Exercise Program Guide

I always appreciate when patients ask me questions, it shows they care about their health and it is my job to educate them on their journey towards wellness. Through these interactions I have come to realize there are some blatant misconceptions about exercise. I'd like to address some of them in order to help hard working people achieve the results they deserve. I put together this post to guide the development of an exercise routine. However, this is a massive topic so please consult with your healthcare and fitness professionals to tailor your program specifically for your needs.

1. Push the intensity - Jogging on a treadmill for 1 hour 5 days a week and staying in the so called "fat burning zone" is relatively ineffective and can even be detrimental. Long distance cardio can result in increased cortisol, decreased immune function, and reduced testosterone levels. You're essentially losing muscle (you'll see why that's important below) while the constant pounding from running does damage to your joints. Instead, if running is something you'd like to incorporate into your routine, focus mainly on high intensity interval training. This type of training allows you to work at a higher intensity in a shorter amount of time, creating a more efficient workout. Here's a basic example, which can be adjusted based on your fitness level and also be applied to skipping, swimming, biking, etc -

Set 1 - Work at 90% of your max for 10 sec, recover at 50% of your max for 20 sec, repeat 10 times
Recover with light movement for 2 minutes
Set 2 - Work at 80% of your max for 20 sec, recover at 50% of your max for 40 sec, repeat 5 times
For a total workout time of 12 minutes!

This type of workout also leads to an increase in Excess Post-exercise Oxygen Consumption (EPOC). This refers to the amount of calories your body has to burn after the workout in order to recover from the "oxygen debt" that the high intensity workout induced. The more intense the workout, the higher your EPOC. If you're going to run, and you're not a competitive distance runner, focus mostly on high intensity interval training.

2. Lift heavy weights through compound exercises - weight training should be the focus of most exercise programs in order to build muscle. The more muscle you have, the more calories you burn at rest (i.e. a higher basal metabolic rate). This doesn't mean you have to be big and bulky, and you likely won't be, unless you have the right hormonal makeup to go along with a specific way of eating and training. To increase muscle activation, go through the concentric or "lift" phase of the exercise as quickly as you can and the eccentric or "lowering" phase of the exercise slowly (i.e. 1 sec concentric to 4 sec eccentric). By combining this tempo with heavy weights, you're recruiting more muscle fibers (both fast and slow twitch muscle fibers vs. only slow twitch) for greater muscle activation. If you perform compound exercises that require more muscle, like squats, deadlifts, and pull-ups, you're challenging your body even more, to which it responds with greater improvements so long as you...

3. Allow your body to recover - With the intensity of the interval training and weight lifting described above comes an equally important need to recover. But with the benefit of EPOC and the added lean muscle you can recover guilt-free knowing your body is still burning calories at an increased rate. This includes getting adequate sleep and nutrition, foam rolling, taking rest days but still staying active (i.e. walking for 20-30 mins daily) and taking contrast showers. You don't build muscle during a workout, you break it down during a workout and build it back up in the hours and days to follow.

4. Find your motivation - I used to workout with the goal of playing professional soccer and I was able to push myself in ways I could have never imagined. Once my attention shifted towards medical school, my goals shifted towards demonstrating to those around me that a busy schedule was no excuse to ignoring your health. I also want to practice what I preach and set a great example for the patients I work with. Mixed in is the motivation to visit my nonna once a week who cooks incredibly delicious meals with no regard for portion control. Find whatever motivates you and build your plan around it.

5. Don't make eating stressful - I'm not a big fan of counting calories, either burned or consumed, as there are very few instances where I see its usefulness. It becomes a process that is too tedious and time consuming, and too many variables exist (i.e. EPOC, the thermic effect of food, different foods with the same caloric content exhibiting vastly different effects on the body, etc.). I will get more into specifics of eating in future posts, but your main focus should be on eating healthy foods that have a high nutrient density. Start your day with a healthy breakfast and if it happens to be a workout day, consume your largest meal soon after the workout. When you happen to have an unhealthy meal or a dessert, don't guilt yourself for it, make sure you savour and enjoy every last bite and get right back to eating healthy at the next meal.

Here's a video from a workout challenge I did to win a ticket to race in Tough Mudder:
https://www.youtube.com/watch?v=KHGO4NLq-6Q
Rest assured my EPOC after this was insane, as I felt like I was huffing and puffing for the rest of the day even though the workout took me under 6 and a half minutes. Give this, or something similar, a try if you (and your doctor) think you're up for it.
Workout instructions - As fast as you can, complete 5 one arm push ups, 30 wide-grip pull ups, 50 squat jumps, 25 pike push ups, 50 plank crawls, 50 in and out crunches, 100 mountain climbers, and 100 push ups.

References
1) Milanović Z, Sporiš G, Weston M. Effectiveness of High-Intensity Interval Training (HIT) and Continuous Endurance Training for VO2max Improvements: A Systematic Review and Meta-Analysis of Controlled Trials. Sports Med. 2015; 45(10):1469-81
2) Costigan S, Eather N, Plotnikoff R, Taaffe D, Lubans D. High-intensity interval training for improving health-related fitness in adolescents: a systematic review and meta-analysis. Br J Sports Med. 2015; 49(19):1253-61
3) Mackinnon L. Chronic exercise training effects on immune function. Med Sci Sports Exerc. 2000; 32(7):S369-76
4) Krüger K, Mooren F, Pilat. The Immunomodulatory Effects of Physical Activity. Curr Pharm Des. 2016; 22(24):3730-48
5) MacKelvie K, Taunton J, McKay H, Khan K. Bone mineral density and serum testosterone in chronically trained, high mileage 40-55 year old male runners. Br J Sports Med. 2000; 34(4):273-8
6) Greer B, Sirithienthad P, Moffatt R, Marcello R, Panton L. EPOC Comparison Between Isocaloric Bouts of Steady-State Aerobic, Intermittent Aerobic, and Resistance Training. Res Q Exerc Sport. 2015; 86(2):190-5
7) Roig M, O'Brien K, Kirk G, Murray R, McKinnon P, Shadgan B, Reid W. The effects of eccentric versus concentric resistance training on muscle strength and mass in healthy adults: a systematic review with meta-analysis. Br J Sports Med. 2009; 43(8):556-68

Contrast Showers

Hydrotherapy has been around for centuries. It involves the use of water and the manipulation of its temperature in order to exert a desired effect. Many of you have already used variations of hydrotherapy to effect the quantity of circulation to various parts of the body, for instance using an ice pack on a sprained ankle or a heat pack to relax a tight muscle.

Naturopathic hydrotherapy goes a bit beyond these basic treatments, implementing the belief that water can also effect the quality of blood in circulation. This is achieved by enhancing blood flow through the organs of elimination and detoxification (skin, liver, kidneys, bowels). There is also a belief that by tonifying the digestive organs, hydrotherapy enhances the nutrition received by the blood which further improves its quality. The best way to achieve this is through alternating hot and cold temperature applications, or "contrast" treatments.

So why does contrast therapy work so well in achieving the aforementioned benefits? It relates mainly to the manipulation of both your metabolism and circulation. When metabolism increases, it should ideally have a corresponding increase in circulation to provide the nutrition required and carry off resultant waste products. The chart below explains the effect of temperature, applied for different periods of time, on both circulation and metabolism.

Application	Time	Temperature	Effect on Metabolism	Effect on Circulation
long hot	greater than 5 minutes	98-104°F, or 36-40°C	Stimulates	Depresses
short hot	less than 5 minutes	98-104°F, or 36-40°C	Stimulates	Stimulates
long cold	greater than 1 minute	51-65°F, or 10-18°C	Depresses	Depresses
short cold	less than 1 minute	51-65°F, or 10-18°C	Stimulates	Stimulates

Both short hot and short cold applications provide the ideal scenario to increase both metabolism and circulation. So how can you reap some of the benefits of these hydrotherapy principles in your everyday life? Sub out your regular hot shower with a contrast shower! Here are the steps...

1) Start your shower with the hot water running and immerse yourself for 2 minutes.

2) After the 2 minutes are up, turn the water temperature to as cold as your body can tolerate for 30 seconds.

3) Turn the water back to hot for another 2 minutes, followed by another 30 seconds of cold.

4) Repeat this cycle for a total of 3-5 times and be sure to finish with 30 seconds of cold water.

Note: the time can vary, as long as a 3:1 or 4:1 ratio of hot water to cold water is maintained (max length of both would be 4 minutes hot, 1 minute cold).

Through improving metabolism and circulation, this type of shower can have positive effects on the function of the immune system and nervous system, speed athletic recovery, and leave you with an overall refreshed feeling. Caution should be applied to those with decreased peripheral sensation (i.e. diabetics), immune dysfunction, or circulatory issues, and you should stop the treatment if any symptoms arise (i.e. dizziness, extreme cold/heat, etc.). Use temperatures your body can tolerate and you will slowly be able to build up a tolerance to slightly hotter/colder temperatures.

This is by no means a cure-all for everything that ails you, but it can be a simple and easy adjunctive therapy applied into your everyday routine. For other hydrotherapy treatments tailored specifically to your condition/treatment goals that are done in clinic, book an appointment with your local Naturopath.

Happy showering!

References
1) Boyle, W and Saine, A. Lectures in Naturopathic Hydrotherapy. Eclectic Medical Publications. 1995.
2) Juliff LE, Halson SL, Bonetti DL, Versey NG, Driller MW, Peiffer JJ. Influence of contrast shower and water immersion on recovery in elite netballers. J Strength Cond Res. 2014; 28(8):2353-8.
3) Hamlin MJ. The effect of contrast temperature water therapy on repeated sprint performance. J Sci Med Sport. 2007; 10(6):398-402.
4) Bieuzen F, Bleakley CM, Costello JT. Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis. PLoS One. 2013; 8(4):e62356

Breakfast - how to do it right

We've all been told breakfast is the most important meal of the day. It is supposed to be the meal that gets us going and sets us up to function at our best. But do we really know what a proper breakfast looks like? Instead of feeling energized, a lot of people find themselves tired and sluggish soon after breakfast, turning to caffeinated beverages and constant snacking to keep them going.

There are varying opinions on the optimal timing and content of breakfast, and the existing literature is not clear cut. I've been asked many questions about breakfast, and I've done my best to answer some of them below based on my interpretation of the literature and what I've seen work. Here's a list of things you should know before planning out the first meal of your day. I don't go too deep into the scientific details but I've listed the references at the bottom of the page if you're interested in more information.

1) Before consuming any food, drink at least 1-2 cups of warm water
While we sleep we become dehydrated via the loss of water through water vapor. This is especially true for those that breathe through their mouths during sleep. Ensuring adequate hydration is important for many reasons, including increasing energy levels and reducing food cravings. The warmth of the water will aid digestion and promote healthy bowel movements. While you're at it, squeeze some fresh lemon into your water to help kick start your metabolism and aid your body's natural detoxifying processes.

2) Consume a meal higher in protein and lower in carbohydrates
Yes, that means the foods traditionally marketed to us as breakfast foods such as cereals, bagels, toast, pancakes, store-bought juices, and oatmeal should be left aside for more protein (aim for at least 20 grams) rich options. Simple carbohydrates like these spike our insulin and decrease our cortisol (which should be high in the morning and decline steadily throughout the day), leading to a crash in energy and a disruption in cortisol's natural circadian rhythm. Complex carbohydrates that are nutrient dense and high in fibre (i.e., vegetables and berries) can and should be incorporated. This will promote healthy insulin and cortisol levels, maintain satiation, and provide sustained energy to get your day started on the right foot. Don't shy away from healthy fats (i.e., almond butter, tahini, pumpkin seed butter, etc.) either, as they provide various important nutritional compounds while increasing the substance of your meal.

3) Should you have your morning brew?
Coffee has some beneficial properties and is enjoyed for its taste by so many people (myself included), so it is difficult to say it needs to be cut out entirely. However, there is a harm to coffee when it is relied upon as a main source of energy. Like any drug, the more you have caffeine, the less sensitive you are to its effects and the more you need to stimulate yourself. Caffeine's diuretic effect leads to a more dehydrated state, and also negatively affects the health of the adrenal glands when consumed chronically in high amounts. The adrenal glands regulate numerous important processes, including our ability to respond to stress, our metabolism, and blood pressure. Therefore, we should not be consuming it on a regular basis in excessive amounts. I recommend limiting your caffeinated coffee consumption to a few cups per week. Consider substituting some days with a Swiss water decaffeinated coffee (the decaffeinating process of Swiss water decaf is chemical free), or stick to only lemon water some mornings.
Note: make sure your coffee is paper filtered, as unfiltered coffee contains compounds that raise LDL cholesterol.

4) You don't have to eat first thing in the morning
I first heard of the idea of intermittent fasting from Yuri Elkaim, my former strength and conditioning coach at the University of Toronto. He is a health and fitness expert, New York Times best-selling author, and big proponent of intermittent fasting. It involves going an extended period of time (for instance 18-24 hours) without food, only consuming water. An example would be finishing dinner on Sunday night at 6pm, and waiting to consume food until 3pm Monday afternoon. I recommend trying weekly or biweekly fasts and seeing how you feel and how your body tolerates it. The health benefits, which are continuing to emerge in the literature, are numerous. They include a decrease in inflammation, increased fat loss, decreased plasma insulin and an increase in the sensitivity of insulin to its receptor. It has also been shown to improve mood and metabolism while decreasing the rate of DNA damage in aging men. Those concerned about losing muscle during fasting need not worry, as growth hormone actually increases during a fast, leading to the preservation of muscle and the use of fat as the main source of fuel.

Some examples of a healthy breakfast include
Eggs and roasted veggies
Smoothie - a favourite of mine is a handful of frozen berries, a handful of spinach and/or other greens I happen to have, 1 heaping tbsp of almond butter, 1 scoop high quality whey or a complete vegan protein powder (I use Vega one all in one natural flavor protein), and unsweetened almond milk to desired thickness
Protein cookies (see recipe posted below) with a nut butter spread on top

Note: eggs should not be scrambled and fried as this results in oxidation of the cholesterol in the egg yolks, and oxidized cholesterol is bad news for the health of our cardiovascular system.


Dr. Neemez Kassam's Protein Breakfast Cookies Recipe
Makes 16 cookies 8 servings (2 cookies a serving)
Ingredients:
1/2 cup butter, softened (1 stick)
1 egg
2-3 tbsp sweetened or unsweetened fruit puree (I had apple sauce on hand, next time I may try it with mashed banana)
1/4 cup Greek yogurt
1/2 tsp vanilla
2 tbsp nut butter
1 tsp baking soda
1/2 tsp cinnamon
2 tbsp cocoa powder
1/4 cup almond flour
2 scoops protein powder (You can use whey protein, 1 scoop vanilla, 1 scoop banana, and all vanilla. Chocolate would be good here too)
1 3/4 cup quick oats
Optional add-ins: chocolate chips, nuts, dried fruit, seeds, etc.
Optional: add in raw honey to taste
Directions:
Preheat oven to 350 degrees. Line a baking sheet with tinfoil or parchment paper
Cream butter
Add in the rest of the liquid ingredients (including yogurt and nut butter) and beat until well combined and slightly fluffy
Add in dry ingredient (except oats or add ins) and mix until combined
Mix in oats, followed by any additional add-ins
Spoon onto cookie sheet and bake 10-12 minutes until cookie starts to brown and is firm to touch


Please keep in mind these are all general recommendations and should be adjusted based on things like health status, activity level, and daily schedule.
I hope this gave you a better idea of what a healthy breakfast should look like. Did this article help? Feel free to comment below!

References

1) Boschmann M, Steiniger J, Franke G, Birkenfeld AL., et al. Water drinking induces thermogenesis through osmosensitive mechanisms. J of Clin Endocrinol Metab. 2007; 92(8):3334-7
2) Padzys GS, Thornton SN, Martrette JM, Trabalon M. Effects of short term forced oral breathing in rat pups on weight gain, hydration and stress. Physiol Behav. 2011; 102(2): 175-80
3) Debono M., Ghobadi C., Rostami-Hodjegan A., Huatan H., et al. Modified-release hydrocortisone to provide circadian cortisol profiles. J Clin Endocrinol Metab. 2009; 94(5): 1548–1554
4) Chan S and Debono M. Replication of cortisol circadian rhythm: new advances in hydrocortisone replacement therapy. Ther Adv Endocrinol Metab. 2010; 1(3): 129–138
5) Yang D1, Liu Z, Yang H, Jue Y. Acute effects of high-protein versus normal-protein isocaloric meals on satiety and ghrelin. Eur J Nutr. 2014; 53(2): 493-500
6) O'Keefe JH, Bhatti SK, Patil HR, DiNicolantonio JJ., et al. Effects of habitual coffee consumption on cardiometabolic disease, cardiovascular health, and all-cause mortality. J Am Coll Cardiol. 2013; 62(12): 1043-51
7) Butt MS and Sultan MT. Coffee and its consumption: benefits and risks. Crit Rev Food Sci Nutr. 2011; 51(4):363-73
8) Traba J, Kwarteng-Siaw M, Okoli TC, Li J., et al. Fasting and refeeding differentially regulate NLRP3 inflammasome activation in human subjects. J Clin Invest. 2015; 125(12): 4592-600
9) Wegman MP, Guo MH, Bennion DM, Shankar MN., et al. Practicality of intermittent fasting in humans and its effect on oxidative stress and genes related to aging and metabolism. Rejuvenation Res. 2015;18(2): 162-72
10) Klempel MC1, Kroeger CM, Bhutani S, Trepanowski JF, Varady KA. Intermittent fasting combined with calorie restriction is effective for weight loss and cardio-protection in obese women. Nutr J. 2012;11: 98
11) Hussin NM1, Shahar S, Teng NI, Ngah WZ, Das SK. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013; 17(8): 674-80
12) Teng NI, Shahar S, Rajab NF, Manaf ZA., et al. Improvement of metabolic parameters in healthy older adult men following a fasting calorie restriction intervention. Aging Male. 2013; 16(4): 177-83
13) Harvie MN, Pegington M, Mattson MP, Frystyk J., et al. The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. Int J Obes (Lond). 2011; 35(5): 714-27
14) Halberg N, Henriksen M, Söderhamn N, Stallknecht B., et al. Effect of intermittent fasting and refeeding on insulin action in healthy men. J Appl Physiol. 2005; 99(6): 2128-36
15) Harvie MN, Pegington M, Mattson MP, Frystyk J., et al. The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. Int J Obes (Lond). 2011; 35(5): 714-27