Where should my priorities be to improve my health?

Austin Baraki
March 3, 2020
Reading Time: 10 minutes
Table of Contents

    People are bombarded with conflicting and confusing information from multiple sources on health related topics. This makes it hard to recognize who to trust, what information to believe, and what to apply to your own life in hopes of improving health and longevity. With this resource we hope to target a handful of behaviors and metrics that will help you meet these objectives, without wasting time and energy on things that are of little or no importance.

    Before we go further, what does the word “health” actually mean? This concept has been debated for a long time; recently, in a 2011 article in The BMJ, Huber, et al. argued that health is “the ability to adapt and self-manage in the face of social, physical, and emotional challenges.” This definition, with its emphasis on “self-management” is powerful and the one we have adopted at Barbell Medicine. We aim to help people build the skills, strategies, and confidence to play an active role in managing their own health.

    With this in mind, our priorities for health and longevity are as follows:

    1.     Engage in regular physical activity that meets/exceeds current guidelines

    2.     Maintain a healthy body weight and body composition

    3.     Get sufficient durations of high-quality sleep

    4.     Avoid smoking and the use/abuse of other addictive substances

    5.     Seek medical care for a limited set of routinely monitored parameters

    6.     Learn about and apply self-management strategies for pain

    7.     Develop and maintain meaningful social connections with others

    Note that all of these recommendations are general and do not focus on specific foods, supplements, exercises, behaviors, or other limited details. This is not because we wish to withhold that “one weird trick,” or the magic “biohack” that will unlock the gates to washboard abdominals and a life free from pain. Such simple, limited solutions to complex problems do not exist. Most of these sorts of things do nothing at best, and promote harmful ideas or erect barriers to making meaningful changes at worst.

    With that in mind, let’s dive into each of these targets. Any one of these points represents a deep subject worthy of a great deal more attention, but for the sake of brevity and utility in this start-up guide, we are just going to touch on them to give you a starting point. The included links will take you to further resources and discussion on each topic.

    Engage in Regular Physical Activity

    Physical inactivity is a major health problem worldwide and is the fourth greatest global risk factor for death according to the World Health Organization (WHO), behind high blood pressure, tobacco use, and elevated blood sugar (WHO 2009). Unfortunately, only 26% of men, 19% of women, and 20% of adolescents in the U.S. meet current Physical Activity Guidelines (Piercy 2018). Even worse, most healthcare professionals are completely unaware of these guidelines. 

    We view physical training as the most important behavior you can implement not only due to its beneficial effects on the other risk factors, but also because it serves as the principal method for maintaining physical independence across the lifespan, even in the face of other health issues that may arise. A substantial proportion of the population carry too little muscle mass, a condition called sarcopenia. This lack of muscle mass raises risks for a number of long-term health issues as well. Resistance training in particular is a powerful intervention for combating sarcopenia.

    Current Physical Activity Guidelines

    ALL individuals (both youth and adults) should meet and/or exceed the following:
    1. 150 to 300 minutes per week of moderate-intensity aerobic physical activity, OR;
    2. 75 to 150 minutes per week of vigorous-intensity aerobic physical activity, AND;
    3. Resistance training of moderate or greater intensity involving all major muscle groups on 2 or more days per week.

    Individuals meeting both the aerobic and strength training components of these guidelines have better health outcomes across a range of conditions, including obesity, high blood pressure, diabetes, and a number of other conditions as well. Bennie 2020

    We created the Beginner Prescription as a guide to getting started with resistance training and as a way towards meeting the guidelines above. If you’d prefer individualized guidance, we offer coaching for people of all levels as well, whether you’ve exercised before or not.

    For those who have concerns about the safety of resistance training for children, we have you covered there as well: start here. These guidelines have also been applied to exercise in the setting of uncomplicated pregnancy as well (see here). 

    For clinicians, we recommend familiarizing yourself with the 2018 Physical Activity Guidelines for Americans.

    Maintain a healthy body weight and composition

    Overweight and obesity are characterized by excess body fat that can negatively affect health. Worldwide, obesity has nearly tripled since 1975 and in the United States, it is estimated that by 2030, nearly 1 in 2 adults will have obesity. And while many people in the world carry excess body fat, recall as discussed above that many individuals carry too little muscle mass as well. Nutrition changes can have powerful effects on both of these conditions.

    Excess body fat is ultimately the result of an imbalance between energy intake and energy expenditure. While many in the public sphere blame obesity on single variables like carbohydrates, animal foods, hormones, sugar, fat, or others, there is never one isolated “cause” of obesity. It is always a complex process influenced by the interaction of a variety of biological, psychological, and social/environmental factors that all need to be addressed.(Garvey 2016)

    We recommend a proper measurement of waist circumference as a quick and easy way to determine if you may be carrying excess body fat.(Ross 2020) Note that your waist size from a pair of pants is NOT the same, and is NOT sufficient here.

    Our recommended waist circumference limits are as follows (see footnote for demographic caveats):

    Male Waist CircumferenceHealth RiskFemale Waist Circumference
    Less than 37 in or 94 cmNo Increased Health RiskLess than 31.5 in or 80 cm
    37–39.9 in or 94-101 cmIncreased Health Risk31.5–36.5 in or 81-88 cm
    Greater than 40 in or 102 cmSignificantly Increased Health RiskGreater than 36.5 in or 88 cm

    *These waist circumference values are for individuals in North America, Europe, or who are of European or African descent, and are independent of height. For those of Asian descent, subtract 3 inches / 7 cm from each value.

    If you find that you have obesity or are at risk for it, the next step involves changing eating behaviors and dietary patterns. Resources for this can be found in our article, “To Be A Beast” and using the NIH Body Weight Planner, as well as our nutrition lectures (Part 1, Part 2). These changes can be difficult for many individuals. In the same way that a variety of biological, psychological, and social/environmental factors play a role in the development of obesity, many similar factors can influence our ability to initiate and stick to a dietary plan over the long term.

    For example, hunger often intensifies during periods of dieting, and we have written about strategies to deal with this. Metabolic changes, access to food, socioeconomic status, education and food preparation skills, among many other factors, often also play a role. In some situations, certain medications can be very helpful in the treatment of obesity by making it easier for people to stick to their dietary plan. We discussed these options here (Part 1, Part 2), as well as the role of bariatric surgery, when appropriate.

    In general, our recommended dietary approach prioritizes a select few components:

    1. Total calories: consuming an appropriate amount of total energy
    2. Protein: meeting dietary protein targets to optimize lean body mass and mitigate the risk of sarcopenia. This usually involves an intake of about 1.6 grams of protein per kilogram of bodyweight per day (0.7 g/lb bw/day) from either animal or plant sources, although this target may shift based on individual factors.
    3. Fiber: consuming a diet high in fiber from food sources, usually about 30–35 grams per day for healthy individuals.
    4. Carbohydrate and fat: intake can vary based on personal preference (e.g., high/low fat or high/low carb). However, dietary fat intake should be biased towards unsaturated sources (e.g., fish/plant sources), with animal-based saturated fats held to approximately 10% of calories or less. One notable exception is that saturated fats from dairy sources (excluding butter) appear to be healthful as well.

    If you are interested in individualized guidance with nutrition, we offer coaching with our staff, including registered dietitians, and physicians. Operating within these criteria gives people lots of room for individualization based on personal preferences. We do not give strong default recommendations for other methods such as low-carb diets, ketogenic diets, or intermittent fasting (among others). This is because the current body of research does not show consistent superiority for these methods over any others, assuming equivalent adherence. With that said, if an individual is able to set up a diet using one of these approaches while meeting the above-listed criteria, and is able to adhere to it over the long term, that is great. However, if using one of these methods violates one or more of the above criteria, we would recommend re-evaluating the dietary priorities.

    For clinicians, we recommend familiarizing yourself with the 2016 AACE Clinical Practice Guidelines for Medical Care of Patients with Obesity.

    Get sufficient durations of high-quality sleep

    Sleep is important for a variety of reasons; it has benefits in mental health and cognitive function, recovery from and adaptation to exercise, cardiometabolic health, and many others. Unfortunately, many people get insufficient or poor quality sleep, and this is always the first area we ask about when an individual reports symptoms of fatigue. Note that we DO NOT recommend using “sleep trackers” or apps, as discussed here.

    We recommend the following good sleep habits (known as “sleep hygiene”):

    1. Maintain a consistent bedtime & awakening time
    2. AVOID napping during the day (if you must, limit the nap to less than 30–45 minutes)
    3. AVOID alcohol and caffeine for 4–6 hours before bedtime.
    4. If you experience heartburn, AVOID trigger foods for 4–6 hours before bedtime.
    5. Maintain a cool temperature and adequate ventilation in the bedroom.
    6. Block out distracting light (e.g., blackout curtains, covering light sources).
    7. Use a form of continuous, non-distracting ambient noise (e.g. a fan or “white noise” machine / phone app).
    8. Reserve the bed for sleep and sex only. Do not use the bed for work, watching television, or using other electronics.
    9. Establish a pre-sleep ritual and use relaxation techniques before going to bed if necessary.

    For those with insomnia, we strengthen these behavioral recommendations (see here for more). Some individuals with more severe cases may benefit from pursuing Cognitive Behavioral Therapy for Insomnia (CBT-I).

    We also frequently screen individuals for sleep-disordered breathing such as obstructive sleep apnea (OSA). It is commonly associated with snoring and carrying excess bodyweight. Specifically, neck circumference is correlated with an elevated risk of developing obstructive sleep apnea (greater than 17 inches / 43 cm in men, or 16 inches / 40 cm in women). It can cause fatigue, high blood pressure, and a number of other medical conditions.

    In order to evaluate an individual’s risk for sleep-disordered breathing, we recommend using The Official STOP-BANG Questionnaire. With this information, you can speak with your doctor about the next steps of evaluation and potential treatment. 

    For clinicians, we recommend familiarizing yourself with the 2019 Clinical Practice Guidelines on the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea.

    Avoid smoking and the use or abuse of other addictive substances

    Tobacco use has been disastrous for human health, with smoking being a particularly popular consumption method. According to the CDC, cigarette smoking is the leading cause of preventable disease and death in the United States, accounting for about 1 in 5 deaths every year. While cigarette smoking has been on the decline in the US, about 14% of adults still currently smoke cigarettes, meaning we still have a lot more work to do.

    Quitting smoking can be difficult. It typically requires multiple attempts and a substantial degree of external support. There are a number of public resources to help people with quitting smoking, as well as medications available through a physician’s care that can increase the chances of success.

    Close behind, alcohol has negative effects on almost every major system in the body, as well as negative effects on others due to injuries and violence. According to the CDC it is responsible for about 88,000 deaths annually in the U.S. While there are some data suggesting that moderate or occasional alcohol consumption is correlated with better health, there is no probable cause for this stemming from alcohol itself. Instead, other factors, such as social interaction and its positive effects may confound those seemingly-healthful results.

    Similar to smoking, there are a number of public resources to help people with quitting alcohol, as well as medications available through a physician’s care that can increase the chances of success.

    If you currently smoke or drink heavily, you are exposing yourself to harm that cannot be overcome through diet, exercise, or other medical interventions. The same can be said for other drugs that are commonly abused. Cessation, or reduction in use of these substances, can be very difficult, but is no less important because of that. As with tobacco and alcohol, resources are available for other substance use as well.

    Routine, appropriate medical care

    There are relatively few health screenings we recommend on a broad scale. Most important among these include:

    1. Blood Pressure
    2. Blood lipids/cholesterol (general target for those without known cardiovascular disease: non-HDL-C less than 130 mg/dL) as well as a one-time Lipoprotein(a) measurement.
    3.  Depression

    Beyond these, other recommended demographic-appropriate screenings can be found using the Electronic Preventive Services Selector (ePSS) tool, which reflect current guidelines from the US Preventive Services Task Force. We are extremely cognizant of the risks and harms of over-testing, over-diagnosis, and over-treatment and recommend only screening for conditions for which we have strong evidence of benefit, such as high blood pressure.

    With this in mind, we DO NOT recommend any OTHER routine screening via laboratory, imaging, or other testing modalities for individuals who do not have symptoms. This includes things like vitamin/mineral testing (e.g., vitamin D), hormone testing (e.g., testosterone, thyroid, cortisol), stress tests, or other lab / imaging tests. While the idea of “early detection” sounds good in theory, it very often does not work out in the patient’s best interest. See our screening podcast and for more on the topic of screening and overdiagnosis.

    A far more effective method than medical testing for reducing the risk of diseases and even certain types of cancer is immunization. We therefore strongly agree with the Advisory Committee on Immunization Practices (ACIP) immunization guidelines for all children and adults. Additional reliable, evidence-based information is available on every available vaccine through the CDC, for both routine immunization as well as recommendations for travelers visiting other countries. Among areas with decreasing vaccine uptake we routinely see large outbreaks of vaccine-preventable diseases, which can lead to permanent complications and death among those who are most vulnerable. So, while there is a substantial amount of public discourse and debate around immunizations, based on the available evidence there is no question that their benefits outweigh their risks.

    For clinicians, we recommend familiarizing yourself with the US Preventive Service Taskforce Guidelines.

    Learn about pain self-management

    Pain is a normal human experience that is a part of life. However, it can be extremely distressing and disabling, particularly when it persists without a clear reason. Learning how to self-manage your own aches and pains is an invaluable skill that can help to reduce unnecessary fear, disability, and the harms of over-medicalization.

    Low back pain is extremely common, and we discuss this at length here (part 1, part 2) as well as on our podcast. Other aches and pains commonly arise in the course of life and exercise as well, and good introductory resources on the topic can be found at: Pain in Training: What do? and Pain Science – Guiding the Path.

    For clinicians, we recommend familiarizing yourself with the 2018 Lancet Low Back Pain Series, as well as Lin et al.’s best practice care for musculoskeletal pain.

    Develop and maintain meaningful social connections with others

    This will be the most indefinite of our recommendations because “meaningful” in this context cannot be easily quantified. There will be significant variation among individuals in the frequency and nature of connections that are made and sustained. However, humans are social creatures and benefit greatly from healthy interactions with others. Positive support from family and friends is important when attempting to change behaviors. Similarly, lack of support can hamstring those efforts and is implicated in increased risk for substance abuse and depression.

    Individuals do not need to reside in a state of uninterrupted bliss, nor is this even possible. Further, we do not have a minimum number of friends to recommend. What is clear is that feeling alone and cut off from peers represents an unfavorable environment for good health.

    While mentioned in the previous section about routine, appropriate medical care, depression puts you at risk for multiple adverse health outcomes. If you suspect that you are depressed, or are suffering from undue emotional distress, seeking professional treatment is highly recommended.

    We hope that this overview is helpful in guiding your priorities in the pursuit of health. Please help us disseminate this information to others who are in need of guidance, who are struggling with their own health, or to those who are confused in a world full of controversy and disinformation.

    In health,

    The Barbell Medicine Team

    Austin Baraki
    Austin Baraki
    Dr. Austin Baraki is a practicing Internal Medicine Physician, competitive lifter, and strength coach located in San Antonio, Texas. Originally from Virginia Beach, Virginia, he completed his undergraduate degree in Chemistry at the College of William & Mary, his doctorate in medicine at Eastern Virginia Medical School, and Internal Medicine Residency at the University of Texas Health Science Center in San Antonio.

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