Author Archives: caitlinburke

Our Little Medical Marvel

In 2021, we got a pair of kittens from a rescue organization. One of them, Grace, was sheer easy mode. Cute, low maintenance, gentle with her claws and teeth, not a big lap cat, but that’s ok. The other, Horatio, was very sweet and cuddly, a fluffy little orange boy who was underweight for age and ended up being sick all the time – we were at the vet almost weekly for a while there. And the vet finally said “I think we should check bile acids.”

Grace and Horatio shortly after their arrival in our home.

Bile acids aid in digestion, and they are, in essence, recycled by the liver as it processes what comes out of the gastrointestinal tract. A portosystemic shunt is an extra blood vessel (in the simple case) that routes blood around the liver, so the kinds of toxins that the liver is designed to filter keep circulating. Testing for levels of bile acids before and after a meal is a clever way of seeing whether the blood is flowing correctly – if it is, acids secreted in response to the meal will be promptly recycled. If not, they just keep floating around, hinting that other stuff is building up in the blood. In particular, ammonia compounds, and they can cause terrible symptoms – lethargy, vomiting, disorientation. Liver shunt is a developmental defect, and while the effects can be managed with diet and medication, the prognosis is poor. In the right cases (simple, one big vessel, rather than complex, with a lot of little ones) surgery offers a chance at a normal life. The detouring vein is fitted with a ring containing absorbent material that, over time, slowly narrows the errant vessel, and the blood follows the path of least resistance right into the liver, as intended.

We were fortunate that Horatio was diagnosed before receiving surgery – some cats are discovered to have this defect only after they fail to recover from a routine desexing procedure. And Horatio was fortunate that we were easily able to manage his special diet and medication to keep him healthy and growing, and willing to pursue surgical correction. He was also lucky to be a perfect candidate – and we were lucky that he was a perfect little gentleman in the car when we drove him two hours to the hospital at the University of Pennsylvania’s Veterinary School, where our regular veterinarian referred him so he could be treated by veterinarians who had actually done this surgery before.

Horatio was a perfect passenger on the way to the veterinary hospital.

We had a few hiccups getting him onto the surgery schedule, but when the day came, everything went as well as could be hoped. The only real surprise seemed to be that he needed a relatively large ring – a size usually needed only for dogs. We found this pretty charming, because we joke that he’s our little golden retriever: friendly, unflappable, and in love with his tennis ball. The surgery protocol called for a 3-day stay, but after the first day or so, that’s often just to ensure that the animal is getting an appetite back, and Horatio bounced back more or less right away. They invited us to pick him up early, saying, “We’re just sitting around watching him eat!” We got him home, and our other cats accepted him back almost right away (our third cat didn’t love his cone at first but got over it). His incision healed promptly, and his first follow-up bile acids test was normal. All of that is wonderful, but that’s not the marvel.

It’s not unusual (although also not universal) for cats with liver shunt to have bright copper-colored irises. That is also a normal eye color for cats, but in liver-shunt cats whose genetic trait for eye color is lighter, another buildup is probably to blame. Horatio had very arresting, deep, copper-colored eyes.

Horatio at about 7 months old, about a month after diagnosis of liver shunt, clearly showing coppery eyes.

It took a few months, but his eyes did start to lighten, and by about 7 months after surgery (during which he was weaned off his special diet and medications with no ill effects), they were yellow.

Horatio grew to be a handsome adult of about 11 lb, with definitely yellow eyes.

Seeing him now, playing chase with the other cats, hanging out and watching the birds, being a cute lap cat, it’s hard to believe he was ever so frail and sick. And while his coppery eyes were gorgeous, we are more than happy to see this clear evidence, every day, that the surgery worked.

Would you like to use photos of Horatio’s eye-color change? Send me an email and let’s talk!

Can a Fitness Tracker Help You Lose Weight?

Sure, but a fitness tracker can’t tell what behavioral changes will result in a change in your body fat percentage or a smaller waist.*

Last week, a Washington Post writer reported “Apple told me it does not track research about weight loss because that is not the focus of the Apple Watch.” So far, good. Then he added, “(That’s disappointing.)” I applaud Apple for declining to make weight claims, because a watch simply cannot “make” that happen. Changing your daily habits consistently enough to change your body in a sustainable way requires a lot of moving parts, and a fitness tracker isn’t a mind reader—it just collects and displays the information that the maker has set as defaults or that you ask it to display. Fitbit, in contrast to Apple, makes weight claims because it has gone in heavy with providing devices to wellness programs and other contexts that have (of course) additional information available for users.

A fitness tracker can nudge you in a particular direction, but you have to have at least the direction (if not a destination) in mind. Is it more steps? Is it more sleep? Is it a particular mix of high- vs moderate-intensity exercise? It is a number of minutes of exercise per week? is it spending less time sitting? It doesn’t know what’s important to you. And I don’t think any of them have integrated food records—food recording is a whole thing with enough twists and turns to earn a master’s degree, and the most a fitness tracker will do is import a calorie total from a dedicated food tracker. And that’s the other common theme, also hit in the article linked above—the writer even passes along the opinion of the WW Chief Scientific Officer to present the typical, binary-opposition response to any discussion of exercise and weight, “But a fitness gadget still can’t automate what Foster considers most important data in weight loss: what you eat.” Of course, says the CSO at the company dedicated to helping people adjust how and what they eat.

What you eat and what your activity pattern is, along with how much and how restfully you sleep, contribute to the condition of your body—from your health to your performance to your body fat percentage to your waist size to your alertness during the day, and on and on. Your fitness tracker can assess your sleep, too—sort of**—but again, just observing it (or including some nudges to remind you that it’s important) isn’t enough to make change happen. People rarely end up with unhelpful eating, activity, and sleep patterns because they want that; they have made a variety of choices against the backdrop of many external factors that are not always easy to change—or, in some cases, identify.

Fitness trackers are undermined by two main issues: People buying one for the first time don’t necessarily know what they want, and once they have one, they almost never know how to configure it to be most helpful. In the early years of Fitbit availability, they were often called “glorified pedometers,” and even the first release of Apple Watch was essentially in that category. There is nothing wrong with a glorified pedometer—for people who just want to nudge more activity into their day (lots of people!), tracking and gradually increasing daily steps is a great approach (and Apple kind of lives this strategy in its track record of offering simple initial versions of hardware and then building on them). But pedometers are simple enough that very little explanation is needed, and as these devices have become more and more glorified, one wonders if people are expecting more simplicity rather than less, as if every new capability is as easy to understand and act on as a steps goal.

Modern fitness trackers are not that simple, and people aren’t prepared to do homework when they get a fun new device (or have it given to them by a workplace wellness program). Someone on Quora recently asked whether it was OK that his watch showed well over 200 “heart points” for the week after he completed a 10k running event, because the “recommended” number of weekly “heart points” is 150. Which brings up another risk: that using a cutesy name to differentiate your exact same base fitness recommendations as every other device—based on CDC, WHO, and AHA† recommendations for the minimum recommended activity level—may increase the probability of that default being misinterpreted.

The WW expert said their users don’t use trackers consistently. This makes perfect sense. WW members don’t need to rely on a fitness tracker; WW is a supportive system that offers them an accounting method for food and basic activity tracking. Indeed, the WW points system is a really nice framework for approaching these things. The recent UCLA assessment of use of the Oura ring‡ (a very simple, screen-free device) found that personalized feedback based on fitness tracker results helps people improve their behaviors and get better results, a classic for the annals of “well, yeah,” but it’s important to have the data. And it’s not like this is easy; having live humans provide that feedback is labor-intensive and costly, and fitness trackers can’t offer that automatically. My own fitness tracker has an “insights” feature that is supposed to do something like this but has literally never, not one single time, told me anything other than the absolutely simplest thing to guess at and thus nothing insightful at all. I have configured that thing to kingdom come and look at it at least 25 times a day, and it still can’t figure out what I care about on its own.

Is it possible to build something inexpensive and easily accessed that can help a person get the most out of a fitness tracker from day 1? I think it could be done to some extent in a booklet or website—and working on a project like that sounds like a dream job to me—but it would go far beyond the user manual (“this option is on that screen”) and deep into helping people identify and prioritize different kinds of goals at a much more granular level than “fit into the clothes I used to wear.” Indeed, it would probably end up being a kind of choose-your-own-adventure curriculum of quizzes and knowledge base that would require a multidisciplinary team and regular updates to do well. Because at the end of the day, a fitness tracker is not a trainer or a coach (or a doctor or a dietician). It’s a compass. It can help you stay on your route, but it can’t plan the route for you.

*The notion of weight loss in and of itself is of no interest to me, and in many cases it is harmful. For example, weight loss is a common feature of serious illnesses such as cancer and dementia. A more rational goal is loss of excess body fat, and while there are no good, cheap, easy options for measuring that with precision, what most people are looking for in a way to track whether a “weight loss” plan is working (losing excess fat, not key body tissues) can be estimated from changes in waist measurement.

**Sleep tracking in a fitness tracker is generally a mix of accelerometer and heart rate data, trying to estimate a rest state from a lack of motion and using heart rate patterns that have been observed in sleep studies to be correlated with one sleep stage or another. Any avid “quantified self” enthusiast can tell tales of a watch that said they were in deep sleep while they were reading in bed or perhaps in REM sleep while playing a video game.

†CDC https://www.cdc.gov/physicalactivity/basics/adults/index.htm ; WHO, https://www.who.int/news-room/fact-sheets/detail/physical-activity ; AHA, https://www.heart.org/en/news/2018/08/21/google-just-launched-heart-points-here-are-5-things-you-need-to-know .

‡”Lifestyle Modification Using a Wearable Biometric Ring and Guided Feedback Improve Sleep and Exercise Behaviors: A 12-Month Randomized, Placebo-Controlled Study.” The study compared simply using the ring with some generic information provided with using the ring while also receiving personalized, reinforcing messages. You’ll never guess which group showed the most improvements. https://pubmed.ncbi.nlm.nih.gov/34899398/

“Is a fitness tracker right for you?” A repeatedly missed opportunity in mainstream media

The Washington Post recently dropped a link to this article from December in one of its newsletters, and I finally realized I’ve seen a lot of these takes over the last few years as wearables have become ubiquitous: maybe you should stop using a fitness tracker, if you’re letting it tell you what to do and it’s making you anxious. These articles feature lots of precious quotes about losing the ability to simply enjoy taking a walk and so on. Not infrequently, the tracker that ends up getting junked is one that was provided gratis by an employer or an insurance company. It’s a basically good idea for an article that is routinely undermined by superficial and extremely incomplete treatment.

Employers and insurance companies often provide simple trackers such as devices from Fitbit, who aggressively courts this business. Based on wristwatches, these devices are easy to use and interact with, and they promise to provide a wealth of data (particularly around notoriously hard-to-measure activities such as sleep). It is common to fall down a whole series of rabbit holes, seeing what it tracks, seeing how you can influence that, and fretting about numbers that don’t seem “good enough.” If you learn more about the technology or just observe very closely, you soon see the weaknesses in the measurements themselves or in the conclusions drawn from them – from simple miscounts of steps to poor extrapolations of mileage to some truly laughable “sleep detection” failures. And once the trust is gone, the brain goes all kinds of bad places.

One problem with mainstream media articles on issues around fitness trackers is that they almost always assume a Fitbit-like wrist device and flatten the discussion to the category of “trackers” as if that is the only form factor. Although some “rah rah fitness tracker!” product pieces discuss the wide variety of options, I don’t think I have ever seen an article about user ambivalence go on to discuss the different types of trackers available. Some people will prefer a simpler device that gives them gentle nudges to move about more during the day, or something that tracks without constant readouts a glance away. Bellabeat makes jewelry-style trackers that can be worn as clips, pendants, or bracelets and that have no screen. There are several simple – and inexpensive – pedometers that can be clipped on or hung from a loop for people who just want to track a step goal, which can also, for that matter, be done with free apps on a smartphone. I understand a bit about how an article is planned in these environments, but this is a great example of how a specific focus robs the piece of value for the reader. In this case the reader is invited to relate to the person who is stressed by the tracker (or to judge that person as weak or not “getting it”), nothing is learned, and the comments section fills up with predictable trash.

Another problem with these articles is the narrative around the value – or risks – of the fitness tracker. Like a lot of issues involving productivity, health, and happiness, the dysfunctional-fitness-tracker story is typically framed around the individual who either can’t seem to get the process right or who is, perhaps rightfully, frustrated by being told what to do by a little piece of metal and plastic. Very few issues involving productivity, health, and happiness are fully in the individual’s control. Between schedules, commutes (or home environments that making working there a challenge), family commitments, and everything else, any change a person wishes to make almost always touches multiple moving parts, many of which touch other people who might push back in ways that are impossible (or inappropriate) to reject.

This willingness to, in essence, blame the individual is particularly annoying to me when a very reasonable quote about the challenges of developing a good food pattern comes from someone who sells coaching or instruction in “intuitive eating.” If it’s intuitive, you don’t need a coach for it. But it’s not even intuitive – the term is used for a variety of practices that involve deliberate food choices, changing your emotional relationship with food, and otherwise being more present and mindful and positive about eating (as opposed to using a reward/punishment frame). I love all those things, and I definitely love an anti-dieting frame for talking about eating, but calling any of that “intuitive” just seems like an extra twist of the knife in the back of everyone who finds it nothing of the kind, ie, almost everyone.

Most surprisingly, I can’t remember seeing a mainstream media article address both user ambivalence AND the source of the tracker. There is a separate genre of article – the discussion of privacy issues around insurance- or employer-provided devices (example linked above) – that clearly details the contextual issues that probably should make an individual reluctant to use a device from those sources. But even mentioning those issues is rare in the “is your fitness tracker making you obsessed” articles, even when quoting people who received the tracker from an employer or insurance company. It beggars belief that these articles have no room for a single quote along the lines of “Yeah, maybe the company-provided device or wellness program isn’t the right path. Some people just need [a different form factor | a free phone app | something that lets them control their data in a particular way].”

The end result is the same careful instruction in learned helplessness that characterizes the fitness / health / wellness industry as a whole: A small insight into a problem. A narrow, narrow discussion of one way of resolving it. An overall emphasis on the individual, with near-zero acknowledgement of the family, work, and social contexts that individuals spend their whole lives in. And no meaningful information about the kinds of questions a person should ask about what they want from a fitness tracker (or other form of accounting – could be a paper calendar with stickers!) that will help them get what they need when embarking on a deliberate change or management of a behavior – or even a hint that such self-understanding is a possibility.

Oprah, Weight Watchers, and “Impossible”

Ready to head back? Cartoon by Robert Leighton (2003)

So Oprah is on Weight Watchers. She recently bought WW stock, which then appreciated like gangbusters, so she has that going for her, which is nice.

I’m seeing a lot of posts chewing over this news, many with disappointment and general comments about the “impossibility” of losing weight. Even if you are Oprah, and rich, and capable, and surrounded by opportunities for help and support.

It’s not impossible to lose weight, but it’s difficult, frustrating, and draining to do things you dislike for reasons that are tied to sadness. If you are mired in a belief that “inside every overweight woman is the woman she knows she can be,” then your framing is your prison. Because if that woman is “inside” you, she IS you.

You can’t take good care of something you hate.

Acceptance in its various forms is often denigrated as passivity, as giving up, as the sweatpants and pint of ice cream of the soul. But sweatpants and ice cream are a perfectly enjoyable part of anyone’s life, and then you put them away, have a good night’s sleep, and get dressed for work and have an apple or whatever and life goes on. You can choose to make a habit of healthful living, and you can choose to make a habit of self-care and enjoyment, too.

Ultimately we are what we repeatedly do. If you keep punishing yourself for some notional failure, trying every 30-day fix out there in hopes something will stick, what will stick is restless program-hopping and the sense of failure. Give yourself the gift of walking away from that. Don’t try to change everything at once, but instead choose one small thing and practice it until you don’t have to think about it anymore. Then build on that track record of success.

“Ready to Head Back?” by Robert Leighton (2003)

“Move More” Is About More Than the Obesity Epidemic

doughty-lumbersexual

White men have been fretting about losing their *mumble*something* for at least 100 years. (Nitpick: I guess ‘lumbersexual’ is a play on ‘metrosexual,’ but it sounds too much like homo/bi/heterosexual to me, possibly because it’s so compatible with the hypermasculine archetypes in the gay community, so I keep thinking the lumbersexuals should be the ones lusting after these Bunyanesque figures.)

As silly as this particular instance is, I feel like this might have a useful connection to other conversations, like boys doing worse in school as more schools do away with recess and popular — and sometimes data — support for stereotypes like men being more likely to die doing something stupid.

As a society, we have recently been putting too much emphasis on sitting quietly (or at least being reasonably orderly) — first, explicitly, with public schools, designed as a method for pre-training a ready workforce, and even more so in the last century as the manufacturing economy gives way to cubicles as far as the eye can see. Women have an advantage in such constricting environments by being socialized to “go along to get along,” but it shouldn’t surprise us when men, who retain “boys will be boys” socializing in spite of these macro changes in our social environment, have more trouble “adjusting.”

I’m not advocating going along to get along — I think rejecting that expectation is healthy, and it’s explicitly a form of privilege to feel free to reject it. I feel like we are seeing a wide range of signs that are telling us we need to move more, do more hands-on activity, inhabit our environments more actively. Women, too! We just don’t have the handy stereotypes to model on.

The Atlantic article goes on to explain that the romance of the lumberjack image was deeply at odds with the hazardous and tenuous life of actual lumberjacks, especially as the industry expanded. Logging remains one of the most dangerous jobs in the United States, a lot of risk for barely $35k a year. This makes the appeal of the mythos greater, of course, rather than less — however you feel about logging today, the historic image is one of honest work to help build a growing nation. Even for people who also enjoy knowledge work, that is a powerful draw — getting up, getting your hands dirty, having a physical object to show for it, a feeling of righteous exhaustion, all in the service of something tangibly useful. You don’t have to wear plaid to split wood, and you don’t have to split wood to enjoy making things. We clearly yearn for more than cubicle life, so let’s make sure we get out more.

The Perfect “Body”

vs-perfect-body

What are we to make of a campaign image like this one? Victoria’s Secret is of course well aware of the politics around terms like “perfect body,” and I am sure it is at least as well versed in the intricacies of Dove’s “Real Beauty” campaign as the people who created it. (VS might be reading too much into negative media and critical responses to Dove’s campaign this year and last, too, though.)

I don’t even have the energy to be outraged by this kind of advertising. It seems self-evidently prescriptive, unkind, and elitist. It would be a great jumping-off point for a university seminar on advertising or internalized sexism — beauty standards seems too obvious.

But it is very hard to see this kind of imagery as anything other than a deliberate taunt. Apparently “the perfect body” (by Victoria) comes in several color ways (as any well-developed product line does) but, judging by the different types of bras listed beneath the models, is one that varies primarily in a woman’s preference for displaying her breasts.

Then again, what else should we expect from the promoter of the world’s most expensive bra?

UPDATE, November 10: Tagline changed to “A Body for Every Body,” but the art is exactly the same. So now instead of saying their waifish models are “perfect,” they are actually claiming they represent “every body.” This is worse, a truly remarkable display of tone deafness.

abodyforeverybody

Dear Trainers, Please Stop

jen-sinkler-lwf
Jen Sinkler prefers actively planning her lifting routines to incorporate cardio conditioning, rather than splitting out cardio and lifting, and she has developed a host of circuits to help others get this all-around benefit, too. Similarly, cardio athletes (like me!) who choose heavily resistance-oriented sports like rowing and swimming combine our enjoyment of cardio with a great full-body strength workout.

Please stop saying “No cardio, just lifting!”

Trainers who focus on resistance training like to use this as a sales pitch. Sometimes they even claim that cardio is harmful, but the more honest among them simply say, hey, cardio is not for everyone (and I’ll get to that later), so we’re just going to lift, because it’s just as good.

Here is the reality: when lifting is just as good as “cardio” for overall health, it’s because it includes cardio.

A good cardio (aerobic) base is, like a good strength base, essential to good human health. Both contribute to various aspects of health: respiratory health, hormonal balance, blood sugar stability, sleep regulation, bone density, mood regulation, and of course heart health — because who cares how good your nutrition is if your heart can’t pump the nutrients through your body?

How do you know you’re doing cardio? Listen to your heart. The aerobic exercise “zone” is estimated to be about 75% of your maximum heart rate, so roughly 140ish for many people. That’s a good place to be for healthful exercise, and roughly the level of effort where you can pass “the talk test” — have a conversation while exercising. You also get health benefit from any level of exercise around 100 heartbeats per minute or more. So wear a heart rate monitor and see what your average heart rate is during an activity you like to do for a half hour or so — like walking or a weights session at the gym. If it averages over 100, you’re doing cardio.

Some trainers will say, “I’m not talking about that! I’m talking about endless hours on the treadmill or elliptical! That’s cardio!” Look, I get it — you don’t enjoy that. I don’t either, for what it’s worth. But you don’t get to make a pile of things you don’t enjoy and call it “cardio.” Because cardio already means something. And not what its detractors say it means — which generally boils down to ineffective training combined with poor nutrition.

Triathletes and ultra-distance athletes, the ultimate cardio athletes, don’t just lean on treadmill rails for a half hour, read the machine’s calories-burned count, and go to Starbucks. And, no matter how much (or little) time you spend on exercise, neither should you. Mix it up — alternate a little faster and a little slower — and use your balance. Try different machines, if you like machines, or walk more during the day. Take a strength-training class. Heck, do a little bit of all of it. If you’re not a competitive athlete, the exact workout you do is much less important than being active — regularly — and being attentive to what you’re doing while you’re exercising. And eat right — that means protein, vitamin-rich foods, and enough. Undereating just leaves you run down, and tears down the important tissues you need for health.

Here are some examples of cardio:

  • Running
  • Swimming
  • Cycling
  • Rowing (sport or just in a rowboat)
  • Dancing
  • Walking
  • Climbing stairs
  • Flipping tires
  • Martial arts, from fencing to MMA
  • Gardening
  • A brisk lifting session in any strength disclipine
  • Yoga
  • Scrubbing floors
  • Shoveling snow
  • Calisthenics
  • Sled drags and sled pushes
  • Hiking
  • Canoeing
  • Skate-, surf-, snow-, or wakeboarding
  • Table tennis
  • Volleyball
  • Badminton

Don’t like running? Don’t run. Hate the elliptical? Don’t even look at it. Hate cardio? I doubt it. Almost every person I’ve heard say they “hate cardio” has also said — sometimes in the very same breath — that they love a good hard workout. And that’s cardio.

There is one thing that the more traditional cardio activities will do much better than just lifting weights faster (or with better management of rests), and that’s make you good at cardio activities. You won’t come away with from a brisk, athletic lifting-only program being able to run a fast mile or run for a half an hour straight. (Same way doing some basic strength training won’t turn you into a powerlifter.) This seems like a non-issue to me, but you will hear a lot of people list benchmarks like that as “what it means to be fit.” They’re wrong, too. That’s a particular form of performance, but basic fitness is really basic, and is not really defined by numbers of pushups, percent of bodyweight lifted on a barbell, or 3-mi run time. Advanced fitness is like any other kind of advanced example of something that fits well or is fitting: dependent on the context.

Basic strength and basic cardio conditioning are a foundation for health and for training performance, and it’s OK to prefer one and be “just OK” at the other. I sometimes wonder if that’s part of the sticking point for “no cardio, just lifting!” advocates — so many of them act as if every exercise has to count and has to be focused on a goal of excellence or at least progress, and they can’t tolerate the idea of doing something they aren’t good at and don’t want to take the time to be good at. So I’d like to offer another piece of advice that has been helpful to people training athletics for ages: leave your ego at the door.

It’s OK to have fun. It’s OK to do stuff you’re not great at. It’s important to eat your vegetables, and it’s even better if you can find vegetables — or recipes for them — that you really, deeply enjoy.

So how about a new pitch? One that has the advantage of reassuring people interested in strength training, that is not actually insulting to perfectly enjoyable other sports, and that, you know, describes what you’re offering? Get a great full-body workout with barbells! Or kettlebells, or whatever. It’s not that hard to just sell what you’re selling — instead of going out of your way to tear down something else.