of my foot.

I had a physical therapy session yesterday, where a few things were pointed out to me.  My hip strength is off, and in fact my right hip is weaker than the left.  And, since the muscles at the bottom of my foot are tight and atrophied, I am taking a much smaller step with the left foot than with the right.

I have some exercises from physical therapy, and with a bit of stretching and attention to my gait, particularly making sure to take a larger step forward with my left foot, I am feeling a bit better today.  In fact, on my lunch break, I went for a thirty minute walk.  In my athletic life prior to this fracture, I would roll my eyes at even considering that to be a workout.  The toes of my right foot ached with each step, but I know I need to build and stretch those muscles so I kept going.

This weekend, I look forward to my first outdoor bike ride since my fracture.  And I look forward to developing stronger hip flexors, and walking like a normal person.

 

I thought I would be recovered by now, but I'm not quite there.  In due time, I will be.

Motivation for Change

I talk about lifestyle change with my patients daily.

One of those conversations occurred last weekend.  A previously healthy woman had a major health scare -- chest pain, followed by a cardiac arrest.  She was resuscitated and I performed an emergency angioplasty on her in the middle of the night to open a completely occluded left anterior descending coronary artery. 

Luckily, she recovered quite well in the hospital, and I had a conversation with her and her husband about diet and lifestyle.  She was hesitant about changing her diet, saying that she felt that this would be very hard for her.

Her husband said, "Honey, you almost died.  You have to do this.  Or you will have another heart attack."

Fear is a big motivator.  But it doesn't do well to lead to permanent changes.  Fear eases as the acute event becomes more distant.  Positive reinforcement is a better motivator to make change.

I love how Dean Ornish says it: "...re-framing the reason for changing from fear of dying to joy of living."

Because, living a healthy lifestyle makes you FEEL good.  Eating clean and exercising gives you more energy, more vitality, better mood.

Lifestyle change is hard.  But, in the long run, when you live cleaner, you live happier.  And that's how I want to frame the conversation with my patients -- good habits aren't punishment, they are changes that will lead to a happier, healthier, and longer life.

Three Weeks in a Boot

I fractured my 5th metatarsal and sprained my right ankle three weeks ago with a clumsy misstep in the middle of the night down the stairs.  Today was my three week checkup.

According to my orthopod, this is an improvement from the initial x-ray.  As I'm not having much pain, he's pleased with my progress.  In another three weeks, I will have another check-up and presumably at that time if all is well, I'll be out of the boot.

My mental state through all of this has definitely improved.  I'm swimming, riding a stationary bicycle and doing spin classes, weight training, and even doing a little yoga.  My goal is to maintain my fitness and improve my eating a bit.  Because I thrive on structure, I've asked my coach to continue to give me a "schedule" of activities, like when I'm training.  It's just that the focus of my training is a little different.

At poolside, about to do my first post-injury swim workout.

A week after my injury, I headed back to the pool.  I can't kick, but I can swim with a pull buoy supporting my legs.  I've noticed that a full swim workout with a pull buoy tires me out slightly more than a standard swim workout.  Getting in the water, I have the chance to flex and extend my ankle a bit more, which is good because with the boot I feel like I have less range of motion.  The pull buoy forces me to rotate my torso, something my coach Gerardo has been telling me I need to do more when I swim but I really haven't truly understood until now.  Last week I swam six times.

I can ride a stationary bike, and can even do a spin class.  I just can't stand on the bike, which is fine by me, because I think that standing on a bike in spin class is a little silly because I don't spend much time standing on my bike when I'm riding on roads.

Sometimes selfies are fun.  That's me getting on a stationary bike a little over a week after my foot fracture.  I felt determined to get in a good workout, no matter what my limitations were.  A lot of people who get on the bikes at the gym aren't necessarily pedaling very fast, and often they seem more interested in looking at their smartphone than working out.  I'm not sure if I got more strange looks because I was the only one on a stationary bike pedaling fast, or because of the boot.  Regardless, after that workout, I felt the best I had since my fall.

I'm doing more strength training, some with my personal trainer Corey, some on my own.  Corey comes up with some good workouts, like step-ups on a bench, hopping in sand on one foot, and the usual upper-body challenges like push-ups, pull-ups, and tough core work.  And, when I'm not training with him, I'm doing some strength workout on my own a couple more days a week.  I have decided to challenge myself with exercises like one-legged burpees, which is a tough cardiovascular and strength workout, and as you might imagine yielded a few odd looks.

I've used my injury to my advantage in counseling patients, and perhaps it helps me empathize.  When a patient tells me he or she cannot exercise due to back pain, knee pain, or whatever issue they have, I can point out my own injury (because it's hard to hide a large orthopedic boot) and talk about how I am finding ways to exercise in spite of it, and encourage them to try to do the same.

I miss running more than you can imagine.  But I'm not focusing on that.  Fractures heal.  This is known.  I will be back to running in a few more weeks, maybe 3 weeks, maybe a little longer.  And in the meantime, I'm going to stay fit, and positive.

New Cholesterol Guidelines

Recent updated guidelines have been released regarding treatment of cholesterol.  Specifically, this statement suggests who should and should not be on cholesterol-lowering statin medication.

There has been a lot of controversy regarding this document.  And, as a cardiologist, I don't necessarily agree with its conclusions.

What's new -- new research?  New studies? No.  This is just a group of experts coming together to give their opinion.

The recommendation that patients with known significant arterial disease -- including anyone who has had a heart attack or stroke -- should receive statins is definitely supported by clinical studies.

But, the guidelines also suggest that many patients who do not have disease should receive statins.  They present a new risk calculator, and if the risk of the patient is greater than 7.5% for a cardiovascular event (heart attack or stroke) that the patient should receive statins.  That would mean millions more patients on statins.

The major problem that I see with the guidelines is the suggestion of statins for primary prevention.  But, the literature on that topic does not suggest a strong benefit.  To prevent one heart attack or stroke over the course of five years, one would have to treat about 150 patients with a statin pill every single day.  So, when looking at a huge population, yes you see a reduction in the number of heart attacks and strokes. But, odds are, if you are one of those 150 people being treated with a statin, there is a 149/150 chance that taking a pill every single day for five years will not prevent any type of event.

Further, there have been meta-analyses, which are studies pooling data from several other studies, that demonstrate that amongst the primary prevention population, there is no reduction in mortality.  In other words, a statin won't prolong your life.

There's a great editorial from John Abramson and Rita Redburg in the New York Times on the new guidelines, similarly skeptical of expanding the use of statins.

So, if you feel good, why should you take a statin, which is a pill that has a decent chance of causing muscle aches and is known to slightly increase the risk of diabetes, has a less than 1% chance of preventing a heart attack or stroke in the next 5 years, and won't prolong your life?  It's a good question.  Can you get the same benefit from improving your lifestyle?

YES!  In fact, lifestyle will give you even more benefit than a statin pill!  Daily cardiovascular exercise for at least 30 minutes, but preferably an hour, will help you feel better, lose weight, drop the cholesterol numbers, and reduce your risk of a heart attack or stroke.  Diet is potent too -- and, a whole-food plant-based diet will make you practically heart-attack-proof.

I'm not a big proponent of statins for primary prevention because the data to support them just isn't that strong.  While the guidelines do support lifestyle, I think that we as a profession and society need to do more to encourage people to be more active, eat better, manage stress, and maintain a healthy weight.  And that is how we will prevent heart attacks and strokes, not by feeding everyone a statin.

From athlete to gimp

With one clumsy misstep on the stairs, and the snap of a metatarsal bone, I went from athlete to gimp.

It's been tough.  I am in an orthopedic boot. I can walk short distances in the boot, but anything longer and I use my crutches, because I've found that walking too much leads to quite a bit of pain. I am taking ibuprofen 800 mg three times a day, and an occasional Percocet.  My foot is still swollen, but it's not quite the blue swollen mess with five sausage-like toes as of just a few days ago.

Other than a short weight training session, I have not been exercising. I'd love to do some nonweightbearing exercises with the boot on, but even shaking around the foot with the boot in place gets to be uncomfortable. And I am afraid to get in the pool to swim for fear that my unprotected foot will hit a wall, the lane marker, or even my other foot. Even the slightest touch to the foot can be uncomfortable.

It's been six days. I feel different. I definitely feel more tired. I have a lot more free time. I'm trying to free time to good use by reading. I'm also getting more sleep than I did on my typical two workout days.

Then there's the emotional impact of all of this. I envy my friends and teammates who are racing.  I wish I could be out running swimming and biking with them. I fear what will happen to  my body without exercise.  I worked so hard earlier this year to get into the good shape that I am in and I don't want to lose it.  I am trying so hard to eat less so that I don't gain weight.

I am so fortunate to be surrounded by good friends, family, and an incredibly supportive boyfriend.  From coming over and bringing me dinner to taking out my trash cans, or hanging out and watching a redbox movie or just being a sympathetic ear, I couldn't ask to be surrounded by better people.

It takes only six weeks for this fracture to heal, but it feels like an eternity.  And I am trying to be positive. But it's tough.

When life gives you lemons, make lemonade.

Life has handed me lemons.

My dogs started whining in the middle of the night.  I came downstairs to let them out.  Half asleep, I thought I was stepping my right foot on the floor, when in fact there were a couple more steps.  I landed on the outside of the foot and fell to the floor, fracturing my 5th metatarsal bone.

I am in an orthopedic boot for the next six weeks.  While I am permitted to bear weight on the foot, I am using crutches because bearing weight on the foot is simply too painful.

Needless to say, I cannot run, and I will not be running the Carlsbad Marathon on January 19 as I had planned.

I suppose I could throw myself a little pity party.  And I'll be honest, as I lay in the emergency room this morning while my foot was x-rayed and splinted, I cried.  No honestly I sobbed.  Not from the pain, but rather because my running is being taken away from me.

I choose to be more positive.  I am going to take a few days off from exercising.  Then I can swim.  I can't push off the wall with my right foot, but I can get in a good workout.  I can lift some weights.  I can aqua jog.  And I'm sure my personal trainer Corey will come up with some fun stuff like one-legged burpees to keep me in shape.

As much as I'd love to become the one-legged fitness wonder, Coach Gerardo asked me to take the rest of the week off from training.  That is to keep me from doing more damage.  He suggests that one can take up to 2 weeks off from training and not lose fitness.

This will be a challenge but I will get through it.  Maybe my body could use the rest.  The last time I was in an orthopedic boot and couldn't run was 8 years ago.  It was during that time that I began swimming and riding my bike.  Ultimately, when my foot healed, I put it all together and became.... a triathlete.  Which I am to this day.

I will take on this new challenge of not running.  I will listen to my coach.  I will rest as I should.  And, in the next six weeks, I am going to become an awesome swimmer.

Fitter and Faster

Something you may have noticed.... I'm smaller.

Back in February, in order to change up my routine with the hopes of becoming a better athlete, I hired personal trainer Corey Enman of Fitamorphosis.  Upon signing on with him, I was measured and weighed.  At 5'10", I weighed 159 lbs, with 24% body fat.  While 24% body fat is a normal body size, it's a bit more than what a competitive female athlete should carry.

In about four months, that became 137 pounds and 18% body fat.  Though, in truth, I've gained about 3-4 pounds of that back, and I'm hovering around 140-141 pounds.

On the left, me in December 2011 at 159 lbs.  On the right, a slimmer and faster me.

As you well know, the exercise was already there, with the usual  swimming, biking, and running prescribed by Coach Gerardo of Fortius Racing, and two personal-training weight session per week.  But, with Corey, I've changed that up.  A once weekly session with Corey consists of high-intensity body weight and free weight exercises to burn fat and build muscle.  These may consist of running a mile in a 20-lb weighted vest while carrying two ten-pound dumbbells, burpees on a single leg, frog jumps, pushing a tire across a gym floor, amongst other challenging exercises done back-to-back-to-back.  Then, I'll usually add in one day a week of Barry's Boot Camp.  So that is two days of solid high-intensity strength training in addition to my cardio.

However, I would credit a better diet with my results.  I don't deprive myself.  I eat around 2000 calories per day.  Breakfast is a soy latte, oatmeal with fruit, and usually a smoothie or another piece of fruit later in the morning.  Lunch is typically a salad with tofu or tempha (a brown rice protein) and tons of veggies, and sometimes some quinoa and avocado.  Dinner is usually a stir-fry.  Snacks are fruit, or veggies and hummus, or trail mix.  And I've curtailed my nighttime noshing.

Key to the diet is logging all my food into MyFitnessPal, a free application, to keep me accountable, and to allow Corey to know what I'm eating.

Initially, my smaller body size didn't transform into much speed.  But, in the ensuing months, I am faster.  In fact, in the past three weeks, I have set new personal bests at the half marathon (1:48:34), 5k (23:01), and 10k (49:04).  Hopefully, that means that the Carlsbad Marathon in January will also be a personal best.

Before the Hard Rock Los Angeles 5K on November 2. 

I wouldn't suggest my previous weight was unhealthy -- it was healthy.  But, my lower weight helps me to move faster.

There's no shortcuts to health or speed -- it's hard work.  If you want the support you need to get your fittest and healthiest body, take Corey's FitCamp classes.  Click Here.

Confessions of a New Vegan Coffee Drinker

I've told you that I've started drinking coffee.

It began in Israel in July, where I was competing in the Maccabiah Games.  Our first event was the Bike Time Trial.  This involved a commute from Tel Aviv up to a kibbutz in the Golan Heights, in the north of the country.  For a race start at 7:30 am, this required us to meet up in the lobby of the hotel at 2:30 am to drop off our bikes.  I had miraculously gotten to bed at 8 pm, so I had some rest.  But I was tired.  We discovered that the hotel was kind enough to open up the coffee cart to provide complimentary drinks.

On a whim, I tried a soy latte.  And I was surprised, it tasted quite good.  And there I was, wide awake, probably the only one awake for the entire two hour bus trip up north!  Shortly thereafter, I got on my bike and had an incredible race, or at least good for me, averaging over twenty miles per hour on a hilly time trial course.

So I figured, if I had a good bike time trial on some coffee, why not try it before other workouts?  And so, I had my daily latte for the rest of the trip.  I noticed that my morning runs were faster on coffee.

Then I got home.  Starbucks around the corner from me got to know that "Doctor Heather is on her way to go swimming."  Yes, my soy lattes fueled my morning swims far better than any green smoothie.

So then it made sense -- why give all my money to Starbucks when I can make my own soy lattes at home?  My parents were kind enough to give me a Breville Automatic Espresso Machine as a birthday present.  And now, in five minutes, I can make my own latte, and it's as good as anything I get at Starbucks, but it's not $3.55 (because Starbucks charges extra for soy milk... grrrr!)

A few things I've discovered as a new coffee drinker --
--Non-dairy creamer isn't soy creamer.  It has palm oil and other artificial crap in it... including casein, which is a dairy product.
--Soy milk seems to work just as well as soy creamer in black coffee.  At least for me.
--Why don't more places offer soy creamer or soy milk instead of that "non-dairy creamer" crap?

Oh and one last thing... I'm addicted.  I need my morning coffee.  At least it's a relatively healthy addiction.

Coffee -- Not so bad, actually can be good!

There was a great review article in JACC (Journal of the American College of Cardiology) this week on the health benefits and risks of coffee.  I read it because after 38 years on this earth, I have finally become a coffee drinker.

A lot of patients seem to think that when they hear the bad effects on the heart due to meat, dairy, cigarettes, eggs, added sugar, oil, and salt, that somehow coffee is another substance of harm.

Actually, to the contrary.  Coffee drinkers seem to have a decreased risk of heart attack, stroke, diabetes, and abnormal heart rhythms.  These benefits can be seen in moderate coffee consumption of up to 4 cups of coffee per day.  These benefits may be due to the caffeine in coffee, but there are other chemicals in coffee that may contribute to these health benefits.

The down side, of course, is that some people feel tremulous or anxious with consumption of caffeine.

So, drink up!

Shabbat Shalom!

Last Friday night, I had a vegan potluck Shabbat at my home. Most attendees were not vegans.

I baked a challah from a recipe for Post-Punk Kitchen.

We had lots of options - matzo ball soup (see my passover post from March for links to that recipe). We had a couscous salad, a big kale and tahini salad, lentils, vegan hot dogs, hummus and an Israeli salad. For dessert we had homemade chocolate coconut ice cream, cookies, and plenty of fruit.