The Five Pillars
Every doctor has his or her own conception of what constitutes good health. As I have
discussed, my concept is a dynamic one in which we become more healthy as our body
systems function at a higher level. The Anti-Inflammation Lifestyle (AIL) promotes health
by improving function at the cellular level. Lowering inflammation enables the cells of our
bodies to work more efficiently and improves circulation which improves the ability of cells to
obtain adequate nutrition and effectively clear toxins and waste. A healthy diet and proper
supplementation together form two of the five pillars which comprise the AIL, the other three
being: exercise, stress management, and restorative sleep. Like the legs of a stool, each
of the five pillars plays a role in supporting the AIL, upon which optimal function and health
“How important is it really to exercise? I eat well, I take supplements, I am not overweight, and
my stress levels are low. My wife and I even walk on weekends. So aren’t I healthy? Do I
really need to do exercise every day?”
I am asked some version of this question on almost a daily basis in my practice. Some people
just hate to exercise. Others are averse to swallowing pills, making it difficult for them to take
important supplements. Still others have difficulty breaking unhealthy food cravings. In the
end the question seems always to be, “Can’t good health be achieved by using four of the five
pillars? Or three?”
Just as the concept of health itself is a relative one (higher or lower levels of function
correspond to better or worse health across a wide Continuum), so should each of the pillars
be considered fluid. It is not so much a question of whether one’s diet is good or bad, whether
one exercises or not, whether one takes all the right supplements or none of them, etc. Rather
it is a question of making effort to move in the right direction along the Continuum of health, and
to do so we must try to move at least to some degree in the right direction along the continuum
of each of the five pillars. The Anti-Inflammation Lifestyle means eating progressively better
over time, taking the right supplements, doing one’s best to create a routine of regular exercise,
not allowing stressful life situations to go unaddressed for too long, and creating healthy sleep/
wake cycles with adequate rest. Can a person be healthy and not eat healthily? Can a person
be healthy without exercising? Without sufficient rest? Without managing their stress levels?
Without taking supplements? Well, four good legs on a stool are a lot better than three, but they
are less strong and stable than five.
Of the Five Pillars of good health, cardiovascular exercise stands in the center, bearing more of
the burden of support than any of the others.
Something I’ve observed both in my practice and in my private life is that certain behaviors (and cravings) tend to run together. For example, many of my patients who smoke find that alcohol is a smoking trigger. For them, these two cravings/behaviors have become linked in such a way that it is nearly impossible for them to resist having a cigarette while they are drinking. The alcohol potentiates the urge for tobacco, and in order for such people to quit one habit, they must quit both at the same time which is very difficult to do. I have also noticed that people who exercise regularly tend to have much healthier than average diets, high in fruits and vegetables and low in saturated and trans-fats. For many of my endurance athlete patients, the mere thought of a fast-food burger with fries is enough to make them feel sick.
While not all drinkers smoke and not all athletes have healthy diets, what seems to be clear is that, for most people, certain behaviors are linked together. Snacking while watching television, listening to music while driving, and reading at bedtime are some simple examples. Once behaviors become linked, they are hard to unlink. If it is your habit to light up a cigarette each time you get into the car or to drink a smoothie after a run, try doing the first without the second and see how it feels. Failure to exercise the second behavior creates a feeling of anxiety and discomfort which many people find intolerable.
What’s more, linked and non-linked behaviors alike tend to cluster together, grouping themselves more broadly into one of two camps: unhealthy or healthy. For example, overeating, a fatty and starchy diet, smoking, excessive beer or other alcohol consumption, and erratic sleep patterns tend to form a group of behaviors which run together. Not all people who habitually indulge in one of these behaviors finds themselves addicted to any of the others. But the more unhealthy habits a person has, the more likely he or she is to develop additional ones. Healthy habits seem to work in the same way, with regular exercise, good eating habits, regular sleeping patterns, and lower alcohol consumption seeming to run together as well. Again, not all people who have established one healthy habit go on to incorporate any of the others, but the more healthy habits a person has, the more susceptible he or she seems to be to acquiring others.
The more healthy habits coalesce into a lifestyle, the more they seem to exclude unhealthy habits. For most people who engage in regular cardiovascular exercise, eat healthily, and take the right supplements, the very idea of smoking cigarettes is disgusting. Similarly, for people who smoke, drink beer daily, and regularly eat fast food high in fats and starches, the idea of taking a 30 minute run in the park sounds equally horrible. Healthy habits and unhealthy habits, as they coalesce into lifestyles, seem for the most part to be mutually exclusive of each other.
Palliative or symptomatic care has become standard of care in the United States. Medicines and therapies which help manage symptoms but do not address the underlying causes which create the symptoms is an easier approach to healthcare in the short-term. With this paradigm, patients can be fit into 5-10 minute office visits which are treatment oriented. But it does not take great powers of observation to grasp the downside of this approach: patients get sicker rather than more healthy, treatments become more complicated and more expensive over time, and we are left with the world’s most expensive, technologically advanced healthcare system and one of the least healthy populations in the Western World. In 2010 the U.S. Center for Disease Control released data showing that 34 percent of American Adults are clinically obese (more than double the percentage in 1980), and the percentage of obese children has tripled over that same time period to 17 percent.
When faced intellectually with a choice of receiving ongoing medical care, either in the form of physical medicine or drugs, or curing the underlying problems and restoring health, most people have no trouble choosing the latter. But engaging with issues of exercise, weight loss, diet, stress-reduction, etc.–issues which entail lifestyle changes–is hard and may be far more than a patient bargained for when she first presented to a doctor’s office with a back strain. From the doctor’s perspective, helping patients regain health require much more time, risks losing patients who are not ready to confront these difficult issues, and is often perceived to work against his own economic interests. Chiropractic doctors are poorly reimbursed by insurance companies, especially when they try to work with patients on improving health, and success in this regard means curing a patient who in turn no longer requires his services.
I made the decision before I ever saw my first patient that I would dedicate my clinical practice toward promoting health, working for cures, and empowering patients not only to get well, but to stay well. That is why dietary management, supervised weight loss, home care exercise and stretching regimens, and stress-reduction techniques are an integral part of my practice. Contrary to the belief that empowering a patient to achieve a higher level of health is bad business, I have found it to be the single best marketing tool of my practice, with most of my new patient referrals coming from other doctors who share this philosophy of truly caring for people and from healthy ex-patients. That being said, I have also learned over the course of my 25 years in practice to respect the timetable and wishes of each individual patient I have the privilege of meeting. Successful care that leads to patients getting control of their migration toward the healthy end of the Continuum means a shared desire undertake change. If a patient, for whatever reasons, is not ready for comprehensive health care management, I have learned that I must respect that decision and help in whatever way I can to meet his/her needs. Approximately half of my practice consists of restorative or palliative care, and while fixing an injury or helping a patient manage with treatments that diminish pain may not be quite as satisfying as helping a patient become truly healthy, it is still a wonderful feeling to be available to anyone in need of help on any level.
We live in a society in which healthcare represents nearly one fifth of our Gross Domestic Product. Last year, more than 300 billion dollars were spent on the diagnosis and care of patients in American hospitals and clinics, and hundreds of billions more went to fill the coffers of insurance companies. We spend more money on health care than any other nation in the world, grossly and per capita. But healthcare is not the same thing as health, and by many meaningful benchmarks, our supremely costly healthcare system has not delivered supreme health to the American people. In terms of prevalence of chronic diseases such as diabetes, hypertension, and heart disease, obesity, infant mortality, and longevity we are ranked near the middle or in the bottom half among industrialized nations, and have even begun to lag behind many poor, underdeveloped countries. Perhaps the most important metric is HALE (Healthy Life Expectancy), which measures the average life expectancy of a population. In 2008, the World Health Organization ranked the United States 27th among industrialized nations on the HALE metric (25 countries make up what is often called the “First World” of industrialized nations). We are living significantly less long than people in countries with socialized medical systems (such as Spain, Italy, Canada, the U.K., France, Germany, Sweden, Norway, Denmark, and Belgium), or people in countries whose healthcare systems are far less technologically advanced than our own (such as Greece, Malta, Singapore, and Andorra). One thing these data make clear is that our costlier, technology-driven healthcare is not correlated with better health.
None of us like the idea of functioning below our potential. But most of us will not seek medical help because we get winded climbing two flights of stairs, or because our necks and shoulders feel tense at the end of the day, or because we don’t feel refreshed when we wake up each morning. We tell ourselves once the Holidays pass we will stop eating all the sweets, or once the kids get back to school we’ll get a healthier routine again, or this will be the summer that we’ll get into great shape. But the more we put off addressing signs of diminished function and well-being, the more likely we are to form habits out of unhealthy behaviors, and bad habits have the further effect of disinclining us toward taking action, creating a vicious circle of bad habits, inactivity, and down-spiraling health. Over time we move in the wrong direction along the Continuum.
Then one day we are bent over, hauling wet clothes out of the washing machine, as we have done hundreds of times before, when suddenly we feel a shock of pain shoot through our lower back, causing our knees to buckle. Or we present for our annual physical and are told that the steady weight gain we’ve been warned about over the last 2 or 3 years has caused our blood pressure or our blood sugar levels to go too high. We hear words like hypertension or diabetes mentioned and we become frightened, leaving the doctor’s office confused and anxious. What is happening is the problem facing the majority of Americans over the age of 35. Our bodies are functioning at progressively lower levels: our muscles have become weakened, our joints stiff, our circulation and immune systems sluggish, our sugar regulating systems out of balance. Inflammation caused by the extra fat we have been ignoring on our bellies is ravaging our body systems at the cellular level. And lower function has finally begun to give way to injury or disease. Our level of health has migrated (gradually, dangerously) to the sick end of the Continuum.
By the time a person is sick (obese, diabetic, hypertensive, etc.) he or she has likely been suffering a downslide along the Health Continuum into lower and lower levels of function and health for years. People who have become habituated to a low level of function have a much harder time addressing the broad issue of their overall health because bad habits shape our lifestyles and are therefore very hard to break. In order to move toward the healthy end of the spectrum, consistent effort over time must be made, disrupting not only patterns of behavior but people’s lifestyles. Because of this, doctors find that it is easier and sometimes wiser from a business perspective to simply treat the injury or disease at hand. A chiropractor, for example, meeting with a patient who strained her back lifting clothes out of the washing machine, may find it easier to treat the back strain, make the pain go away, and attribute the problem to “getting older,” rather than attempt to take on the underlying issues of de-conditioning, obesity, poor diet, etc. The patient leaves after a few visits feeling better, the back mostly returned to its ‘normal’ state of low grade stiffness and occasional discomfort but no longer in pain. She has not been taken to task for having acquired some bad eating habits, putting on weight, or not exercising. The doctor can expect to see her again in 3-6 months for the next episode of pain which will require a couple of more weeks of treatment. Eventually, she will become a ‘chiropractic patient,’ someone who comes in for monthly or even weekly treatments with which she is better able to manage her bad back.
I used to be able to sleep so well, but as I age I find it harder and harder to get a truly refreshing night’s sleep, even when I get seven, eight, or even nine hours.
As mentioned earlier, our bodies produce two important substances to help us achieve and maintain deep sleep: melatonin and GABA. As we age, we produce less and less of both even though we need restorative sleep as much or more in middle and older age than we did in young adulthood. The result is often a failure to spend enough time in the deeper levels of sleep, especially REM. Even if we don’t wake up in the night, we may be getting nudged out of the deeper levels of sleep, re-starting our 90 minute sleep cycles at phase one, then cycling down to level four or five before getting disrupted again by a partner moving in the bed, the sound of a motorcycle roaring past our house, or an ache in our hip or shoulder, starting the cycle over again at phase one. Instead of spending progressively more time in REM during each successive sleep cycle, we may be spending less time and getting less deep restorative sleep.
Sensory deprivation (ear plugs and eye shades) are a good place to start. Marissa can show you the ones we like best, just ask her at the front desk. There are also medicines which work to induce sleep, such as Ambien (a benzodiazepine) and Lunesta (a non-benzodiazepine), both part of the class of drugs known as sedative/hypnotics. These drugs act to stimulate GABA receptors and have been shown to be clinically effective for insomnia. However, both drugs have been reported to have significant side effects and can become habit forming. Many patients who use these drugs regularly suffer fatigue and diminished mental concentration during the day. By contrast, we have had great success with a natural remedy: Best-Rest Formula, by Pure Encapsulations. Best-Rest includes melatonin and GABA in very low doses, along with valerian, chamomile, and other natural extracts. Best-Rest has not been shown to be habit forming or to cause rebound insomnia when coming off its use. The side effects have been minimal in comparison to sedative/hypnotic prescription medicines. I use Best-Rest and earplugs whenever I go through periods of difficulty falling asleep or staying asleep.
Tip: The best way to eliminate sleep disturbance is to remove all obstacles to restorative sleep. If your mattress or pillow are not comfortable then it is time to consider changing them (remember that we spend one third of our lives pressed against our pillows and mattresses). If light or noise are a problem, consider sensory deprivation methods (ear plugs, eye shades). If you have post-nasal drip, consider drying agents or nasal lavage. As we age, natural sleep aids such as Best-Rest Formula by Pure Encapsulations can supplement us with the GABA and melatonin we lose as we age.
My spouse gets up before me and often wakes me up with noise or by turning on a light.
A spouse, family member, or roommate’s alarm clock, the sounds of dishes clanking, water running, mobile phones chiming, or music playing are common morning disturbances for a lot of people. Light which hits the face can stimulate a wake-up reflex. If these things are interfering with your ability to get that final dose of REM sleep needed to restore you, you may want to try earplugs and/or eye shades. There are new products on the market which are extremely comfortable, easy to use, and inexpensive. It may take a few nights to get used to, but sometimes simple sensory deprivation (dark and quiet) is all a person needs to maintain deep sleep.
I keep waking up in the night to use the bathroom. What can I do about this?
Repeatedly waking to use the bathroom is one of the most common causes of sleep disruption. The chief reason for this problem is overhydration, the result of a baseless medical mantra which you may have heard: ‘You must drink at least eight glasses of water each day to be healthy.’ I do not know who began this medical meme, but there is absolutely no data to support the idea that 8 glasses of water per day is healthy. On the contrary, overhydration (too much water) can cause significant health problems, stemming primarily from sleep disruption and, over time, the washing out of important minerals, called electrolytes. I exercise nearly every day and lose a fair amount of water and electrolytes through perspiration. Over the course of a typical day, I will drink somewhere between 20 oz. and 40 oz. of fluids (3-5 glasses), either in the form of filtered water, mineral water or green tea.
If I drank 64 oz. of water each day (8 glasses) I would suffer from overhydration and need to supplement my diet with magnesium, calcium, manganese, potassium, and sodium to avoid symptoms of fatigue, muscle cramping, and poor concentration. In addition, I would most likely need to use the bathroom between 2-3 times each night in order to empty my bladder as my body works overtime to rid my system of excess fluid. Less overall fluid intake and no fluids late at night are recommendations I make to my patients on a daily basis.
Tip: A good routine to get into is to brush and floss your teeth immediately after dinner. The small bits of food which become trapped between the teeth and gums stimulate salivation which in turns fuels the desire to eat more. Follow brushing/flossing with a small glass of purified or mineral water and then have that be the last liquid of the day . Empty your bladder just before bedtime and you will notice that you are less likely to wake up in the middle of the night to use the bathroom.
I Could Have A Sleep Disturbance Problem. What Should I Do About it?
Let’s look at some of the more common problems one at a time:
I have a hard time staying in one position while I sleep. My shoulder bothers me if I sleep too long on my side, my neck can’t get comfortable when I’m on my back, and my lower back bothers me in the night. What can I do about this?
First of all, let’s talk about the basic equipment we use for sleep: your mattress and pillow. How comfortable are they? How old are they? We spend about one third of our lives in our beds, yet many us pay little attention to whether we are comfortable and happy with our mattresses and pillows.
As a chiropractor I am often asked, “Which mattress/pillow do you recommend?” My answer may surprise you, but the truth is that the best mattress for you is the mattress that you sleep best on. Everybody is different and no one mattress or pillow works for everyone. There is a widespread idea that firm mattresses are better for the back than soft ones. In fact, that is only true for about 25% of people. Approximately 25% of people do best on softer mattresses, and about 50% of people do best on mattresses with medium firmness.
Generally, if you are a side sleeper you will do better on softer mattresses or (even better) a memory foam mattress which will cause less hip and shoulder compression while you sleep. If you are a back sleeper, you will likely prefer a firm mattress which gives better support to the lower back. But these are not hard and fast rules. The only way to know which mattress is best for you is to sleep on it for a few weeks. And the same is true of pillows. Some prefer high, some low, some softer, some firmer. Comfort is the key and each person must find his or her own particular fit. Sometimes a pillow or mattress feels wonderful for one night (or for half an hour while lying on it in a store) but over time becomes progressively uncomfortable. Other times, the love affair has a rocky start but gradually blossoms into something beautiful. I was sure right away about my current mattress but my wife took nearly three months of getting used to it before she declared that it was true love.
This presents a bit of a problem. How do you know which is best for you before you go out and spend a lot of money on a new mattress? The answer, unfortunately, is that you don’t. This is the reason why I became a Tempur Pedic distributor. Tempur Pedic makes a great memory foam mattress. I like memory foam because it allows the body to sink into it without causing compression–great for side sleepers like me–and it comes in various degrees of firmness to suit any body. But what makes Tempur Pedic the best company in my mind is not that it is the ‘best’ mattress out there (there are a lot of great mattresses on the market today) but rather that they offer a 90 day free trial. As far as I know, they are the only company to give this kind of offer. We love our Tempur Pedic ‘weightless’ mattress. But if you don’t like yours after sleeping on it for a month, two months, even three months, you can call Tempur Pedic and have them come to your house and take it back for a full refund. Each year at least one of our patients returns a Tempur Pedic mattress he or she purchased through our office and we are so happy about it! Why? Because usually that person has learned what it is that he/she needs (something firmer, something softer, etc.) without having lost their money. Imagine how I would feel if I had recommended an expensive mattress which did not work out!
Tip: As a medical distributor, we are able to prescribe Tempur Pedic products as medically necessary devices, enabling some degree of insurance coverage to defray the cost. Some of our patients with Flex Accounts have purchased Tempur Pedic mattresses and pillows with no out of pocket expense.
I have post nasal drip and when I lie down I have to keep swallowing or clearing my throat which keeps me from being able to fall asleep. What can I do about this?
This is a common problem, especially for those who suffer from allergies. There are many good medicines on the market which can dry out your nasal passages and/or open your sinuses for better breathing. Sometimes teasing out the cause and selecting the right remedy can be tricky. I recommend speaking about this with your primary care doctor.
Tip: If you do not want to use medicines of any kind (and many of my patients don’t), another way to go is nasal lavage. This involves the use of hypertonic saline (salt) wash to flush the nasal passages. Over the counter devices such as Neti Pot can be helpful. At our office we use ENT-Sol which is a more concentrated solution with an applicator that can apply more force to the flushing. These are inexpensive and natural methods for dealing with chronic sinus and nasal passage issues and can help with post nasal drip. The key is to perform lavage at least one hour before bedtime, as doing so can promote the drainage of congested passages increasing the likelihood of post-nasal drip for up to an hour.