Over the past few years, the number of adults living with obstructive sleep apnea (OSA) has steadily increased. If you’re not familiar, OSA is a sleep-related breathing disorder that impacts one’s ability to breathe during sleep. Across the world, it’s predicted that at least a billion people have this condition, with 25 million estimated to have OSA just in the United States alone [1],[2].

Alarmingly, it’s also predicted that 80 percent of all sleep apnea patients remain undiagnosed [3]. This statistic is disturbing, especially considering the consequences associated with this common condition. If left untreated, sleep apnea can lead to serious health conditions, including high blood pressure, type 2 diabetes, and stroke – and it some cases, it can even be fatal.

Why are there so many undiagnosed OSA patients?

The sleep community is worried that the number of undiagnosed OSA patients has consistently remained so high. It is especially concerning since sleep apnea is highly treatable. There are many options out there for patients to consider. When trying to wrap our heads around this health issue, it comes down to analyzing the circumstances that perpetuate a failure to diagnose.

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With sleep apnea specifically, one important obstacle for diagnosis is patient fear. Fear not just of the sleep apnea diagnosis itself, but of the treatment options available. Many people have seen or are aware of CPAP devices, the main way sleep apnea is treated, and have decided that it is not for them.

A new generation of therapy

Unfortunately, these fears are rooted in past misconceptions of sleep apnea. Because of this, many OSA patients are stopping their care journeys before they even begin. What many people don’t realize is that sleep apnea therapy options have come a long way over the past several decades. Now, there are multiple solutions that have been uniquely designed using a patient-centric approach.

Newer solutions offer improved comfort, ease of use and support increased mobility for sleep apnea patients – all to ensure that patients stay adherent to their treatment plans.  Instead of being afraid of treatment, patients need to give themselves a chance to find the best solution for their unique needs.

As with most chronic conditions, there are a million questions that go through a patient’s mind after an initial sleep apnea diagnosis. As sleep experts, it’s our job to work with OSA patients to determine the best treatment plan for both their specific condition and their lifestyle.

Even in patients who do seek a diagnosis, we can face barriers with treatment. Unfortunately, patients can struggle to adhere to some prescribed treatments. This is because some therapies are uncomfortable and interfere with sleep habits.

But sleep apnea therapy has changed.

Not your father’s CPAP

Traditionally, the gold standard for sleep apnea therapy has been Continuous Positive Airway Pressure (CPAP). CPAP machines work by sending a constant flow of air pressure to the patient’s throat during sleep. This keeps the airway open and thereby treats the pauses in breathing associated with sleep apnea. As an additional benefit, many patients stop snoring, breathe regularly, and get a restful night of sleep with CPAP therapy.

However, people can find it difficult to adjust to sleeping with their CPAP equipment. Patients will sometimes complain about difficulty moving around in their sleep. They struggle with the pressure in their nose and airway. Some even struggle to comfortably watch TV before bed because of their masks.

Thankfully, there are new advancements in sleep technology that are paving the way for new options for more comfortable yet equally reliable treatment. No longer the bulky machines of the past, modern CPAPs, and their accompanying masks are:

  •  smaller and quieter
  •  portable
  •  offer greater ease of movement during sleep
  •  provide precise pressure control at the lowest effective pressures

Newer CPAP mask designs even include cushion options for additional comfort. Some have open-face masks that allow for the ability to comfortably wear glasses, read and simply relax in bed. In addition, other options and alternatives continue to present themselves.

Related Content:  How Your Dentist Can Help with Sleep Apnea [Author’s note: click the link to learn more about Mandibular Advancing devices (MADs) which are effective therapeutic options for OSA.]

Positional therapy: non-invasive and just as effective

Even with these new innovations that offer more freedom and comfort for CPAP users, sometimes CPAP therapy just doesn’t just fit in with a patient’s lifestyle. For patients living with a certain subset of sleep apnea, there is another option for successful treatment: positional therapy.

Patients with positional OSA primarily experience disruptions in breathing when sleeping on their backs. In fact, it’s estimated that up to 47% of all sleep apnea cases are positional [4]. In the past, these patients have gone to extreme efforts to avoid sleeping on their back – with some resorting to sleeping with a tennis ball sewn into the backs of their pajamas to encourage sleeping on the side.

As an alternative method to CPAP therapy, positional therapy wearables like Philips NightBalance work by encouraging users to remain off their back with gentle vibrations. As one of the most non-invasive sleep apnea therapy methods, positional devices are lightweight, portable, and easy to use. Like CPAP, they have also been proven to reduce the snoring that is typically associated with sleep apnea.

As an additional perk, positional therapy devices have demonstrated high adherence rates. A recent study in the Journal of Clinical Sleep Medicine found that short-term adherence with positional sleep apnea devices jumped from 75 to 95% when compared with other sleep apnea therapy methods [5],[6]. A clinical trial also found that these positional devices are effective in reducing Apnea–Hypopnea Index (AHI), an indicator of the severity of a patient’s OSA [7], [8].

Surgery is for sleep apnea is an option 

Some patients seek a solution that will fix or cure their sleep apnea so that ongoing therapy is not required. One such option is surgery of the upper airway.

-Surgery to enlarge the airway

Most such procedures are aimed at enlarging the airway in the area behind the palate and tongue. This is generally accomplished by removing tissue or rearranging the tissue in such a way that the airway remains open during sleep when the pharyngeal muscles relax.

However, it must be realized that these procedures do not work in everyone and an examination of the airway under general anesthesia is often required to determine in whom such procedures will work and which procedure would be best for each patient.

-Hypoglossal nerve stimulation

A new approach to OSA therapy called hypoglossal nerve stimulation (HGNS) has emerged over the last 4-5 years. This therapy involves the placement of a nerve stimulator under the skin on the chest which is connected to the nerve that controls a muscle under the tongue which opens the airway.

This device is turned on at night and, in many patients, can effectively treat OSA [9]. However, it only works in patients with very specific characteristics such as only a moderately elevated body mass index (BMI) and those not collapsing at certain places in the airway. Because of this, as described above, an examination of the airway under general anesthesia is usually required.

Looking ahead

Solutions like positional therapy and HGNS give me a great sense of hope for the future of sleep apnea diagnosis and treatment. Through years of research, sleep therapy companies have begun to develop patient-centric therapies that are fundamentally changing the way patients live with sleep apnea.

Another hope for the future is drug therapies for OSA. Although there are currently no FDA-approved therapies to treat sleep apnea, studies suggest that this may well be possible. [10]

As a result of these advances, people suffering from this chronic condition no longer have to fear diagnosis or treatment plans. Instead, they can move forward on a path to living more healthy and restful lives.

Related Content: Are You Falling for These 11 Sleep Myths?


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[1] Benjafield A, Ayas N, Eastwood P, et al. Estimation of the global prevalence and burden of obstructive sleep apnea: a literature-based analysis. Lancet Respir Med 2019, Aug 7(8):687-698.

[2] https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/

[3] https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/

[4] Heinzer, R. et al, Prevalence and Characteristics of Positional Sleep Apnea in the HypnoLaus Population-based cohort, Sleep Medicine 2018; 48:157-162

[5] Long-term effectiveness and compliance of positional therapy with the Sleep Position Trainer in the treatment of positional obstructive sleep apnea syndrome. van Maanen JP, de Vries N. SLEEP 2014;37(7):1209-1215.

[6] Benoist, L., de Ruiter, M., de Lange, J., & De Vries, N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep medicine. 2017 34, 109-117

[7]  Berry R, Uhles M, Abaluck B, et al. NightBalance Sleep Position Treatment Device versus Auto-Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea. J. Clin Sleep Med. 2019 July 15:15(7):947-956.

[8]  Eijsvogel, M. M., Ubbink, R., Dekker, J., Oppersma, E., de Jongh, F. H., van der Palen, J., & Brusse-Keizer, M. G. (2015). Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. Journal of clinical sleep medicine, 11(02), 139-147.

[9] Strollo P, Soose R, Maurer J, et al; STAR Trial Group. Upper airway stimulation for obstructive sleep apnea. New Engl J Med. 2014 Jan 9;370(2):139-49.

[10] Taranto-Montemurro L, Messineo L, Sands S, et al. The Combination of Atomoxetine and Oxybutynin Greatly Reduces Obstructive Sleep Apnea Severity: A Randomized Placebo-controlled Double-Blind Crossover Trial. Am J Respir Crit Care Med. 2019 May 15;199(10):1267-1276.

Editor’s note: Although the author is employed by Philips Sleep and Respiratory Care and they could benefit from this article, we have accepted it for publication because it contains valuable information for our readers. This post has not been sponsored by Philips.

If you have ever felt confused or even intimidated by how to start eating healthy, you are not alone. There are thousands of articles, books, and infinite resources of information on the topic—all of which can be overwhelming off the bat! However, the reality is: Healthy eating is simple, easy, and approachable. All you need to do is stay consistent with daily habits, make informed decisions, and manage your self-control.

New Dr. Olson‘s Review Notes appear at the end of the story.

Take the first steps towards this positive lifestyle change by implementing the following strategies to make eating healthy easier over time:

1. Throw out junk food

The first step to take on a healthy eating journey is to throw out all the junk food in your home. By doing this, you eradicate the temptation of giving in to a craving. Did you know that some studies have suggested that junk food alters the brain1 in obesity-prone animals and humans in a way that is similar to what occurs in addiction? Processed food is purposely manufactured that way to encourage you to keep buying it (think added sugar and salt)!

2. Be realistic and specific to your goals

Ask yourself what goals you personally want to accomplish. Is it reducing the consumption of red meat, learning how to count calories to lose a certain amount of weight, improving your current physical condition, or something else?

Be realistic about how you plan to make every goal a reality. Even accomplishing short-term goals are a milestone—don’t discredit them. Start small by replacing all your drinks with water as opposed to soda. Or begin eating vegetables with every meal for one week. Short-term goals act as the foundation for your long-term ones. Lifestyle changes don’t happen overnight. They take time and are never instantly gratified.

3. Prepare a grocery list ahead of time

Never go to the grocery store when you’re hungry or lacking a prepared list. Doing so makes you more prone to buying things impulsively and spending money on unhealthy items. Before you make your next trip, have a healthy food list ready in your pocket. Then stick to the corners and edges of the grocery store. That’s where the produce and raw proteins are sold. Everything else in middle aisles is mainly comprised of processed and canned foods and snacks usually with too much sugar or salt. Save yourself the temptation by completely avoiding this whole area.

Be sure to read the labels on the food before you buy. Nutrition labels provide information about calories, macronutrients (carbohydrates, protein, fats), and percent of daily values supplied per portion of the food. Changes to the labels in 2021 have made them easier to use.2 including preservatives and other additives (such as coloring dyes) in descending order of predominance. By reading the ingredient list, you can see whether or not something has been processed with chemicals as opposed to being prepared organically or sustainably.

4. Prep meals ahead of time

Meal prepping3 helps you establish and solidify what your diet plan will look like for the week. This removes the factor of feeling inclined to grab take-out during a work break or buying a meal on a whim. Moreover, meal prepping saves you time and money!

Dedicate a day to cooking an entire week’s worth of meals. You’ll never have to come home worrying about what to eat for dinner again or feel tight on time because there’s always a delicious and wholesome meal waiting for you in the fridge.

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To take meal prepping one step further, always pre-chop fruits and vegetables once they’re taken home from the grocery store and package them in containers.

5. Be mindful of how you prepare food

Just because a type of food is healthy, such as green beans or a piece of salmon, it does not mean it stays nutritional if prepared in an unhealthy way. Avoid frying your food in oil, deep-frying them, or heavily salting them. These elements add excess amounts of sodium and fat to your foods. These additions automatically counter the food’s nutritional value. Instead, sauté, bake, or grill meals using non-stick pans4 with a small amount of cooking spray.

Additionally, healthy meals don’t need to be bland and dreadful to eat. There are numerous spice combinations you can use on food that is even more delicious than salt and actually have beneficial properties. For example, ginger is a common spice in Asian cuisine that has been shown to have multiple bioactive activities including anti-inflammatory, anti-oxidant, and anti-nausea.5

6. Simplify your meal recipes

A recipe, like healthy eating, does not have to be complicated. The best basic rule to follow is to eat a plate comprised only of vegetables, whole grains, a healthy protein, and fruits—according to studies illustrated on a chart from Harvard’s School of Public Health6. For example, a meal that satisfies this recommendation is a plate of grilled chicken, steamed vegetables, whole grain rice, and a small fruit bowl, and a glass of water on the side.

7. Snack healthy throughout the day

To keep your appetite at bay and raise you up from moments of low energy, eat healthy snacks throughout the day. Unsalted nuts make great snacks7 that not only taste good but are also filling. 

If you’re a diabetic, snacking is especially beneficial since it helps to regulate your blood sugar level. Snacking also prevents large spikes in blood sugar levels from occurring which may reduce your likelihood of developing cardiovascular issues, obesity, and Type 2 diabetes in the long run.

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8. Practice the healthy eating mindset

A healthy eating mindset is defined by being mindful of your eating habits and decisions. Focusing on the flavor and texture of the food you eat enhances your enjoyment of the meal. It also slows down eating which allows food cravings to pass and helps you eat less.8

Having a healthy mindset includes practicing self-control in the face of junk food and understanding why it’s better to make a healthy decision rather than an unhealthy one.

9. Satisfy your cravings with wholesome alternatives

Whenever you crave something salty or sweet, seek out healthy alternatives. For example, if you have the urge to eat a pack of cookies, opt for eating fruit instead. If you have savory cravings, a burger or any other greasy food may emotionally satisfy them. But don’t give in because filling up on those foods often ends up making you feel worse.

Dip carrot sticks or celery stalks in homemade chickpea spread to satisfy the craving and get a fiber bonus. Try olive spread smeared on whole-grain crackers to calm a craving for salty food. Be creative, but always choose fresh, whole foods over highly processed foods with added salt or sugar.

10. Exercise in conjunction with eating healthy

Last but not least, add exercise to a healthy diet habit to reap the full benefits of a wholesome lifestyle. Daily exercise may also help maintain your weight and reduce your chances of developing chronic diseases. It also boosts mood and improves your overall emotional and sense of physical well-being.9 Exercising also increases your self-awareness of how food affects you over time, which is another factor that impacts potential food choices.

The bottom line

Once you have the right strategies in mind to tackle healthy eating and take action to follow them, staying healthy will become easier over time. Don’t give up on trying to live a healthy lifestyle. If mistakes happen along the way, remember that it’s normal, and don’t be discouraged. What really matters at the end of the day is being intentional with this lifestyle change to improve your well-being and overall quality of life.

In conclusion, stay consistent with healthy eating habits and remember that a positive and dedicated attitude towards healthy living is just important as eating clean.

Related Content: Healthy Eating Tips for Nurses & Doctors Who Work Long Hours



  1. Max F Oginsky, Paulette B Goforth, Cameron W Nobile, et al.  Eating ‘Junk-Food’ Produces Rapid and Long-Lasting Increases in NAc CP-AMPA Receptors: Implications for Enhanced Cue-Induced Motivation and Food Addiction,
  2. Changes to the Nutrition Facts Label. Food, and Drug Administration, current 02/10/21 

  3. Meal Prep: A Helpful Healthy Eating Strategy. Harvard School of Public Health, The Nutrition Source.  https://www.hsph.harvard.edu/nutritionsource/2017/03/20/meal-prep-planning/

  4. Healthy cooking tips. Better Health Channel. https://www.betterhealth.vic.gov.au/health/healthyliving/healthy-cooking-tips 

  5. Qian-Qian MaoXiao-Yu XuShi-Yu CaoRen-You GanHarold Corke, et al.

    Bioactive Compounds and Bioactivities of Ginger ( Zingiber officinale Roscoe).  PubMed,  2019 May 30;8(6):185. https://pubmed.ncbi.nlm.nih.gov/31151279/

  6. Healthy Eating Plate, Harvard School of Public Health, The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/

  7. Carettin AlasalvarJordi-Salas SalvadóEmilio Ros, et al.   Bioactives and health benefits of nuts and dried fruits.  PubMed, 2020 Jun 1;314:126192. https://pubmed.ncbi.nlm.nih.gov/31958750/
  8. Heidi Godman, Contributor.  11 Benefits of Mindful Eating, U.S. News, Health. 2019 Oct. https://health.usnews.com/wellness/food/articles/benefits-of-mindful-eating
  9. Eduardo Matta Mello Portugal, Thais CevadaRenato Sobral Monteiro-Junior, et al.

    Neuroscience of exercise: from neurobiology mechanisms to mental health.  Neuropsychobiology PubMed 2013;68(1):1-14.

Medical Reviewer Notes by Dr. Olson

First, congratulations to Trevor for being clean and sober. I work as a psychiatric consultant in a substance use disorder clinic and I know it isn’t always easy, but one of the things that helps with recovery is to replace old ways of trying to feel good with new ones that are healthier. I support all of his recommendations.

I would add one thing: keeping a food diary. I use the app “My Fitness Pal,” although there are many others. It really gives me some accountability and as I review my daily behavior, it impacts the food choices (e.g. a bedtime snack) and keeps me on track. It also allows for increasing your daily calorie allowance and that helps with motivation when I just don’t feel like going to the gym or taking my dog for a longer walk.

It shouldn’t be surprising to learn that doctors and healthcare providers are often frustrated when patients with eating and weight concerns don’t follow their advice. They caution and cajole, nudge, and lecture these patients about the importance of weight loss often to no avail. An unspoken question comes to mind, “Why do these people continue to sabotage themselves?”

Here are five possible reasons why patients ignore their doctors’ advice on weight loss and fitness.

1. Fear of failure and hopelessness

Most patients with eating and weight concerns are not new to the concept of diets and exercise. In fact, providers may not know that their patients have gained and lost 50, 75, or more than 100 pounds several times in their lives.1 These patients have been there and done that, and it hasn’t turned out as well as everyone had hoped.

For most of them, the deprivation they felt while dieting was stupefying, and the restraint they had to muster daily was insufferable until they finally ran out of self-control and self-discipline and gave into eating normal portions, sweets and treats, and foods that they enjoyed.2,3 While providers are trying to psych them on starting a new health regimen, they’re recalling the last time they let their gym membership lapse and the closet full of smaller-sized clothes they fear they’ll never squeeze into again.

2. Depression

Many patients with eating and weight concerns have neurotransmitter imbalances causing depression and anxiety.4 Maybe they started out with the happy genes, but more likely not. Even if they did, the weight stigma and fat prejudice that runs rampant in society, not only through the media but from surgeons to secretaries in medical offices, would have demoralized them and shattered their self-esteem.

Patients who misuse food when they have the blues or the blahs may not even know that they’re depressed. Those who have social anxiety may not realize that eating is their way of coping when out to dinner with friends or attending a work party. They don’t want to hurt their bodies. They only want to feel the way that others appear to feel—relaxed and normal—when they’re around people.

Related content: How to Help Your Partner Make Healthy Lifestyle Changes

3. Lack of life skills to attain and maintain health goals

Most of us weren’t raised with a full complement of the life skills needed to maintain a healthy lifestyle. For example:

        • effective self-care,
        • healthy relationships,
        • work and play balance,
        • emotional management,
        • goal achievement,
        • problem-solving, and
        • self-regulation.

Moreover, we don’t all start out on an equal playing field. Sadly, dysfunctional families too often produce children who are lacking in life skills and end up with a diminished quality of life in adulthood.

Expecting these patients to make healthy choices when they’ve never been taught how to delay gratification or tolerate frustration is a waste of time.

Hoping that they’ll call a friend when they’re upset rather than down a pint of Häagen-Dazs is misplaced optimism if they were raised in an insular family that mistrusted outsiders. Encouraging them to take a walk to unwind is wishful thinking if they feel they must be productive 24/7. We need effective life skills if we’re going to effectively take care of mind and body.

4. Mixed feelings about the weight loss advice

It may seem like a no-brainer to medical professionals that everyone would want to lose weight and be attractive. This is not always the case. Sexual abuse survivors often feel less vulnerable and safer with more meat on their bones. People who are more sexually active when they’re thinner sometimes fear that weight loss will compromise their marital fidelity.

Patients who’ve suffered emotional and physical abuse may insist that they want to date. However, they are afraid of relationships because of what has happened when they’ve let their guard down in the past. In other cases, holding onto excess weight may be a badge of suffering, a way to signify that life hasn’t been good to them. These are serious psychological dilemmas that won’t go away without clinical attention.

5. Rebellion – but not just against weight loss advice

One of the most common reasons for not following medical advice is unconscious rebellion. This is a characteristic of people who are confused about care versus control.5 If they had parents who were domineering, critical, and demanding (and parental dependence was encouraged), they, while wanting to follow providers’ advice, would resent being told what to do. They dislike being pressured, even to do what’s good for them. Further, they will avoid doing it out of misplaced spite.

Rebellion is a complex dynamic which most patients and providers are unaware of. Even though professionals try to care for them, these patients only feel and fear that they’re being controlled. No wonder what doctors say seems to go in one ear and out the other. It’s easy to see why this dynamic may seem like self-sabotage, but it’s much more unconscious and complicated.

The bottom line on why patients ignore doctors’ weight loss advice

Doctors and healthcare providers need not feel that without a graduate degree in psychology they can’t possibly do right by their patients who have eating and weight concerns. They do need to recognize that patients are not intentionally trying to remain unhealthy and hurt their bodies. And they must offer empathy and compassion for their minimal and inconsistent efforts.

If doctors are able to do these things, they will find themselves on the right track. In addition, providers would also benefit from encouraging patients to get support from eating disorders therapists so that no one has to wrestle with eating and weight concerns by themselves.


  1. Eric Stice, Kyle Burger, and Sonja Yokum, “Caloric Deprivation Increases Responsivity of Attention and Reward Brain Regions to Intake, Anticipated Intake, and Images of Palatable Foods,” abstract. NeuroImage (February 2013): vol. 67, 15: 322–330. https://doi.org/10.1016/j.neuroimage.2012.11.028. Accessed 12/20/20
  2. Paul S. Maclean, Audrey Bergouignan, Marc-Andre Cornier, Matthew R. Jackman, “Biology’s Response to Dieting: The Impetus for Weight Regain,” American Journal of Physiology: Regulatory, Integrative and Comparative Physiology (September 1, 2011): vol. 301, no. 3, R581-R600 DOI: 10.1152/ajpregu.00755.2010. Accessed 12/20/20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174765/
  3. A. G. Dulloo and J..P Montani, “Pathways from Dieting To Weight Regain, To Obesity and To the Metabolic Syndrome: An Overview,” abstract. Obesity Reviews (2015), 16: 1–6. doi: 10.1111/obr.12250, https://www.ncbi.nlm.nih.gov/pubmed/25614198. Accessed 12/20/20
  4. Karen R. Koenig and Paige O’Mahoney, Helping Patients Outsmart Overeating: Psychological Strategies for Doctors and Health Care Providers. (New York: Rowman & Littlefield, 2017), 36-7.
  5. Chelsea Fielder-Jenks, “Binge Eating Disorder and Anxiety,” Eating Disorder Hopehttps://www.eatingdisorderhope.com/information/binge-eating-disorder/binge-eating-disorder-and-anxiety. Accessed 12/22/20.

    First published 5/12/17. Updated and republished 12/25/20

Eating disorders are among the most dangerous and difficult to treat of all mental health disorders. Eating disorders do not discriminate. They can be found in both genders, all age groups, and across a wide variety of races and ethnic backgrounds. Eating disorders adversely impact the health and well-being of those affected. And, sometimes, eating disorders can become quite severe and, without aggressive medical treatment, can lead to death.[1]

This article will explore the key features of these often misunderstood disorders.

Our unhealthy relationship with food

Were you ever told you must clean up your plate?  Or eat your Brussel sprouts before you could have dessert? If so, you aren’t alone. Many of us grew up being harangued with some variation of these types of “eat your food or else” threats. However, they are just one of many contributing factors to American’s unhealthy relationship with food. Among others are:

      • Our belief that anything enjoyable is inherently wrong
      • Thinking that things that are good for us are not enjoyable
      • Eating and dieting are national obsessions
      • Obsession with thin beauty is reinforced by the media
      • Dietary recommendations are conflicting, contradictory, and constantly changing
      • Physicians and other health professionals may not recognize there is problem until it is quite advanced

The dichotomy between good food and bad food generates fear, anxiety, and guilt. We feel guilty about eating enjoyable foods, yet we use them to lift our moods, reward behavior, and celebrate milestones. 

This mentality leads to problems with eating disorders.

Different manifestations of unhealthy relationships with food

There are different manifestations of disordered eating, including:

      • Some individuals gorge themselves into obesity
      • Others eschew food altogether.
      • Yet others gorge on food and then purge.
      • And some rigidly obsess about what they eat.

Many of us may do these things to a lesser degree or intermittently. But in some individuals, these patterns take control of their lives. At this point, we say that they have developed a serious eating disorder.

Types of eating disorders

The three types of eating disorders most discussed and researched are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating. [A detailed discussion of specific diagnostic criteria can be found here.[2]

  • Anorexia Nervosa 

Anorexia nervosa is characterized by weight loss (or lack of appropriate weight gain in growing children), difficulties maintaining the right body weight, and a distorted body image. 

  • Bulimia Nervosa

Bulimia nervosa is characterized by a cycle of bingeing, self-induced vomiting, and/or laxative abuse designed to undo the effects of binge eating.

  • Binge Eating Disorder

Binge eating disorder is the most common eating disorder. It is characterized by recurrent episodes of feeling out-of-control while quickly consuming large quantities of food. Binges are accompanied by feelings of guilt and shame. Purging and laxative abuse do not occur with this disorder.  

Other subtypes of eating disorders

These disorders are not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5.)

The pursuit of a healthy diet is considered laudable. But when fixation on eating a correct diet becomes the most critical part of one’s life, it is regarded as a disorder.

Muscle Dysphoric Disorder is sometimes referred to as “Bigorexia,” “Megarexia,” or “Reverse Anorexia.” It is not listed in DSM-5 as a separate diagnosis but rather as a subset of Body Dysmorphic Disorder.{3] While it shares several characteristics with anorexia, it is a desire to be bigger rather than smaller.

Diabulimia is not recognized as a formal diagnosis by the medical or psychiatric communities. However, it has been referred to as the world’s most dangerous eating disorder. It refers to an eating disorder in a person with diabetes, typically Type I Diabetes, wherein the person purposefully restricts insulin to lose weight.

How common are eating disorders?

The National Institute of Mental Health (NIMH) reports that binge eating disorder occurs in 1.2% of adults. The rate twice as high among females. Bulimia nervosa affects 0.3% of adults and is five times higher among females than males. The lifetime prevalence of anorexia nervosa in adults is 0.6%, and it occurs three times more among females than males. 

Many more individuals may experience the symptoms of an eating disorder but do not yet have a formal diagnosis. Also, many individuals struggle with body dissatisfaction and subthreshold disordered eating attitudes and behaviors.

Related content by the same author: Body Dysmorphic Disorder: Obsession with a Flaw Interferes with Life

What causes eating disorders?

A considerable amount of research has been done on the biological, psychological, developmental, and sociocultural risks associated with eating disorders. While the number of risk factors identified as contributing to the development of eating disorders has increased, evidence for the cause of eating disorders [5] has not been conclusive. 

Risk factors are first present in early adolescence, but eating disorders tend to emerge in late adolescence and early adulthood. Eating disorders do not present in the same way from one person to the next. However, research has found similarities in significant risks for developing eating disorders.

  • Risks for developing eating disorders

There are three variables that are commonly associated with eating disorders:

      • Perceived pressure to be thin
      • Internalizing a thin-ideal
      • Body dissatisfaction

In the last few years, research has shifted toward the genetics and neurobiology of eating disorders. Most researchers no longer believe that the cause is a matter of “will” or self-control.

  • Poor food choices

People routinely make poor choices, despite knowledge of negative consequences. Still, individuals with anorexia nervosa make bad food choices to the point of starvation.

One study found that individuals with anorexia engage a different part of their brain when making food choices compared to healthy subjects. The part of the brain identified is associated with habitual behaviors.[6]

Related Content:  5 Reasons Why Patients Ignore Doctors’ Weight Loss Advice

  • Genetics

Another report suggests a genetic model that considers environmental, nutritional, and genetic factors in eating disorders.[7] Evidence for a genetic link is supported by the fact that eating disorders occur more frequently when a close relative has an eating disorder or a mental health condition. 

  • Other risk factors:

      • Perfectionism
      • Body image dissatisfaction
      • Personal history of an anxiety disorder
      • Always following the rules
      • Weight stigma
      • History of dieting
      • Type 1 (insulin-dependent) diabetes
      • Teasing or bullying
      • Racial and ethnic minority groups 
      • Loneliness and isolation
      • Psychological trauma
      • Bullying
      • Weight stigma

Perfectionism is one of the most common risk factors for eating disorders. Eating disorder risks are higher in racial and ethnic communities, particularly for those undergoing rapid Westernization. Bullying leads to low self-esteem, isolation, and poor body image. 

Over 70% of people with eating disorders reported mental health issues.[8] The most common are anxiety disorders, followed by mood disorders, self-harm, and substance abuse. Perfectionism and negative emotions (anger, sadness, guilt, anxiety, and disappointment) are frequently associated with eating disorders.

Eating disorders in athletics

Both female and male athletes are at higher risk of developing an eating disorder compared to non-athletes [9] This is especially true for athletes participating in sports where leanness confers a competitive advantage.

Eating disorders are more prevalent in appearance-oriented athletic activities called “aesthetic sports“[10] (swimming, gymnastics, dance, and bodybuilding) than in ball sports. 

Early specialization in a sport appears to be a factor. Athletes tend to under-report their disordered eating. In combat sports like martial arts sports, athletes compete within weight classes. Disordered eating and pre-competition of rapid cutting of weight are everyday occurrences and predispose to eating disorders.

Diagnosis and treatment

Treatment begins with a good medical evaluation by a health care provider. Severe cases may require stabilization in a hospital experienced in the safe refeeding of severely malnourished individuals.[1]

Much of the psychiatric treatment of eating disorders focuses on psychotherapy with one of the following:

  • Cognitive Behavioral Therapy (CBT)

CBT is the leading evidence-based treatment for all eating disorder diagnoses in adults. It can also be adapted for adolescents. CBT is designed to produce changes in thinking. In eating disorders, it focuses on what is keeping the eating problem going. CBT includes homework exercises to complete between therapy sessions. Issues addressed include shape and weight, dietary rules, moods related to eating, perfectionism, and low self-esteem.

  • Family-Based Treatment (FBT)

FBT is the leading evidence-based treatment for eating disorders in adolescents and children. In FBT, parents play an active and positive role to help their child. 

  • Interpersonal therapy (IPT)

IPT is a time-limited, focused therapy developed for the treatment of depression that has been adapted for eating disorders. It recognizes the importance of current interpersonal relationships in the recovery process. 

  • Cognitive remediation therapy (CRT)

CRT was developed initially for patients with brain injuries. patients with eating disorders have deficits in their thinking. In particular, they have inflexible thinking. 

The Eating Disorder Assessment for DSM-5 (EDA-5) is a semi-structured interview meant to assist in assessing a feeding or eating disorder according to DSM-5 criteria. It is intended for use by clinicians who have some familiarity with the feeding and eating disorders. It is available electronically and in Spanish as well as other languages. The EDA-5 is available at no cost for use in clinical settings.

In those individuals with co-morbid mental conditions like anxiety and depression, anti-depressant medications are indicated.

Treatment outcomes

The best predictor of outcomes in treating eating disorders[11] is the degree of symptom reduction early in treatment. Other predictors of treatment success relate to

  • Body Mass Index (BMI)
  • fewer binge/purge episodes
  • higher motivation
  • lower depression
  • lower concerns about shape and weight
  • fewer comorbidities
  • better interpersonal functioning
  • fewer family problems

The bottom line 

Eating disorders are serious and, at times, life-threatening mental illnesses that require knowledge about the risk factors, causes, treatment options, and outcomes. 


    1. Mehler P. Medical Management of Severe Eating Disorders. The Doctor Weighs In, 2020 Dec 1. https://thedoctorweighsin.com/medical-management-severe-eating-disorders/ Accessed 12/10/20.
    2. National Eating Disorders Association. What Are Eating Disorders? https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia  Accessed 12/10/20
    3. Veale D. Body Dysmorphic Disorder. BMJ 2015350 doi: https://doi.org/10.1136/bmj.h2278 Published June18, 2015. ( Cite this as: BMJ 2015;350:h2278)  Accessed 12/10/20. Ed. note: this reference is behind a paywall.
    4. National Institute of Mental Health. Easting Disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml Accessed 12.10/20
    5. Rikani AA, Choudhry Z, Choudhry A et al. A critique of the literature on etiology of eating disorders. . 2013 Oct; 20(4): 157–161. doi: 10.5214/ans.0972.7531.200409
    6. Foerde K, Steinglass J, Shohamy D, et al. Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience (Advancce online publication), 2015 Oct 12. doi:10.1038/nn.4136. https://shohamylab.zuckermaninstitute.columbia.edu/sites/default/files/2017-02/karinsNNanorexia.pdf
    7. Himmerich H, Bentley J, Carol Kan et al. Genetic risk factors for eating disorders: an update and insights into pathophysiology. Therapeutic Advances in Psychopharmacology 2019 Feb 12. https://doi.org/10.1177/2045125318814734 https://journals.sagepub.com/doi/full/10.1177/2045125318814734
    8. Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors, Current Opinion in Psychiatry: November 2016 – Volume 29 – Issue 6 – p 340-345 doi: 10.1097/YCO.0000000000000278 https://journals.lww.com/co-psychiatry/Abstract/2016/11000/Epidemiology_of_eating_disorders_in_Europe_.5.aspx
    9. Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management, British J Sports Medicine, 2015, httpss://dx.doi.org/10.1136/bjsports-2015-095735 https://bjsm.bmj.com/content/50/3/154.short
    10. Thiemann P, Legenbauer T, Vocks S. et al. Eating Disorders and Their Putative Risk Factors Among Female German Professional Athletes 2015 March 31. https://doi.org/10.1002/erv.2360 https://onlinelibrary.wiley.com/doi/abs/10.1002/erv.2360
    11. Vall E, Wade T. Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta‐analysis, International J of Eating Disorders, 2015 July 14, https://doi.org/10.1002/eat.22411. (behind a paywall). https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22411

Severe eating disorders are the only mental illnesses regularly accompanied by dangerous, life-threatening medical complications. Significant medical instability results from a number of abnormalities, such as progressive malnutrition, purging behaviors, and blood chemistry abnormalities.

In fact, the disorder can compromise virtually all of the body’s vital organs and systems.

There are a number of different eating disorders that lead to excessive weight loss and associated medical complications. The most common include:

In this article, I will focus on the medical complications of these disorders. I will also discuss how to manage because it is crucial to saving the lives of individuals suffering with a severe eating disorder. Further, it is key to helping patients achieve the medical stability and cognitive function necessary to engage fully in the recovery process.

Related content:
What You Need to Know About Eating Disorders
Eating Disorders: Risk Factors, Diagnosis, Treatment, and Outcomes

Medical complications of severe eating disorders

Common medical complications associated with severe eating disorders include the following [1,2]:

      • Gastrointestinal complications, including diarrhea, delayed gastric emptying (gastroparesis), constipation, abdominal pain, and swallowing difficulties) 
      • Liver function test abnormalities
      • Electrolyte abnormalities
      • Pseudo-Bartter’s syndrome (a complex of metabolic abnormalities related to purging)
      • Eye pain
      • Edema
      • Osteoporosis and osteopenia,
      • Superior mesenteric artery (SMA) syndrome
      • Cardiac dysfunction & arrhythmias
      • Muscle weakness
      • Traumatic falls

Medical complications of eating disorders can be treated effectively

The good news is that nearly all medical complications of eating disorders can completely resolve with safe nutritional rehabilitation and weight restoration. This is true regardless of how extensive they are.

Patients are resilient if they get the correct (and timely) treatment with a balance of informed medical and psychiatric care. This is especially critical for more chronic patients and patients of advanced age.

The bad news, however, is that eating disorders themselves are commonly undertreated. This means that a large number of patients receive only partial treatment for the complex medical and psychiatric concerns associated with these illnesses.

It is important to understand that severe eating disorders can be deadly. Anorexia nervosa, for example, is considered the deadliest of all mental illnesses with a mortality rate estimated to be ~10%. [3]  Further, AN patients carry an increased risk for suicide.

Many patients with severe eating disorders will require a high level of care

More than one-third of individuals suffering from eating disorders will require treatment at a higher level of care. This can range from 24-hour inpatient psychiatric care to comprehensive daytime behavioral programming. 

Most treatment programs offer some degree of minimum internal medicine and/or nursing support to manage medical issues of eating disorders. However, some patients may be so medically compromised by their illness that they require specialized medical, hospital-based stabilization prior to entering a residential eating disorder treatment program.

Determining what level of care a patient with an eating disorder needs can be challenging for reasons that include:

      • patient resistance,
      • secrecy shrouding eating disorder behaviors and symptoms,
      • the body’s ability to feign stability.

Determining the appropriate level of care needed

It is not uncommon for patients, families, and providers to begin with the least intensive intervention. However, starting a treatment plan with the appropriate level of care can have a significant impact on the patient’s health. It is also a factor that influences success in recovery and satisfaction with treatment.[4]

The American Psychiatric Association (APA) has outlined five levels of psychiatric care. They are divided between outpatient and inpatient treatments.

It is important to note, however, that this guidance fails to completely outline a crucial sixth level of care. This is the one that involves specialized medical treatment for individuals experiencing extreme medical instability that results from physical complications of malnutrition and purging. 

For this severe subset of patients, intervention should include medical stabilization in a specialized, hospital-based medical unit prior to beginning traditional behavioral eating disorder treatment.

Expert consensus suggests inpatient stabilization should occur when a BMI is <14 or when that patient’s weight is <70% of ideal body weight (IBW).

  • Weight specific recommendations to levels of care

In general, patients with AN or Avoidant/Restrictive Food Intake Disorder (ARFID) whose weight is:

      • below 70% IBW should first be treated in a specialized medical unit for the medical stabilization of those patients,
      • between 70 to 84% of IBW, are best served in an inpatient or residential treatment center,
      • between 85% to 95% of IBW, a partial hospitalization program (PHP) is generally appropriate.[5]

It is important to remember that no guideline is absolute when it comes to these complex illnesses. The frequency of purging behaviors and other physical or psychiatric symptoms must be considered alongside patient weight to ascertain the appropriate level of care that may be needed.

What is inpatient medical stabilization for eating disorders?

In general, initial medical stabilization in a hospital-based unit is recommended for eating disorder patients who are severely low weight, seriously medically compromised, or at risk for major complications from refeeding syndrome. The latter is a dangerous metabolic disturbance that can occur when nutritional rehabilitation is first initiated.

Patients with any/all of the following criteria may require medical treatment from experienced providers in a specialized medical hospital unit before entering a behavioral treatment program in a traditional eating disorder unit:

      • weight <70 percent of ideal body weight or BMI <14
      • unstable vital signs such as low or irregular heart rates or low blood pressure
      • cardiac disturbances such as abnormal heart rhythms or heart failure
      • loss of consciousness due to low blood pressure
      • acute kidney or liver failure and/or
      • critical electrolyte abnormalities such as low potassium or low phosphorous of extreme degrees.

What is the goal of medical stabilization of patients with severe eating disorders?

The goals of medical stabilization are to improve and normalize the patient’s vital signs, cardiovascular system, and bowel function as well as restore levels of key electrolytes including phosphorus, potassium, magnesium, and calcium in a timely manner. Medical stabilization also involves nutritional rehabilitation to support weight restoration.

Most experts agree that careful caloric initiation is vital to medical stability and improved cognitive function. It is hallmarked by the ability to tolerate and complete the most basic activities of daily living. Inpatient medical units have the expertise and resources to deliver any form of nutrition required, including oral, enteral, or intravenous calories.

It is important that each of these goals is met in order for a patient with an eating disorder to be considered medically stable. Once the patient has achieved medical stability, he or she can continue in recovery by transitioning to a 24-hour psychiatric facility. It is important that the psychiatric facility has the ability to sustain medical progress while incorporating the following interventions:

      • intensive psychotherapy,
      • ongoing weight restoration,
      • other evidence-based recovery interventions.

Understanding the difference between medical and psychiatric treatment 

It is also important that providers, patients, and families understand the difference between inpatient psychiatric treatment and inpatient medical stabilization for the most severe eating disorders.

While an inpatient psychiatric facility offers round-the-clock behavioral treatment and likely some degree of medical support, an inpatient medical stabilization program requires a hospital-based telemetry unit.

Its full-time internal medicine physicians, nurses, dietitians, and skilled rehabilitation providers expertly treat any life-threatening medical complication of severe eating disorders. These medical teams collaborate with psychiatrists, psychologists, and behavioral health technicians to support behavioral recovery.

It is important for patients and families to understand that patients with serious complications due to eating disorders will be too weak, medically unstable, or cognitively impaired to engage in meaningful therapy during medical hospitalization.

Inpatient medical and inpatient psychiatric programs must work together to support survival and recovery in medically complex patients. Initially, however, there is no substitute for 24/7-available medical, dietary, and nursing expertise on a dedicated medical stabilization unit.

Avoiding refeeding syndrome

Increasing caloric intake quickly in individuals with severe anorexia nervosa or ARFID, without frequent monitoring of blood tests and electrolyte replenishment, can lead to refeeding syndrome. A dangerous shift in fluids and electrolytes within the body are characteristic of the disorder.

It occurs in a small subset of patients when calories are introduced quickly, lab tests are not checked frequently, and resultant abnormalities are not treated in a timely fashion. The lower the patient’s BMI, the greater the risk of refeeding complications.[6]  

  • Cardiac complications of refeeding

When the body is starved or severely malnourished, the heart muscle may atrophy. This causes diminished cardiac output. Further, the body begins to break down its own tissues—including fats and muscle—in an attempt to create the energy needed to maintain basic bodily functions. These changes can affect the body’s major electrolytes, including phosphorus, potassium, and magnesium.

  • A shift to carbohydrate metabolism

When food is reintroduced during the refeeding process, there is an abrupt shift from fat and muscle metabolism back to carbohydrate metabolism.  This increases the body’s uptake of phosphorus and other key electrolytes into newly developed cells. This leads to dangerously decreased levels of these electrolytes in the blood.

This sudden change in the balance of electrolytes causes the atrophied heart to work harder, which can cause irregular heartbeat, muscle damage, weakness, seizures, and even death. When the resultant blood chemistry abnormalities are not detected or are not addressed in less than a few hours, patients may be at risk for the refeeding syndrome characterized by the following:

        • cardiac failure, 
        • respiratory failure,
        • rhabdomyolysis (muscle death),
        • hemolysis (red blood cell rupture) and/or
        • seizures.

These life-threatening complications are preventable when refeeding is administered by eating disorder experts. However, many medical providers are not trained to identify or address refeeding syndrome in patients with extreme anorexia and ARFID. This unfortunate reality underscores the need for severely underweight patients to begin the refeeding process in a specialized inpatient medical setting capable of treating the most serious eating disorders.

Eating disorder patients with normal or high BMI

Assuming that patients with a “normal” or “higher” BMI are always stable enough to access lower levels of care may inadvertently cause harm. Some of these patients may present with a falsely elevated weight.

They can also be at risk for dangerous complications due to excessive purging behaviors followed by abrupt cessation or significant and rapid “weight disruption” that is marked weight loss over a short period of time.[6]

Thus, regardless of current weight, it is essential to consider the severity of purging behaviors and absolute weight loss when choosing an appropriate level of care.

Again, consider medical stabilization first for those showing severe weight disruption (more than 25% body weight loss in a short time period). Include as well those needing to safely “detox” from severe self-induced vomiting and laxative or diuretic abuse.

The bottom line on the management of severe eating disorders

Eating disorders at any stage are complex and can be life-threatening. Seeking treatment for a severe eating disorder can be overwhelming. This is especially true when life-threatening medical complications are present. However, helping providers, patients, and families understand which level of care provides adequate medical support to address these complications and restore medical stability is an important first step in the recovery journey.


1. Cost J, Krantz M, Mehler P. Cleveland Clinic Journal of Medicine, Medical complications of anorexia nervosa. (2020) 87 (6) 361-366; DOI: https://www.ccjm.org/content/87/6/361

2. Mehler, P. International Journal of Eating Disorders, Medical complications of bulimia nervosa, and their treatments. (2011) 44(2):95-104. DOI: https://doi.org/10.1002/eat.20825 

3. Berends, T, Boonstra N, van Velburg A. Current Opinions in Psychiatry, Relapse in anorexia nervosa: a systematic review and meta-analysis. (2018) 31(6): 445-455. Doi: 10.1097/YCO. https://pubmed.ncbi.nlm.nih.gov/30113325/

4. Cost J, Mehler P. Eating Disorders Review, Level of Care Considerations for Severe and Extreme Eating Disorders. (2019), Vol 30. https://eatingdisordersreview.com/level-of-care-considerations-for-severe-and-extreme-eating-disorders/ 

5. Mehler P, Crews C. Eating Disorders-The Journal of Treatment and Prevention, Refeeding the Patient With Anorexia Nervosa. (published online 2010) https://doi.org/10.1080/10640260127719

6 Garber, A. K.. Journal of Adolescent Health. Moving beyond “skinniness”: presentation weight is not sufficient to assess malnutrition in patients with restrictive eating disorders across a range of body weights. (2018), 63(6), 669-670. https://www.jahonline.org/article/S1054-139X(18)30425-7/fulltext

Body dysmorphic disorder is a mental disorder in which a person can’t stop thinking about some perceived flaw in their appearance. It may be a flaw that doesn’t exist or is so minor it isn’t noticed by anyone else. It leads to feelings of embarrassment and shame.

Sometimes people with the disorder avoid social situations because they feel their “defect” will be on display. A fairly common example is a person who has had multiple rhinoplasties to fix their imagined nose defect. And yet, after each surgery, they are always dissatisfied with the results.

Before I dive into a more detailed discussion of body dysmorphic disorder, let me share my personal story of the “flaw” that bugged me: man boobs.

I was ashamed of my body

Ever since I was a teenager, I’ve been ashamed of my body. It never looked like I wanted it to.

But most of my self-hate centered on the excess fat tissue in my breasts. Man boobs further undermined my fragile sense of manhood. I think I understand why transgender men always first want to get rid of their breasts.


When I was about fifty, I finally had enough money to consider seeing a plastic surgeon to have a breast reduction. I contacted a plastic surgeon who’d gained his reputation by creating lips out of vaginal tissue. Perhaps that should have been a clue.

When I arrived for my appointment, he said, “Loren, take off all your clothes and stand here in front of me.” That was just the beginning of the trauma. I didn’t like being naked in front of anyone.

As I stood there, he took out a Magic Marker and began drawing black lines all over my body. “We can nip this, tuck this, suck that.” And on and on he went. He found flaws on every part of my body, a lot more than I thought I had.

He recommended several procedures, gave me a cash-only price for the overhaul. Then he suggested I would probably want to schedule a three-week vacation in the Caribbean for my recovery.

I had no idea my body was so disgusting. The entire visit was traumatizing.

I’ve also got hooding

Several years later, I reconsidered having the surgery. I had a patient who was a nurse who worked for a plastic surgeon. I asked her, “Who do you think is the best plastic surgeon in Des Moines?”

In response, she asked, “Oh, are you going to do something about the hooding over your eyes?”

Hooding? What hooding? I didn’t know I had hooding. I asked, “What’s hooding?”

“It’s all that loose, baggy skin that hangs down over your eyes so you can’t see very well.”

She was barely out the door when I called the plastic surgeon. “I want to consult with you about a breast reduction and to have you look at my hooding.”

I called my husband and said, “I’ve scheduled a visit with a plastic surgeon to have a breast reduction. And I’m also going to talk to him about my hooding.”

“What’s hooding?” he asked.

By the time I got home, he had scheduled an appointment with the same plastic surgeon to have his hooding removed, too.

Then I hit the tree

That evening we were going out. I was still wound up about the surgeon. As I backed the car out of the garage, I backed it into a tree that had been there for twenty years.

“Watch where you’re going!” Doug said, less supportive than I’d hoped.

“I can’t see. I’ve got hooding!”

I had the breast reduction and the “hooding-ectomy.” I was pleased with the results, and I felt more comfortable in my skin, albeit with less of it.

My life didn’t change dramatically following the surgery. The only change was in my attitude about my body.

Now, I often joke, “Apparently God wanted me to have boobs because they seem to have grown back.” And yet my attitude remains improved.

Other stories by this author: Seizing Permission to Live Life on Your Own Terms

Body dysmorphic disorder

Psychiatrists make diagnoses of a “disorder” when a collection of the symptoms reach such a degree that they begin to interfere significantly with one’s life.

People may have some of the symptoms of a disorder without having those symptoms interfere in their lives. I was distressed by my man boobs. However, I didn’t spend hours and hours checking them in the mirror every day.

However, I have seen men at the gym check out their muscle definition in the mirror three times during a single workout. That’s the difference.

Common symptoms of Body Dysmorphic Disorder include:

      • Preoccupation with a “flaw” in appearance that isn’t apparent to others
      • A belief that this flaw makes you ugly
      • The belief that others take special, negative notice of the flaw and may mock you
      • Constant and unfavorable comparison with others
      • Seeking frequent reassurance from others
      • Socially isolation
      • Seeking repeated cosmetic procedures with little satisfaction.

Men and body image

The perception that men are protected from concerns about body image is false. A preoccupation with your body build being too small or not muscular enough occurs almost exclusively in males. 

When I was a child, people measured men’s attractiveness by their behavior and achievements. Our parents told us: Never hit a woman. To me, the implied message was never hit a woman, but always hit a man when you need to.

We were told to be confident, one of the guys, and tough enough to take a beating. Any preoccupation with the appearance of our bodies was considered a girl thing.

Today, men also pursue masculinity by demeaning femininity.

  • The stereotype of fat men

The stereotype of fat men is that we are lazy, unmotivated, and undisciplined. Being fat leads to discrimination in employment, healthcare, and education. Men are judged by body size, muscle definition, and fat composition.

The optimal male body is lean and athletic, V-shaped, with well-defined muscles. Men crave more muscles and less body fat even at the expense of their health and well-being.

We have in our heads an image of the ideal body. We judge others by that idealized image. We also judge ourselves by it.

  • Depression and obesity

Is depression a cause or an effect of obesity? The answer is yes. This is because it is both.

We isolate ourselves if we are fat. And we eat to lose the pain of loneliness.

Then we isolate ourselves even more because the added weight makes us even more depressed. We begin to feel hopeless. But we want some immediate relief. So, we eat.

It becomes a vicious cycle.

To lose weight means continuous self-denial of things we love. To deny ourselves those things, we must believe that there is a brighter future ahead. What if we lose hope that a brighter future is possible?

My trials and tribulations with weight loss

To lose significant amounts of weight, you need to become obsessed with it — every thought and conversation centers on your diet.

The last time I had an acceptable BMI and body weight, I was running six miles 4–5 days per week and biking over 100 miles per week.

I couldn’t maintain that lifestyle. It required too much time and too much sacrifice of other things I loved like time with family and friends.

I always felt hungry. I was pissed off because others seemed to maintain their weight without those sacrifices.

My dominant mood was self-pity. It made me bitchy and irritable.

I didn’t like feeling that way about myself. So, I wanted to do something, anything, that would give me some relief.

Often that momentary relief came in a bag of Oreos. And then the guilt returns like a yo-yo with more feelings of hopelessness.

Currently, I’m using an intermittent fasting plan. I eat my first meal at 10:00 a.m. and I don’t eat after 8:00 p.m. Calories are not monitored.

Calorie restriction is accomplished only by limiting the time in which they can be consumed. It’s too new to me to analyze its effects, but one effect is clear: I don’t feel the self-pity, the bitterness, or the constant preoccupation over food.

Related Content: Medical Management of Severe Eating Disorders

Someone finds me attractive?

At a gay resort a few years back, I ambled back to my room from the pool in my swimming trunks. I met a man on the sidewalk. As we approached each other, he put his finger beneath my chin and slid it below my belly button. He smiled and said, “Delicious!”

I was shocked by his remark. I thought Does he see what I see when I look in the mirror? The answer is “No.”

I believed that since I am not attracted to someone with my body type no one else could be either. I expected him — if he noticed me at all — to feel the same way about my body as I felt about it.

I felt uncomfortable about exposing my body. I expected him to be as uncomfortable seeing my body as I was displaying it. I couldn’t believe my body would ever be attractive to anyone else.

Getting over the shame of my body

Oddly enough, I got over the shame of my body at clothing-optional resorts. Being with a group of naked people boils life down to the basics. You are a blank slate with no pretenses.

Nothing is more authentic than being naked in the presence of others.

Finding acceptance — without adornments and disguises — can be very liberating. When you find that others welcome you as you are, it’s possible to accept yourself as you are.

The gay men at clothing-optional resorts are no different from anyone else except they like to take their clothes off. If you put a group of gay men together, naked or clothed, sexual tension will be in the air you breathe.

In a nude resort, sexual attractions persist but are not amplified. Sex happens, but it isn’t the entirety of the experience.

On being “gay fat”

The “body positive” movement is designed to help people with marginalized shapes learn to love their bodies. Advocates base this campaign on the idea that privilege should not fall only to the thin and fit. The crusade has been expanded to advocate for bodies of color, disabled bodies, and extremes of tall or short.

For a larger gay man like me, trying to fit the queer men’s definition of beauty is like the ugly step-sister trying to fit into the glass slipper. When compared to heterosexual men of the same size, bigger gay men are more likely to be ignored, treated rudely, or mocked. Many gay men say that their Body Mass Index (BMI) is healthy, but they don’t feel normal by gay standards.

The LGBTQ community’s binding principle is supposedly diversity. But the politics of exclusion leaves many men feeling left out. Those who don’t believe a hierarchy of body image exists in the gay community probably find themselves near the top of the pyramid.

Some gay men join gay “bear” groups because they recognize they can never fit the ideal. Bears protest being denied fun and loving relationships based on weight and size.

But some big men have felt rejected by the bear group because they aren’t hairy enough. Or they don’t have the right belly shape, or aren’t muscular enough. One said, “Not just any fat, hairy guy can qualify.”

Over-weight men are often their own harshest critic of their weight. They make comments like “Most of the fat-shaming I’ve experienced is aimed inward.”

It isn’t just average-weight people who incorporate the stereotype that fat men are lazy, unmotivated, and undisciplined. All of us do.

Body-shaming is real

I’ve always been a big person. I have gone into stores to shop for clothes and find that none fit when I try them on. I have had a clerk say to me, “We don’t sell anything here for men who look like you!”

People have recommended stores for big men where nothing was stylish or had any fit or structure. I cried in a dressing room in a store for big men that had stylish, well-made clothes designed to enhance the attractiveness of larger men. And they fit me.

Choosing not to date someone who is fat is one thing, but believing that fat people are lazy, unmotivated, and lacking in self-discipline is quite another.

Telling a large man he is fat is redundant. He knows. Body shaming is real. It happens in personal contacts, dating apps, and social media.

Body shaming is not saying “You’re not my type.” It is when fat people are ridiculed, insulted, demeaned, and told they’re ugly. Or lazy. Or unmotivated.

These remarks come from those who do not understand how impossible attaining and maintaining the desired weight is for some.

When someone in response to your interest says, “You’re not my type,” it may hurt, but it hurts much more when people shame us.

Words become weapons if we believe that an insensitive comment is correct. Cultural change and the reduction of stigma occur only slowly. But we can’t change culture through humiliation and insults.

Promoting inclusion

To promote inclusion, we must first recognize the ways we exhibit exclusion.

We must acknowledge that the LGBTQ community is not free from prejudice. When a person says they feel too fat to attend a Gay Pride rally that is supposed to be a celebration of diversity, we have a problem. When someone has the wrong body shape to be a bear, we have a problem. When a person feels it’s necessary to respond to a “ping” on a dating app with a humiliating response, we have a problem.

We must also understand that sometimes the harshest judgments we make are those we make against ourselves. Those of us who struggle with our weight must advocate for ourselves. We must understand that we are just as worthy of loving and being loved as anyone else.

Extreme weight loss can result in many different problems: eating disorders, compulsive exercising, body dysmorphic disorder, low self-esteem, depression, appearance obsession, cosmetic surgery, and dangerous nutritional practices. Some turn to steroids and street drugs, sacrificing health to achieve the body-ideal.

You are delicious to someone

Many people believe “No one will want me with the body I have.” Mirrors are dangerous for men who feel marginalized. But the truth is not everyone sees us the way we see ourselves. Your body, as unappealing as you think it is, may be just the ticket for someone else.

A personal weight loss plan must focus on the goals of health and improved activity. You may not find the elusive love of your life. Further, if you don’t feel worthy of being loved, surgery and other forms of aggressive weight loss won’t solve the problem.

The task is to believe that you are delicious to someone just the way you are.

Excuses, excuses, excuses. Who hasn’t used one or more of them to justify why they can’t (won’t) exercise. The problem is most of them are bogus and can easily be debunked. Let’s take a look at some common (and beloved) excuses for not exercising. And, the reasons why they just don’t hold up. Is your favorite exercise excuse on the list?

Exercise excuse #1: It’s not worth the effort

There is a huge body of evidence that documents the health benefits of exercise. Here are some of the findings:

As the World Health Organization points out, “better health is central to human happiness and well-being.” So, is it worth the effort? You bet it is!

Excuse #2: I don’t have enough time to exercise

People who exercise regularly also live busy lives—they have two jobs, two kids, too much to do, and too little time…just like non-exercisers—but they still find time for regular physical activity. They make exercise a priority. It becomes an expected part of their everyday lives.

So, Couch Potatoes, take a look at how you are spending your time. Is that late-night TV show really more important than a good workout? Or, here’s another possibility, could you find a way to watch it and walk on a treadmill at the same time?

How to Make Fitness a Lasting Habit
5 Simple Fitness Workouts That You Can Do at Home

Excuse #3: Exercise is so boring

Then, find an activity that isn’t boring. If you hate running, try hiking. If swimming bores you stiff, try biking. Consider dance classes, tai chi, mountain climbing, wall climbing, rowing, cycling, kickboxing, or regular boxing. Come on now, there are a zillion fun ways to get moving. Find one you like and, as the Nike folks say, “Just Do It.”

Excuse #4: I hate exercising alone

Then group classes might be just the ticket for you. There are plenty of free as well as paid options. There are big gym classes, small gym classes, and even live-streamed group classes. Alternatively, find a friend or two to walk with – socializing is good for your health too. Or, make a habit of hiking with your family every weekend.

If you want to push yourself to get the most out of your workouts, then consider hiring a personal trainer. Trainers can be particularly helpful if you want to optimize the benefits from activities where technique is important, such as weight training, yoga, or pilates. And, along the way you make a new friend.

Exercise excuse #5: My back hurts

When I was a practicing emergency physician, we routinely prescribed bed rest for back pain. Boy, were we wrong. We now know that getting up and moving is better for people with back pain. 

Gentle yoga classes may be particularly helpful in keeping chronic back pain in check. My husband, who was hospitalized for severe back pain in the 1980s, has controlled his chronic back pain for years with yoga-like stretches. He explains more in this video we made to celebrate his 80th birthday!

Excuse #6: I’m too old

I am not too old to exerciseMy mother-in-law, Annie, was in her 80s when she surprised us by being featured in the book, Growing Old Is Not for Sissies: Portraits of Senior Athletes (1986 version) (photo above). If her story isn’t enough to convince you, get your hands on this wonderful book to see how people are working out and staying fit all the way into their 100s.

It is important to know that it is never too late to get started. One of the more famous characters in the San Francisco Bay Area running community was former hod-carrier, smoker, and drinker, Walt Stack, who started running in his late 60s. He went on to run more marathons and even ultra-marathons than many of his running peers.

Exercise excuse #7: I have kids to take care of

Hey, chances are your kids need to get more exercise, too. Make working out a family activity: walk together, bike together, play baseball together. Lots of activities now target moms with young kids—yoga classes for mom and baby, for example. An added benefit of making a point of exercising if you have kids is teaching them, by example, the importance of getting regular physical activity.

Excuse #8: I’m too fat

exercise excuse - overweight man exercising

Overweight and obese people benefit from exercise just like thinner people do.

No matter how overweight or obese you are, you will benefit from physical activity. A friend of mine who lost more than 200 pounds told me he started with a very modest goal. He parked his car at the far end of the parking lot so that he had to walk farther to get to his office. Over time, he gradually upped the ante. He eventually took up bicycle riding.

He is now a “century” bike rider. That means he does 100-mile bike rides. You don’t have to aim for 100-mile bike rides, but you should aim for increasing your activity until you have reached at least a half-hour of modest to vigorous physical activity per day.

Excuse #9: I’m thin already

Although exercise can help you maintain a healthy weight, everyone can benefit from increased physical activity. Go back up to Excuse #1 to see how.

Exercise excuse #10: I’m not a gym rat

Gyms are not just for folks with perfect bodies. In fact, many gyms now target people who are just starting to exercise or who are seriously out of shape.

If you decide to join a gym as your form of exercise, choose one that is convenient so you don’t waste a lot of time getting there. Also, be sure it has a good variety of equipment, including the type of equipment you like to use the most. And, if you like to take group classes, check out their offerings before signing up.

Further, you should take advantage of the gym’s trainers. They can show you how to do the exercise in a manner that promotes fitness and avoids injury. If gyms still aren’t your thing, then consider converting your guest room into a gym. We did that 25 years ago and now use that room more than any other in the house.

Excuse #11: I have cancer

An April 2020 article in The Scientist reviews the scientific evidence that shows that physical exercise may play a role in fighting cancer. It also improves treatment outcomes and the overall health of cancer patients.

Excuse #12: I have arthritis

Sorry folks, you can’t use this one either. The Arthritis Foundation encourages people with arthritis to get exercise, particularly walking and mind-body exercises such as tai chi, qigong, and yoga. 

Closing question about excuses for not exercising:

Did your favorite excuse make this list? If not, post it in the comments section. I’ll bet there is a way to debunk it too.


The original version of this post was published on 7/8/2016. It was reviewed and completely revised and updated by the author on 8/17/2017 and again on 5/7/2020.

The keto, or ketogenic, diet is growing in popularity. It focuses on eating almost no carbs. Instead, you replace your daily calories with fat and protein to encourage your body to enter a state called ketosis, where it starts to burn fat for energy.

While this sounds like the ideal weight loss plan, it can be challenging to understand or even to know where to start. What do you need to know about the keto diet before you decide to try it out?

1. It’s not something you can do casually

The keto diet requires a change in your mindset. The entire basis of keto is that you maintain perpetually low carb levels so that your body has no choice but to burn fat for energy. This, in turn, can help you lose weight as your body turns to your internal fat stores to keep you moving. It’s called a diet, but it’s more of a lifestyle change.

Your body converts carbohydrates into glycogen which is stored in your muscles. This is why athletes will eat a ton of carbs before running a marathon or playing a football game. The glycogen stores serve to fuel them during their match.

Without that extra glycogen from carbohydrates, your body still needs a source of energy — especially if you’re active or moving around a lot. Athletes are used to eating more than 200 grams of carbohydrates a day, but that’s many times the amount you’ll want to eat on the keto diet.

2. The basis of the keto diet

How do you get started with the keto diet?

The keto diet is a high-fat, low-carb, moderate-protein plan. You need to take your regular carbohydrate intake — which for most Americans is between 200 and 300 grams a day — and reduce that to 20-50 grams a day. To do that, you need to learn how to calculate your macros.

Macros are the three primary nutrition groups you’ll want to pay attention to — fats, carbs, and protein. Carbohydrates are the only macronutrient that isn’t necessary for survival. There are no essential carbs, which means you can reduce them dramatically while still maintaining a healthy diet.

Ideally, on the keto diet, you want to get between 60-75% of your calories from fat, 15-30% from protein and only 5-10% from carbs.

Tracking your macros can be difficult at first. You need to learn how to read labels to figure out what has a lot of carbs and what is suitable for your diet. You also need to learn how to calculate your net carbs. You can’t just count all the carbs you eat during the day. Instead, you take note of the total number of grams of digestible carbs that you eat. Then, you subtract the number of grams of indigestible fiber you consume. The result is your net carbs. 

All that’s left to do now is choose the right foods to help push your body toward ketosis.

3. Choosing the right foods

How do you reduce your regular carb intake while still enjoying the foods you love? Start paying attention to the carbs in everyday meals. Things like natural fats — butter, various oils — and meats have no carbs per 100 grams. Many kinds of cheese also have zero carbs – be sure to check the label. Eggs usually have one carb per 100 grams, and vegetables that are above ground have anywhere from one to five carbs.

On the other side of the spectrum, you’ll want to avoid things that have too many carbs. Pasta, bread and most sweets are anathemas on the keto diet. You can eat an entire day’s worth of carbohydrates in a single protein bar.

So what do you want to eat?  Eggs are an excellent option for the keto diet. Each egg contains 13 percent of your daily recommended protein intake, based on a 2,000-calorie diet, in addition to 5 grams of fat and tons of vitamins and minerals. In addition, lean proteins like chicken, turkey and red meats are low-carb options that can help you meet both your fat and protein macros for the day.

Don’t neglect your vegetables and fruits. Veggies that grow above ground have very few carbs per serving. Further, they are chock full of healthy fiber that helps reduce your daily net carb intake.

4. It’s not for everyone

While the keto diet can be a great way to lose weight, it’s not for everyone. Doctors don’t recommend this extremely low-carb diet for pregnant women or breastfeeding mothers.

Although many people with Type 2 diabetes become more sensitive to insulin on a ketogenic diet, particularly when they lose weight. Furthermore, diabetics on medications that lower blood glucose by increasing insulin levels (e.g, insulin, sulfonylureas, glinides) must monitor their sugars closely while on this diet because of the increase in insulin sensitivity. 

A study of the keto diet in mice found that this high-fat, low-carbohydrate diet could raise the risk for Type 2 diabetes in otherwise healthy individuals. It doesn’t allow the body to use insulin properly, which can, in turn, lead to insulin resistance. This adds one more note of caution related to keto diets and diabetes. 

Related content: Why All the Confusion About Healthy Diets?

Make sure you talk to your doctor before you make any major changes to your diet to make sure you’re healthy enough for this kind of lifestyle change. The goal is to get healthier, not make yourself sick trying to lose weight.

Take it slow and enjoy the results

Don’t try to cut your daily carb intake down to 5% in one shot. The most important thing you need to know when starting with the keto diet is to take it slow. Take time lowering your carbs until you reach your desired macros.

Don’t get discouraged — you will feel like crap as you work toward ketosis. They call it the “keto flu.” It’s the result of your body making the shift from burning glycogens to burning fat.

If you can keep your body in ketosis, it can be a fantastic tool to help you lose weight. Just be sure to talk to your doctor before making any major changes to your diet. If done properly, the keto lifestyle can be the health boost you need.

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When most adults think of exercise, it usually involves working out in a gym, going to a class or lifting weights at home. For kids, however, getting exercise means being physically active while playing and having fun. Children love outside activities like running around playing tag, jumping rope with their friends, and going for walks with their parents.

Today, children and teenagers are, unfortunately, spending more sedentary time indoors than ever before. And, most of this time is spent in front of a screen. This sedentary lifestyle may contribute to childhood obesity and other lifelong health issues. Helping children internalize the importance of physical activity as a path to lifelong health and fitness is extremely important.

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So, how do you make sure your child is spending a healthy amount of time outside being physically active? Below are some fun activities that both children and parents can enjoy together!

games children

This graphic is very clever but also a bit misleading. Most sources recommend having 10 instead of 9 squares in a game of hopscotch! (see below). Graphic source: Adobe Stock Photos


Children all over the world have played this simple game, or something very similar to it, for decades! To play this game, draw a traditional hopscotch diagram like the one shown below, using sidewalk chalk or washable paint.

Number the squares from one to ten. Throw a pebble, twig or bean bag into the Outside Activities for Childrenfirst square. If this lands on a line, or outside of the intended square, you lose your turn. If this happens, pass the marker to the next player. Hop on one foot into the first empty space, and then each next numbered space, making sure to skip the number that the marker is on. At the 4-5, 7-8 and 10 markers, jump with both of your feet! When you get to the end, head back toward the start, pick up the marker- still on one foot!- and complete the course.

If you finish the course without making any mistakes you pass the marker to the next player. On your next turn, throw the marker to the next number. If you fall, jump outside the lines, miss a square with the marker or skip a number, you lose your turn and must repeat the same number on your next turn. Whoever reaches 10 first, wins!

“Red Light, Green Light

With enough room, this is the perfect game to play outside. To play this game, pick one person to be the “traffic light” at one end of the playing field. All the other players are sent to the opposite end. The traffic light turns their back on the rest of the group. When they yell “RED light” everyone must freeze where they are. When “GREEN light” is yelled, everyone in the group runs as fast as they can to reach the end of the field, before the traffic light yells to stop again. If anyone is spotted moving after the red light is called, they are sent back to the starting place. The first person to tag the traffic light wins, and gets to be the next traffic light.

Dodge Ball

Any game that involves throwing a ball at opponents, and being the smart one by dodging incoming objects, certainly screams “Teenage fun!” The objective of this game is to eliminate all players on the opposite team by hitting them below the waist with the ball. If you are tagged, or if a ball you threw is caught, you are “out.” You are then are sent to the sidelines. You can also be tagged “out” when you step into a designated dead-zone. Or, if you step over the boundary line between the two teams. You win when all the opposite team members are eliminated. You can also win if you have more players than the opposing team at the end of a timed 2-minute game.

Freeze Tag

This is a variation of original Tag where if the person who is “it” tags you, you must freeze in place. Another participant can tag you to unfreeze you, but they do so at the risk of being tagged themselves! This game can be played for hours and everyone involved has a good chance of being “it” at least once.

Scavenger Hunts

You can find all sorts of backyard scavenger hunt checklists online. However, making your own has several benefits. If you create your own, you can customize it to your own backyard and make it so that all ages can play. You are teaching the children to be creative and learn how to problem-solve.

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Other simple and free ways to keep children active

  • Skipping rocks at a nearby lake or pond
  • Rolling down a grassy hill
  • Finding the perfect climbing tree
  • Swimming or just playing in the water
  • Jumping rope
  • Riding a bike
  • Studying the ecosystem under a stepping stone
  • Setting up the game of Twister outside
  • Having a contest to see who can Hula Hoop the longest
  • Checking out your local Frisbee park
  • Walking the dog or riding a horse
  • Hiking with parents or friends
  • Playing sports with friends (soccer, softball)

This list could go on and on. There are so many different ways for kids to be active while having fun.

Related stories: Why Recess is So Important for Children

At least an hour a day

In the United States, both the C.D.C. and the American Heart Association recommend that healthy children participate in at least an hour of vigorous activity every day, preferably outside.

This can work to prevent heart disease, cancer, chronic disease, and obesity. Getting your children to play outside isn’t just for fun, it’s good for their growing bodies and minds.

By encouraging your children to spend time outside every day, moving and staying active, you are cultivating a love of exercise that will hopefully carry them well into their teenage years, as well as into adulthood!

 For more helpful tips and ideas to get your children active, check out this Ultimate Guide to Exercise for Children in School and at Home from Maryville University.

This previously published post has been updated and reformatted for republication.


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Just because you’ve got your driver’s license doesn’t mean that you should forget about biking. Sure, there are scenarios where having a car does come in handy, but for everything else, cycling is the way to go.

After all, there are certain benefits of riding a bike that driving a car could never live up to – some are quite obvious, like the health benefits of biking, and others not so much.

Whether you’re looking to include some physical activity into your daily life, or want to do something good for the environment, this article will give you plenty of reasons why hopping on your bike could be the best thing you did in a while!

Health Benefits Of Biking: 5 Ways It Boosts Your Health

Your health comes first, which is why I wanted to start this article with a round-up of some of the most important health benefits you’ll experience as soon as you get in the habit of cycling instead of driving!

1. Cycling exercises the most important muscle – your heart

Photo Source: Pixabay

Sure, your thigh muscles and your glutes might be the first ones to come to mind.  But, when you think about getting a good workout, here’s the thing:

By getting your heart rate up cycling strengthens your heart muscles. It also reduces your risk of developing several cardiovascular diseases, including stroke, high blood pressure, and heart attack.

Moreover, compared to those who lead a sedentary lifestyle, those who participate in physical activities such as biking can experience an overall improvement in cardiovascular function, too.

And while I don’t recommend ditching your blood pressure meds just yet, there’s a reason to believe that including cycling into your daily routine might have a positive impact on your blood pressure. It can almost be as effective as prescription medication. If you’re a poor Paintballer like me, you may notice your bruises healing faster too!

In short, if you want to do something beneficial for your heart, ride your bike!

2. Your Risk Of Getting Cancer May Drop – Significantly

Besides the evident impact it has on your cardiovascular health, cycling also lowers your risk of cancer. Now, I know that might seem too good to be true. But the link between moderate levels of physical activity and cancer has been the subject of several studies, and so far, the results seem promising:

  • Incorporating physical activity, such as opting for riding a bike as a means of commuting, into a sedentary lifestyle, can reduce your risk of cancer significantly.
  • Moreover, according to a study that involved nearly 14,000 men, maintaining a higher level of physical activity as you approach middle age could potentially lower your risk of colorectal, prostate, as well as lung cancer. Furthermore, it can improve the survival rates of patients following a cancer diagnosis.

3. And The Same Goes For Your Risk Of Getting Diabetes

Type 2 diabetes has become a serious public health concern. Given that the two primary factors that help lower the risk of developing this condition are as simple as maintaining a “normal” weight and eating a healthy diet, seeing the rates continue to rise is quite shocking.

Considering the high number of diabetes-related complications, I don’t have to tell you how vital it is to keep this condition under control.

And, as a recent study suggests, cycling might be the way to lower glucose levels.  The study examined the link between commuting and recreational cycling habits and their risk of type 2 diabetes. They found a link does exist – the more time you spend cycling, the lower your risk of developing this disease.

4. You’ll Lose Weight – Without Even Trying

While the exact number might be hard to pinpoint, as it depends on a lot of factors, including your weight, speed, and resistance, to name a few, one thing’s certain:

Cycling burns a lot of calories!

Now, when I say „a lot,“ I mean something along the lines of 240 to 355 calories per half an hour of moderate-speed biking.

I’m stating the obvious here, but riding a bike involves a lot of pedaling.  The repetitive motion causes large muscles in the lower body to contract and expand continuously.  It makes it a perfect example of isotonic exercise.

Moreover, even though it seems like your lower body is doing all the work, your core, as well as your arms are engaged, too. This is especially true for all the adrenaline junkies who do trail-biking, but if you venture off the beaten road, get a mountain bike.

Photo Source: Pexels

5. Your Immune System Might Experience A Boost, Too

Last, but not least, there’s a reason to believe that all these health-promoting effects that cycling has on your body – such as preserving muscle mass, maintaining a healthy weight, and stable cholesterol levels – might have an „anti-aging“ effect on your immune system, too.

As we age, our thymus gland begins to shrink, which affects its capability to produce new T-cells, and, as a result, we become more susceptible to all sorts of new threats, including infections and immune disorders. By the time we reach the age of 65, we’re left pretty vulnerable.

That’s where cycling comes in:

New research shows that the thymuses of “senior” cyclists maintained their functionality, producing as many T-cells as the glands of much younger individuals. In short, thanks to cycling, these seniors had immune systems that could rival those of healthy 20-year-olds!

More Reasons Why Cycling Is Way Better Than Driving

Now, besides the apparent health benefits of biking, there are a few more reasons why choosing your bike over a car might be the best commuting-related decision you’ve made in a long time.

So, if improving your overall health isn’t a reason enough for you, let’s take a look at how biking can affect other aspects of your life, as well!

  1. Cycling can make you a better lover, because, as it turns out, being physically active can be almost as good of a cure for erectile dysfunction as Viagra. Plus, you’re going to feel much better about yourself, which will ultimately boost your self-esteem, too!
  2. It’s cheaper than driving a car, as any car owner out there can tell you. The costs keep piling up – maintenance, gas, insurance, registration, it all eats away at your budget. So, when you ditch that vehicle in favor of a bicycle, you’re doing your wallet a huge favor, too!
  3. You’ll be doing something highly beneficial for the environment, and at this day and age, we should all be looking into ways to “go green.“ Opting for a pollution-free means of transportation could be a simple, yet effective way for you to make a positive environmental impact!

That said, if you’re seriously thinking of retiring your car for good, you might want to look into electric bikes – because we all have days when we don’t feel like pedaling.

Pedaling Is The Way To Go

Before you ride off into the sunset, here’s what I’d like you to remember:

There is such thing as “too much of a good thing.”

Related Content:  The Health Benefits of Birding

It’s better to start small and give your body some time to adjust, especially if you haven’t been the most physically active person in the past. And don’t worry; you won’t miss out on any of the health benefits of biking if you choose to take it slow.

Oh, and one last thing:

Don’t let me catch you riding around without a helmet!


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A widely held belief is that we absolutely need carbohydrates for successful workout recovery. The reasoning behind this is that carbohydrates help replenish glycogen. They also spike insulin which supports muscle protein synthesis. If that is the case, does that mean that low carb diets like the keto diet are detrimental to workout success?

Why carbohydrates are recommended?

After a tough workout, your glycogen stores become depleted. In case you are not familiar: glycogen is carbohydrate stored in muscle tissue. It fuels much of your workouts.

Traditional sports nutrition advice says we need to replenish that lost glycogen as soon as possible. Failing to do so is bound to slow down your recovery.

More specifically, taking carbohydrates within a couple of hours after vigorous training is believed to:

  • Replenish muscle glycogen
  • Spike insulin which is an important anabolic hormone
  • Increase water content within muscle tissue
  • Lower levels of cortisol, a catabolic hormone

However, many of these claims are now being questioned. And some are really not all important for the average person.


If you’re someone who works out three times a week, for example, there’s no need for you to speed up the rate at which your muscle glycogen gets replenished. As long as you’re eating some carbohydrates, your glycogen stores will get back to normal within two days.

Besides that, studies have found that protein, especially the amino acid leucine, spike insulin just as much as carbohydrates. Studies also found that taking carbs together with protein was no more effective than a placebo when it comes to workout recovery.

The keto diet and workout recovery

The ketogenic (keto) diet is controversial in regard to sports nutrition. Because carbs are considered essential for performance and post-workout recovery, a diet deficient in carbs seems like a recipe for disaster. But the human body is complex and able to adapt to things we think impossible.

So, what does the science say about keto diets
and workout recovery?

Dr. Jeff Volek, a renowned low-carb researcher led a study that was published in a 2016 issue of Metabolism. The study revealed that 10 ultra-endurance athletes who had been following a keto diet for at least 6 months showed a higher fat oxidation rate and a lower carbohydrate oxidation rate during exercise. They also showed similar muscle glycogen levels at rest as the control group.

The study also found that glycogen levels recovered at the same rate in the keto group as well as the control group. This was despite the fact that the keto group consumed a diet containing 5% carbohydrates while the control group diet had 50% carbohydrates.

This study concluded that endurance athletes could maintain normal muscle glycogen content, utilization, and recovery after long-term adaptation to a ketogenic diet.

This study shows that adapting to a low-carb diet like keto makes the body use fat for energy during workouts while sparing muscle glycogen. With less glycogen lost, you need fewer carbs to recover. However, it takes several months to truly adapt to low-carb diets, so performance and recovery may suffer in the meantime. This has been confirmed by short-term studies.

Another thing to keep in mind is that ketosis, which is the primary goal of the ketogenic diet, is not the end goal of this diet. Instead, it is keto-adaptation (after long-term ketosis) that matters, especially for athletic types. 

Some limitations of the keto diet

There is a caveat to using keto for workouts. Researchers agree that workouts that heavily rely on anaerobic metabolisms, like strength training, will not work on a fat-fueled diet. That’s because ketones and fat cannot be metabolized anaerobically.

But this may apply only to athletes. Common folk may actually do quite well on a low-carb diet where strength training and other anaerobic-heavy workouts are concerned.

A study published in Nutrition & Metabolism found that the keto diet combined with resistance training reduces body fat without affecting muscle mass in untrained overweight women. So, there was no major impairment.

Central Fatigue

Another problem with the keto diet when it comes to workout recovery is how it affects central fatigue, meaning feelings of tiredness caused by changes in brain chemicals.

There’s evidence that when you’re burning more fat, the brain takes up more tryptophan – a precursor to the production of the feel-good neurotransmitter serotonin, which makes you feel tired.

Eating too much protein on this diet, which isn’t uncommon in people who regularly exercise, can also lead to elevated ammonia production during workouts. Ammonia alters energy metabolism in the brain and also communication between nerve cells, all of which leads to feelings of fatigue.

However, most of this evidence is based on short-term research, and longer studies on keto-adapted subjects are needed to check if keto truly does make you feel tired after workouts.

What else you need to consider

A major benefit of the keto diet is that it enhances fat burning. Most people follow this diet for this very reason. Even athletes may use it to shed pounds before major events.

What’s best about keto is that it is proven to burn fat while sparing muscle – something not found with most other weight-loss programs. The keto diet also does not affect resting metabolic rate (RMR) even after it leads to major weight loss.

And while you can definitely use this diet to burn fat, there are things you need to consider if you’re someone who’s an athlete or very active:

1. Increasing sodium intake

Another pioneering expert in keto sports nutrition, Dr. Stephen Phinney, recommends consuming more sodium on a keto diet. Between 3,000 and 5,000 mg of this important electrolyte is necessary to maintain normal metabolism and hydration levels, especially if you’re athletic. Besides sodium, Dr. Phinney recommends consuming 3,000 to 4,000 mg of potassium and 300-500mg of magnesium.

2. Carb cycling

The cyclical ketogenic diet (CKD) involves cycling between the standard keto diet and a high-carb diet. Usually, dieters will eat low-carb for 5-6 days of the week and do a carb refeed on days 6 and/or 7.

On carb-refeed days, you will be temporarily kicked out of ketosis. This helps restore muscle glycogen to greater levels than you could achieve by maintaining ketosis. This approach seems to work better for athletes than standard keto.

3. Targeting carb intake

Another option is to target your carbohydrate intake around your workouts. This is called the targeted ketogenic (TKD). This nutritional approach was developed to help athletic types fuel their workouts and improve post-exercise recovery.

If you’re someone who takes part in vigorous anaerobic activity, this method may be best for you.


Post-workout recovery is an essential aspect of all types of training. Resting is one part of the process, proper nutrition is another.

Usually, you will hear that carbohydrates are essential for proper workout recovery. And, that low-carb diets like keto cannot help with this process. However, this is simply not true.

The keto diet does not impair post-workout recovery in most cases. But it isn’t perfect, and whether you should consider it for your exercise regime boils down to personal choice. The reason? We don’t know everything about sports nutrition.   

So the question of whether carbs are necessary for
workout recovery or if ketones can suffice remains open.

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What You Need to Know About the Keto Diet

I doubt anyone would argue with me if I were to say that exercise is one of the most beneficial things you can do to improve your overall quality of life. Not only does it give you more energy and a stronger, healthier body, it also helps with your mental state.

Together, these positive influences can go a long way in affecting other aspects of your life, such as your social interactions. To put it simply, there’s an abundance of reasons why you should start exercising if you’re not already, and really, there’s no reason not to.

Good Pain

Now that we’ve got that established, it’s important to understand the risks of exercise.  More specifically, the significant risk of a specific phrase which we’ve all heard before, and that is, ‘no pain, no gain.’

Although it’s not inherently wrong—in fact, it has an element of truth to it—the issue with this statement is that most people, especially those starting out in fitness, don’t really know what the ‘pain’ part is referring to.  

Surely, pain is a bad thing? We’ve lived our whole lives avoiding it! Well, yes and no; to an extent, this line of thinking is actually correct and the very reason I dislike the expression, ‘no pain, no gain’— it’s vague.

Some discomfort is part and parcel of a good workout. The body is an efficient machine.  So if we didn’t place any stress on the muscles, they wouldn’t grow.   Sol, why waste energy building something up which isn’t needed? There would be neither weight loss nor strength gain. So feeling mild discomfort when exercising is exactly what we want and could be termed ‘good pain’.

What Causes Good Pain?

Aerobic vs. anaerobic respiration

In order to contract the muscles, the body, of course, needs energy. This is generated via the breakdown of glucose (a sugar molecule) in a process which, under normal conditions, requires oxygen and is hence termed aerobic respiration.

However, during particularly intensive bouts of exercise, there may be insufficient amounts of oxygen for the increased energy requirements of the body, and so an alternate method is utilised—anaerobic respiration.

While this pathway does indeed provide you with the necessary energy for those last few reps or that last half mile, it also results in an uncomfortable buildup of lactic acid. It’s the cause of what people mean when they talk about how you should ‘feel the burn’ when working out.

Fortunately, the discomfort caused by lactic acid build-up is short-lived and should usually go away soon after finishing your exercise, when the body goes back to using oxygen to break down glucose.

Better still is the fact that the more you exercise, the more efficient your lactic acid clearance will get. In other words, as you get fitter, your lactate threshold (essentially the point beyond which lactic acid begins to build up) will also increase.   The burning sensation will begin much later on in your exercise. When it does occur, you’ll also be able to withstand it for longer.

Delayed onset muscle soreness

So that’s ‘good pain’ during the workout itself. But what about the ache you sometimes feel in your muscles a day or two after a session? Usually, that’s also fine.

This pain, known as delayed onset muscle soreness (DOMS), will generally happen to you for one of two reasons. First, you’ve recently started exercising again after a long period of inactivity, or second, you’ve incorporated a new activity into your routine. DOMS comes about as a result of numerous microscopic tears in the muscles which occur during the eccentric (lengthening) portion of an exercise, such as running downhill or crouching down for a squat.

Fortunately, the DOMS should ease off over the next few days, but to speed up the process, you should go ahead and do some light exercise, such as taking a walk or going for a swim. It’s important that it is just light exercise, though. Anything more intense could lead to further damage in the muscles, prolonging the soreness, and in extreme scenarios can even lead to permanent muscular damage. Don’t worry, though, this is very rare.

Bad Pain

Without fail, this ‘good pain’ can quickly take a nasty turn if you’re not careful. Drs Edward McFarland and Andrew Cosgarea of Johns Hopkins Medicine say ‘bad pain’ occurs when the muscles, tendons, ligaments, cartilage, or bones in the body are exposed to excessive amounts of stress.

In some cases, these stresses might happen during a short period, such as a single workout. For example, trying to lift too much weight with the incorrect form might leave you with an aching back for days, weeks, months, or even years. Trust me, I’ve been there.

In other cases, the excess strain placed on the body is a result of an accumulation of stresses over time, i.e. exercising over and over again without giving your body time to recuperate. Despite what many gym enthusiasts swear by, overtraining does exist and can have some serious physiological and even psychological repercussions.

Related Content: Pain in the Hamstring? Here’s What You Need to Know

How to Recognise and Avoid Bad Pain?

Unfortunately, there really isn’t a single, sure-fire way to confirm whether what you’re feeling is ‘good pain’ or something more serious.

Training regularly will help you learn about your body and enable you to distinguish real injury from harmless, short-term discomfort. That doesn’t really help you if you’re just starting out though.

So, for beginners, it’s recommended to start out slowly and gradually increase the intensity of the exercises as you progress. A good rule of thumb is that a slight burn that goes away a while after the muscles stop working is probably perfectly fine. A lingering ache is a sign that you’ve overdone it and you should immediately stop what you’re doing to prevent worsening the injury.

Another thing to bear in mind is that ‘good pain’ should never affect your joints. If you’re jogging, for example, and feel pain in your knees, don’t push through it. It’s better to cut your run short and be fit enough to run again the next day rather than to keep running and spend the next two weeks healing.

Treating Bad Pain

Luckily, most injuries arising from exercise aren’t severe and should heal fully without the use of any special methods. The first and most important thing to do is cut back on the exercise for a while.

Depending on the severity of the injury, this could simply mean decreasing the intensity or even stopping altogether. Note that this doesn’t mean you should resign yourself to the way of the couch potato for the next few days.

On the contrary, keeping the blood flowing to an injury by moving and stretching it helps speed up the healing process. In the case of a hurt joint, movement prevents it from stiffening up.

Another thing you could do is apply ice—for how long and how often depends on the injury. However, about 15 minutes repeated every hour for a day or so is common practice. With all that said, these are just loose guidelines and tips. It’s vital that you seek out professional help if you feel like what you’re experiencing isn’t normal. There’s no substitute for a professional’s advice.

Related Article:  5 Natural Ways to Speed Up Muscle Recovery After a Workout

Final Thoughts

Ultimately, ‘good’ and ‘bad’ pain are two sides of the same coin. Differentiating between them, however, can be easier said than done.

My advice to you, at the risk of sounding cliché, is to remember that exercise isn’t a competition. It is a way for you to get healthier and happier with your life. Don’t fall victim to your ego and keep pressing on with an exercise that’s causing you pain.

The reason you’re exercising in the first place is to get healthier, after all. If you’re suffering; stop, rest, and start again on another day. Eventually, you’ll learn what your body can handle and how to avoid hurting yourself, but this takes time, so meanwhile take it slow, don’t rush it, and just enjoy yourself!