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Play It All

How To Keep Your Child On The Field And Out Of The PT Clinic

Taylor was recently referred to physical therapy with a painful shoulder and a right hand that frequently went numb. For the last five years, she had been a year round participant in softball. At the age of fifteen, she was missing out on softball and a good night sleep secondary to the pain and limited function in her right arm.

Andy played soccer, and at the age of thirteen, he developed knee pain that prevented him from changing directions and sprinting. Andy practiced or played soccer four days a week for 50 of the 52 weeks in a year. It took four years of year round soccer to create the knee damage that required surgery and an twelve week rehab.

Many of the young athletes we treat in physical therapy are the victims of over exposure to the same training stimulus for far too long a period of time. Gymnastics, dancing, baseball, soccer, and softball are worthwhile endeavors, but a developing body needs a break in order to stay healthy. This becomes even more important as the athlete becomes stronger or more skilled.

Take a moment and read the *article by Jane Brody in the May 7th, 2018 edition of the New York Times. Jane interviews several Orthopedic Surgeons that are treating younger patients with injuries that usually occur ten or fifteen years later in an athlete’s career. The research they present is clear; year round single sports participation is not the best way to excel in athletics or remain healthy.

The recent popularity of the club system has children playing the same sport year round. In the clinic, we are treating more young athletes with old person overuse injuries. Participation in a variety of athletic activities is infinitely more beneficial and safer than single sports specialization. It is no coincidence that most successful collegiate and professional athletes are the product of multi-sport participation.

*New York Times, Jane Brody, May 7, 2018, How to Avoid Burnout in Youth Sports. View article: https://www.nytimes.com/2018/05/07/well/how-to-avoid-burnout-in-youth-sports.html

Michael S. O’Hara, PT, OCS, CSCS

 

 

100 Steps Per Minute

Step Cadence and Fitness

Exercise researchers have been studying gait cadence for years.  A cadence of 80 steps a minute is a stroll.  100 steps a minute is considered a brisk walk.  At 130-140 steps a minute, you move into jog or slow run.  Recent high tech evaluations of gait cadence has been able to predict the onset of dementia in older people.  For many people, walking is their primary form of exercise.  Gretchen Reynolds has written an excellent *article on the walking cadence that produces optimal health benefits.

A compilation of many studies has found that 100 steps per minute is the sweet spot for walkers under the age of sixty.  The data for older walkers has yet to be fully evaluated, but it appears a slightly slower cadence is a good goal.

I like evaluations of performance.  Evaluations tell you if you are getting better or getting worse.  The human body is in a constant state of adaptation and never stays the same.  Keep track of your cadence by counting your steps for twenty seconds and then multiplying by four.  Use that information to track your fitness level.  Ideally it should get easier to walk, at faster pace over a greater period of time.

15 x 4 = 60 Pokey Joe.

20 x 4 = 80 Still too slow.

25 x 4 = 100 Good job.

Michael S. O’Hara, PT, OCS, CSCS

*Walk Briskly for Your Health.  About 100 Steps a Minute, Gretchen Reynolds, New York Times, June 27, 2018

View: https://www.nytimes.com/2018/06/27/well/walk-health-exercise-steps.html

You Have A Social Media Disease

There Is No App for Thumb Pain

Your thumb is made up of an intricate system of tendons that enable very precise movement.  The joints of a thumb are fairly small and yet we are able to produce an amazing amount of force with this single digit.  In this age of all things digital, the modern American thumb has been subjected to greater workloads.  Problems with thumb pain, numbness, and limited function are becoming more common complaints in physical therapy.  I have some suggestions on how to manage pain and limit the damage and embarrassment of excessive social media thumb exposures.

Thumb Tendon Troubles

Dr. De Quervain was the first to clinically described thumb tendonopathy, and we call thumb tedonosis De Quervain Syndrome.   The test for De Quervain Syndrome was created by a clinician with an equally odd name and it is called the Finkelstein test.  Place your thumb in the palm of your hand.  Make a fist with the finger around the thumb.  Hold the wrist in neutral and then deviate the wrist toward the pinkie finger.  If you feel pain it is a positive Finkelstein test.

Resolution of thumb tendonopathy pain happens quickly when you give in to the symptoms of pain and modify your activities.  Rest the thumb tendons by using your fingers instead of your thumb on that smart phone.  Avoid fitness activities that put stress on the thumb.  Lifting in front of the body with the palms facing inward is often the lift that new mothers perform and develop painful thumb tendons.  Early on in the pain onset, icing is often helpful.  In physical therapy, we are successful with soft tissue mobilization, ultrasound, and manual therapy.  A gauntlet type thumb splint you wear at night is an unattractive but provides aviable position of rest for severely aggravated thumb tendons.

The Numb Thumb

Irritation of the median nerve in the carpal tunnel of the wrist will create thumb, second, and third finger numbness and pain.  An injury of the recurrent median nerve in the front of the palm will produce numbness in the thumb and limited strength during thumb opposition–thumb to pinkie finger.  Patients with neural irritation often develop numbness, weakness, and then pain.  The pain often wakes them from sleep and disrupts hand function.

Once again, you will resolve a numb thumb with rest.  Once neural irritation gets fired up, it takes longer to resolve than an aggravated tendon.  Giving in to the numbness and resting the hands will produce better results if you start early.  Two weeks of avoiding the aggravating hand activity produces good results.  Night splints for the wrist and thumb are often helpful.  A carpal tunnel release is a common surgical alternative that takes pressure off the median nerve.

Gumbie Thumb Beware

Every joint has a certain degree of stability and certain degree of mobility.  Our spine, knees, hips, shoulders, and elbows must move enough to produce motion but not so much that they fall apart.  The amount of movement in our joints is largely an inherited characteristic–you can blame Mom and Dad.  The person at the extreme end of the scale (“double jointed”) needs to take certain precautions with their thumbs.

The Beighton Score is a popular screening technique for joint hypermobility.  It has been around for thirty years and is used in research all around the world.  The scoring is based on eight passive range of motion assessments and one active range of motion assessment.  One point is assigned for each of the following.

A pinkie finger that can be passively bent backward more than 90 degrees.

A thumb that can be pulled down to the front of the forearm.

Elbows that passively hyperextend to 10 degrees.

Knees that passively hyperextend to 10 degrees.

The subject can place the palms on the floor during a straight leg, forward bend.

Researchers disagree on the score that should be a threshold for concern about systemic joint hypermobility.  I have found that fitness clients and physical therapy patients that score a 5/9 or higher require modification of their training programs.  It is not uncommon to encounter physical therapy patients that have a Beighton Score of 9/9.  Hypermobile individuals need to take more precautions when they perform repetitive tasks such as texting on a smart phone.

Kimberly Salt wrote an excellent article on social media induced thumb pain in the May 19, 2018 issue of the New York Times.  Take a minute and read, Me and My Numb Thumb: A Tale of Tech, Texts and Tendons.

Michael S. O’Hara, PT, OCS, CSCS

Lumbar Spine Fitness Guidelines

Janet injured her lower back while exercising in her local gym.  She was taking a trip through her favorite “ab ciruit” when she felt a snap in her lumbar spine.  The next day she was unable to stand up straight.  Two weeks later, we met her in physical therapy for her initial evaluation.  She was ready to return to her fitness program three weeks later.  Janet was very concerned she may suffer another exercise induced back injury and requested some advice.  These are the simple guidelines I give to physical therapy low back patients returning to exercise.

Mobilize the Thoracic Spine and Hips

Movement is supposed to happen at the thoracic spine and hips.  Unfortunately, prolonged sitting, deconditioning, and poor training choices tends to restrict mobility in these areas.  If you are unable to rotate and extend at the hips and thoracic spine, your brain will use other joints to make up for the deficit.  Pushing extra rotation and extension forces into your lumbar spine is never a good thing.  Dedicate some training time to improving thoracic spine rotation and hip extension / internal rotation range of motion.  If you sit for a living, work on your mobility everyday.

Make the Lumbar Spine Stable

Most fitness clients believe that more lumbar spine movement is a good thing.  They perform toe touches, back twists, and the many breeds of up and down dogs.  Unfortunately, greater lumbar spine range of motion is positively correlated with a higher incidence of lower back pain.  The incidence of low back pain escalates even further when we move those hypermobile lumbar spine segments against a resistance.  What does keep lumbar spines healthy is high level of lumbar spine strength endurance.  Can you hold the lumbar spine stable and prevent movement from occurring at the pelvis and five lumbar vertebrae.  Your lumbar spine stays happy and healthy when you focus training efforts on planks, roll outs, crawls, carries, and Pallof press exercises.  Avoid the sit ups, crunches, sidebends, toes to bar, and other assorted “ab” exercises that create lots lumbar spine motion.

Avoid Muscle Isolation Exercise Activities

The muscles that support the lumbar spine work together as part of a neurally connected team.  Training activities that support better communication between the team members will create optimal performance.  The neuroanatomy saying is “What fires together, wires together”.  Ditch the “upper abs”, “lower abs” baloney and sprint away from anyone who trys to strap you into a machine in an effort to “isolate your obliques”.

On her discharge from therapy, Janet was unable to perform a single roll out and fatigue fairly quickly with a twelve pound suitcase carry.  For the last three months, she has followed the guidelines and her progress has been excellent.   Janet is currently performing a suitcase carry with fifty pounds and has worked up to ten full reps on an ab wheel roll out.

Michael S. O’Hara, PT, OCS, CSCS

The Cumulative Effect of Activity

Many people are put off from starting an exercise routine because they are overwhelmed by the time commitment they feel is necessary.  Fitness magazines, exercise experts, and everything on youtube preaches–

–30 minutes of cardio three times a week

–45 minutes of strength training twice a week

–150 minutes of exercise per week

Most of this well-intentioned advice is wrong.  Nearly everyone can derive significant benefit from short bouts of fitness activity that are performed on a consistent basis.  Walk for five minutes twice a day.  A simple routine of two strengthening exercises will take no more than five minutes.  Climb the stairs in your home three times once a day.  Practice getting up and down of the floor.  Stay consistent with a routine of short exercise bouts and you will be healthier and stay independent for a lifetime.

More research has demonstrated the beneficial effect of short exercise sessions interspersed throughout the day.  Read the March 28, 2018, New York Times article by Gretchen Reynolds, Those 2-Minute Walk Breaks?  They Add Up.  View the article: https://www.nytimes.com/2018/03/28/well/move/walking-exercise-minutes-death-longevity.html

Mike O’Hara, PT, OCS, CSCS

Triathlon Success: Hamstring And Glute Togetherness

To keep a triathlete healthy and resilient, the hamstrings and gluteal muscles must work together as a team.   The athlete fires the gluteals and hamstrings simultaneously to stabilize the pelvis and produce force through the lower leg.  When you run, bicycle, or swim, these muscles work at a team to produce efficient propulsion and reduce stress on the lumbar spine and knee.  A triathalon is the ultimate long duration physical endeavor.  Triathletes need hamstrings and gluteal muscles that can stay on and strong for a long time.

Most fitness programs do not properly train the muscle of the posterior chain.  Fitness center exercise generally involves training the hamstrings as knee flexors on some type of “leg curl” machine.  Gluteal training rarely occurs past neutral hip extension, with little effort on improving overall hip range of motion.  Any type of seated gluteal training is inappropriate for an athlete.

The term physical therapists and strength coaches use for butt muscles that are non- responsive is “gluteal amnesia”.  Our sedentary lifestyle involves very little of the glute recruiting sprinting, deep squatting, and climbing that activates the gluteal muscles.  We mistreat our gluteal muscles with hours of compressive sitting and little in the way of full range hip movement.  Many fitness clients and most physical therapy patients need some remedial gluteal training.  Give these three drills a place in your triathalon training program.

Single Leg Bridges

Lay supine with the arms braced against the floor to stabilize the upper body.   Bend the knees and place the feet flat on the ground.  Lift the right leg up off the ground.  Using the muscles in the back of the left leg, lift the hips up off the ground.  Push up through the heel of the left foot and drive the left hip into full extension.  Hold at the top for three seconds and then lower in a controlled manner.  Perform ten repetitions on each leg.  Common mistakes are allowing the pelvis to tilt and not fully extending the hip.  Hamstring cramping is an indication that you are not using the glutes enough and need to focus on creating a better mind to butt connection.

Goblet Squat

The squat movement pattern is a skill that is easier to teach if you add some load.  You can use either a dumbbell or a kettlebell for this exercise.  It has been my experience that the exercise is easier to learn with a kettlebell.  Hold a kettlebell by the horns, with the elbows down, and the kettlebell close to the chest.  Keep the chest proud and pull the abdominal muscles tight.  You may have to experiment with foot placement as everyone has different hips.  The position you would place the feet if you were going to jump is a good starting point.  Initiate the squat by pushing back the hips.  Keep the torso tall and descend.  Let your pelvis fall between the hips. The elbow should drop down between the knees.  Nothing will inhibit your progress more than thinking about how you are moving during goblet squats.  Keep your brain quiet and get in some repetitions.  Effort has amazing capacity to improve motor control.   Perform ten repetitions.

Mini Band Monster Walk

Your will need a mini resistance band–a nine inch loop of resistance band, (two dollars from performbetter.com).  Most fitness clients will do well with a green or yellow mini band.  Place the mini band loop around both legs just above the ankles.  Assume an athletic stance with the feet straight ahead, knees bent, and hips flexed.  The band should be held taught throughout the exercise.  Imagine your feet are standing on railroad tracks.  Walk forward for ten steps on each side, keeping the feet over the railroad tracks.  Walk backward for five repetitions on each leg.  Try to keep the hips and shoulders level throughout the exercise.

Once you have mastered all three exercises, build your gluteal and hamstring performance by traveling through the program for two or three trips.

  1. single leg bridges  R and L x 10
  2. goblet squats x 10
  3. mini band monster walk x 10 each leg

View video of the exercises here: https://youtu.be/QeteeLPF4AU

Kat Wood, DPT, ATC

Triathlon Success: Core Connection

In the fitness world core stability training has gained a solid foothold and more people are getting away from spinal damaging resisted twisting machines and the ever present sit up gizmo.  Most people know how to perform a “plank” exercise and have added this drill to their fitness routines.  Learning how to properly brace the core stabilizers and perform a sustained plank type isometric exercise will resolve back pain, improve the hip to shoulder girdle connection, and make you a better movement machine.  The problem is most people never advance beyond the basic plank exercise.  Triathletes need significant anti-rotation and anti-extension core strength and endurance.  I have three drills that will help keep you strong and resilient in your quest to complete you first tri.    Read the directions and give these activities a place in your fitness program.

Alternate Single Arm Planks

Position the body in a toes and elbows plank, but separate the legs so the feet are wider than the shoulders.  Lift one arm up at a 45 degree angle in relation to your body and hold for five seconds.  Lower the arm back down and try the other arm.

If you are unable to perform the alternate arm plank on the floor, regress the exercise by placing the hands on a bench in a push ups position.  Lift one arm up at a 45 degree angle in relation to your body and hold for five seconds.  Lower the arm back down and try the other arm.  How many and much?  Perform three to five repetitions on each arm.  Work up to longer hold times instead of more repetitions.  Five repetitions on each arm with a ten second hold is a good goal.

Pallof Press

You need a cable machine or resistance tubing set at mid torso level.   Position your body at a 90 degree angle in relation to the pull of the cable.  Assume an athletic posture with the feet at least shoulder width apart and the spine neutral.  Push the hips back a little and keep a slight bend in the ankles and knees.  You should look like a tennis player preparing to return an opponent’s serve.  Use a strong overlap grip on the handle and set the hands in the middle of the chest.  Brace the midsection and hips and move the handle out in front of the body and then back to the chest.  Select a resistance level that permits execution of all repetitions without losing the set up posture.  If one side is more difficult, start the exercise on that side.  Perform fifteen repetitions on each side.

Many of us have terrible respiratory patterns.  We are unable to fully inhale and exhale when under any physical stress.  The Pallof Press can be used to improve respiratory control.  Use the same set up and press the cable out.  Hold the cable with the arm fully extended while inhaling for four seconds and exhaling for six seconds.  Bring the arms back in and then repeat.  Perform four of five inhale / exhale respiration repetitions on each side.

View the video here: View Video

 Michael S. O’Hara, PT, OCS, CSCS

World’s Best Diet Part 9–Fasting

If you google the word diet, you will come up with over 200,000 results.  Every week, month, year, and decade a new study or article comes out claiming certain foods are killing us, or that some other food or nutritional approach will lead us to the promised land.  Unfortunately, articles are written to create traffic, so scientific research is often misreported or spun to sell magazines or generate website traffic.  The truth is, there are many ways to skin a cat.  All of the evidence on nutrition (in regards to weight loss) points to two undeniable truths.  First, that dietary adherence is king.  It doesn’t matter how perfect or evidence based a nutrition plan is, if you can’t follow it, it doesn’t matter.  Before starting any eating plan, you must ask yourself how easy it will be to maintain long term.  Second, you must achieve an energy deficit to lose weight (eat less energy than you expend each day).  Though “calories in, calories out” may be slightly over simplified, it is still the underlying rule to any weight loss success.   For any weight loss plan to work, you must consistently follow the pla, and you must be in a caloric deficit.  This series will highlight the nine most popular current nutrition approaches, and the pros and cons of each.

Fasting

Claims: There are a ton of different approaches to fasting.  The most common are ADF (alternate day fasting) and IF (intermittent fasting).  ADF simply means that one day you eat nothing, followed by a day of standard eating.  IF is a restricted eating format where you don’t eat for a given period of time (16 hours being the most popular) followed by a feeding window where you eat regularly (8 hours in the 16 hour example above).  Every person fasts when they sleep by default, the various fasting protocols simply extend this fast one way or the other.  Purported benefits include improved insulin sensitivity, improved heart health, weight loss, better brain function, and some eve claim better performance.

Reality:  There is nothing magical about fasting.  When calories are controlled for fasting protocols seem to offer many of the health benefits that other diets show (improved heart health, improved insulin sensitivity, weight loss, etc.).  One unique potential benefit is that of life extension.  Several animal studies have shown this to be the case, but more research is needed.

Pros:No off limit foods.  Even without tracking food directly many people will eat less food by reducing the window of time in which they eat food.  This is probably one of the simplest plans to follow in concept.  If you can tell the time you can follow this plan.

Cons: No emphasis on food quality, or protein intake.  May not get enough vitamins and minerals in if you aren’t sure to emphasize getting a large amount of whole and unprocessed foods since you aren’t eating on a daily basis.  May be harder to maintain muscle mass (though research hasn’t shown this yet).  Could lead to binge eating behaviors during the feeding window in some individuals.  If this is you, this plan is not right for you.

Jeff Tirrell, CSCS, CFSC, Pn1

Triathlon Success: Hip Flexor Function

Two of the most important muscles for efficient running and a pain free set of knees are not visible in the mirror.  Most people have never heard the names of these muscles.  Located deep inside the body, covered by innards and all too often, layers of mesenteric fat, these muscles labor unloved and forgotten.  Triathletes interested in optimal performance and a body that remains injury free should give some attention to the iliacus and psoas muscles.

Anatomy

Five muscles flex the hip–bring your femur forward.  Three of the hip flexors attach to the front of your pelvis and run down the front and sides of your thigh.  They are the sartorius, tensor fascia latae, and the rectus femoris.  Two of the muscles attach to your spine and posterior pelvis and travel across all of the lumbar vertebrae, the sacroiliac joint, and the front of the hip joint.  They are the iliacus and psoas muscles.  The sartorius, tensor fascia latae, and the rectus femoris can lift your femur to parallel, 90 degrees hip flexion, and no further.  The iliacus and psoas are responsible for lifting the hip above parallel.  Many people have very weak iliacus and psoas muscles and are unable to flex the hip above 90 degrees.

Multi Joint Control

“Hip flexor” is a very simplistic description of the function of the iliacus and psoas muscles.  The iliacus and psoas flex the hip, but they also rotate the hip, stabilize the pelvic girdle / lumbar spine, decelerate hip extension and co-contract with a team of muscles to hold us upright.  Properly functioning iliacus and psoas muscles keep the pelvis stable when you walk or run and this mitigates stress on the knees and lower back.  When the iliacus and psoas muscles are weak, the pelvis tilts forward and backward.  This rotates the femur in and out and twists the knee.  Your knee joint likes to bend back and forth and dislikes any extra rotation.  Extra knee rotation wears out the back of the kneecap (patella) and places stress on the supportive cartilage (medial and lateral meniscus) of the knee.  A triathlete with a wobbly pelvis places significantly more stress on their lumbar spine.

Triathalon Considerations

Riding a bike shortens and neurologically anesthetizes the iliacus and psoas muscles.  A tight psoas muscle compresses the lumbar vertebrae together and increases pressure in the lumbar discs.  Athletes with “quad strains” often have pain in the sartorius and rectus femoris muscles that has been brought on by overuse of these muscle as they compensate for a weak iliacus and psoas muscles.  Tight and inhibited iliacus and psoas muscles are responsible for the wobbly gait pattern you frequently see as the triathlete transitions from the bike to the run.  Two drills that will improve the function of the iliacus and psoas muscles are listed below.  Read the directions and watch the video.

Standing Hip Flexor Isometric

The Standing Hip Flexor Isometric drill functions as both an evaluation and a method of restoring iliacus and psoas function.  If you struggle with this exercise, you need to spend some time and effort on improving the performance of your iliacus and psoas.  Listed below is a description of the exercise and several activity regressions and progressions.

You need a box or exercise bench.  The taller you are, the higher the bench.  Six feet tall, try a bench that is 24 inches high.  Five foot, four inches, try a twelve inch box.  A mirror for visual feedback is helpful.  Stand with the right foot on the bench and the left foot on the floor.  Hold a pvc pipe, broomstick, or golf club overhead.  Brace the abdominal muscles to keep a tall spinal position and tight lordosis (inward curve) in your lower back.  Lift the right foot off the bench by pulling the thigh up with the muscles in front of the hip.  Hold the foot off the bench in a solid and stable position for five seconds and then lower.  Do not let the position of the spine change.  Do not bend the left knee or tilt the pelvis.  The only joint that moves is the right hip.  Athletes should be able to lift and hold the right knee 30 degrees above waist level.  Start with sets of three repetitions and alternate sides.  As you get stronger, increase the duration that you hold the foot up to ten  seconds.  If one side is weaker than the other, perform more repetitions or an extra set on that side.

Bench Assisted Hip Flexor Stretch

This drill will improve hip extension range of motion and enhance mobility in all of the hip flexor muscles.  Bicyclists often have very flexed lumbar spines and limited lumbar and/or hip extension.  This mobility exercise is the antidote for the physical restrictions created by too much time in the saddle.

You will need an exercise bench or a padded chair that is 12 to 16 inches tall.  Place a cushion or Airex pad directly in front of the bench.  Set up with the left foot on the floor in front of the Airex pad and aligned with the left hip.  Place the right knee on the Airex pad and the front of the right foot up on the bench.  Stay tall through the spine and hold the position for twenty to thirty seconds.  For many people this will be enough stretch.  If you are able take the arms overhead.  Work further into the movement by bending the front knee and moving forward.  Repeat on the other side.

Video of these exercises can be found here: View Video

 Michael S. O’Hara, PT, OCS, CSCS

World’s Best Diet Part 8–The Mediterranean Diet

If you google the word diet, you will come up with over 200,000 results.  Every week, month, year, and decade a new study or article comes out claiming certain foods are killing us, or that some other food or nutritional approach will lead us to the promised land.  Unfortunately, articles are written to create traffic, so scientific research is often misreported or spun to sell magazines or generate website traffic.  The truth is, there are many ways to skin a cat.  All of the evidence on nutrition (in regards to weight loss) points to two undeniable truths.  First, that dietary adherence is king.  It doesn’t matter how perfect or evidence based a nutrition plan is, if you can’t follow it, it doesn’t matter.  Before starting any eating plan, you must ask yourself how easy it will be to maintain long term.  Second, you must achieve an energy deficit to lose weight (eat less energy than you expend each day).  Though “calories in, calories out” may be slightly over simplified, it is still the underlying rule to any weight loss success.   For any weight loss plan to work, you must consistently follow the pla, and you must be in a caloric deficit.  This series will highlight the nine most popular current nutrition approaches, and the pros and cons of each.

Mediterranean

 

Claims: This diet emphasizes plant based foods such as fruits and vegetables, whole grains, legumes and nuts.  You are encouraged to use oils instead of butter, spices/herbs instead of salt, limiting red meat to 2x/month, and moderate to low red wine consumption.  The claims are that you will see reduced mortality rates, lower many cancer risks, and improved heart health.

Reality: This is another sensible eating plan that has been around for a long time.  Emphasizing whole foods such as fruits, veggies, whole grains, nuts,  and beans should be a no brainer.  There is a body of literature (albeit correlative in nature) that shows majority of health markers improve on this style of eating plan.

Pros: Fiber rich diet focusing on veggies, fruits, grains, olive oil, nuts/seeds, and legumes.  Encourages the social aspect of eating, and doesn’t directly forbid any food.

Cons: de-emphasizes lean protein consumption  by recommending fish/poultry only be eaten 2x/week, and read meat less than 2x/month.  Following this approach could lead to inadequate protein intakes.  No emphasis on food quantities, which may lead to some people over eating these “healthy” foods.

Jeff Tirrell, CSCS, CFSC, Pn1

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