Physical Therapy at Hogwarts

Photo Courtesy of Rich Gordon

What would physical therapy look like if it took place at Hogwarts School of Wizardry and Witchcraft? (School of Harry Potter and his friends throughout the series of books by J.K. Rowling). Would it be held in the hospital wing or would we get our own separate space?  Would there be kettlebells and barbells involved?  Do the railings on the moving stairwells remain in place for stair training or might they disappear mid-session?  Could we play tug-of-war with a giant for some strength gains and dodge fire from the nostrils of a dragon for our agility and plyometrics?  There are plenty of choices of creatures to use for hippotherapy.  And would the only sport we're looking to return to be Quidditch?  Or would there also be other activities that these wizards would be trying to return to that would need improved physical function?

I wish I had counted how many times Harry Potter (and his friends) were injured and sent to the hospital wing as I worked my way through the series. Definitely some unique mechanisms of injury in each novel.  I'm currently reading the seventh book, my first time through the entire series, and it has been really fun especially because I can talk to patients about it a lot. There's one injury in which Harry hurts his arm and a charm is placed that removes the bones from his arms entirely. I found this funnier than I probably should have, picturing a hand and arm without bones to give it any structure.  A jello arm.  Or maybe more like an octopus.  

Reading the Harry Potter books is just one thing I've been doing so I can better connect with my patients.  They are, after all, kids! But it gave me the chance to think about reality in comparison to the fictional fantasy world that Harry lives in.  Would physical therapy at Hogwarts look like it does at my current job at Seattle Children's Hospital?  Or more like my previous jobs?  Because those do not look the same.  What I do now is not what I did as a new grad physical therapist four years ago, and I can't imagine my care will look the same next year as it does today. There's evolution in this profession, if you put some effort into it.  As a physical therapist, I think you really need to grow and learn constantly - and as much as you put into it, the more you can get out. Sometimes I just can't help myself to keep learning because it pays me back in dividends with patient care.

As I’ve mentioned before in this post, I currently have a student on clinical affiliation working with me at Seattle Children's.  She's my first student. She knows it. I'm having a blast... you'd have to ask her if she is. Despite the fun, at the end of the day she's here to learn. I don't think she's here to learn exactly how I evaluate and treat patients.  Her evaluations don't look like mine... but she understands why I choose to use the methods I do, and she's got her own system that she's working on improving. I think she's here to learn ways to better communicate with patients to help them get better and continue perfecting her own ways of helping her future patients.  If you watched me evaluate and treat a patient - and then each of my coworkers evaluate and treat the exact same patient - the things you would see would be different from each treating therapist. We have different levels of experience and different opinions on what we find most effective - and overwhelmingly I think we all agree that as long as the patients are getting better, it might not actually matter what specific way anything is done. 

So through this teaching experience, I've been trying to emphasize soft skills with my student (mine. I’m claiming her) because I don't remember that being emphasized so much for me. I don't remember anyone telling me to take the extra few minutes to get to know the person I'm working with before considering the problem they'd like me to help them solve.  I did have one clinical instructor tell me that “what I lacked in knowledge, I made up for with personality” which seemed like an insult on my intelligence but now I look at it as if my class clown personality is a good thing. The longer I've been doing this, the more I recognize the value in connecting with patients and their families. According to dictionary.com, soft skills are "personal attributes that enable someone to interact effectively and harmoniously with other people." I'm working on my soft skills with my student just as much as I've committed to working on them with the patients I work with.  To an extent - some of soft skills is the personality you have and were born with.  But as I've learned more about the soft skills and have spent more time around kids, I've learned that soft skills can be developed and deserve attention.  

In healthcare, therapeutic alliance is a specific soft skill.  Wikipedia presents this definition: therapeutic alliance is "the relationship between a healthcare professional and a patient.  It is the means by which a therapist and patient hope to engage with each other, and effect beneficial change in the patient." This book chapter goes into extensive detail on therapeutic alliance - in case you want more detail and the history of this concept.

Ariel tiara for my birthday... thanks coworkers!

I'm a pediatric physical therapist which means that every day I work with kids who are experiencing pain and I try to convince them to do various activities which may be uncomfortable or scary for them.  If they don't trust me, it doesn't go well.  So I have to earn their trust, and I have to earn it quickly. With kids, therapeutic alliance can be achieved in numerous ways.  You have the obvious choices: sports they play, favorite video games, instrument they’re learning, how school was that day, what their favorite subject is, clubs or hobbies they participate in, sometime religious organizations are a favorite past-time, or the really young kids usually have a favorite Superhero or Disney Princess.  I can't tell you how many times I've admitted that Ariel is my favorite Disney Princess.  I can't tell you how many times I haven't been able to answer if I like Marvel or DC... I can't keep them straight!  My coworkers decorated my desk with Little Mermaid everything for my birthday last month - complete with a tiara!  I also love to ask what they kids are reading... because I love to read and have often read the books they're talking about, or can get them telling me about their favorite characters.

So, in an effort to better connect with my patients (and my boss who loves all things HP and who I devote far too much time trying to be besties with) I'm almost finished reading the Harry Potter series for the first time. It shocks me how many kids have read these books... I love it. That's no short book series! And they can tell me their favorite parts, or if they were a Harry Potter character for Halloween, or that they wish Quidditch was a real thing they could do, or they're wearing socks from their Harry Potter house today.  The list goes on.

When my student completed her first evaluation working with me, she did a great job.  She measured the right things and asked enough questions to help get the patient started on the road to recovery.  But the kid had really unique vibrant-colored hair.  We went through the feedback of how things went, and I think my student may have thought I was a bit crazy when I asked if she had noticed the patients hair... because if I had been treating the patient, it would have been the first thing I commented on. Without a doubt.  The hair had nothing at all to do with the kid's pain or functional issues... but everything to do with making them more comfortable, getting them talking and seeing how we interact.  I pointed out that if she had taken the extra minute to discuss the kids hair color, she probably could have achieved better therapeutic alliance, because you're relating to the patient. 

With kids it can almost be easier to connect, but some you really need to dig to find a topic they’ll open up about. If you find a topic they like and don’t know much about it, let them teach you!  Everything I learned about motocross, horseback riding, Aquaman, dancing, certain cuisines of various countries, European Soccer, some of the lingo the kids use these days - I’ve learned it all from my patients.  Once you develop a little trust and repoir, you can more easily provide patients with realistic expectations of what's going to happen with them moving forward, which is essential to their physical therapy outcome.

To the PTs who are finishing their clinical affiliations - or to new grads who haven't yet learned much about the soft skills - I urge you to consider the soft skills as you complete your schooling. This is yet another reminder from me of how the words we use matter, like I wrote about here.  The benefits of how you will relate to your patients will be worth it, and the patient care is, in my opinion, more fun.  And at the end of the day, wouldn't it be great if we all were just having fun?!

In the words of Albus Dumbledore, Headmaster of Hogwards, "It is our choices, Harry, that show what we truly are, far more than our abilities."

Good for your Health

I was recently reminded of the different types of health and felt that I had not been giving adequate attention to certain areas both in my own life and when considering the priorities of my patients.  There are numerous websites that categorize health and/or wellness so the one I've selected to use for the blog is just an example of many, but it's thought provoking. When I was asked about the types of health, I only guessed three of them, but after discussion, it was easy to see how there could be others and how important these might be to some people and prioritized differently for others. Missing from this particular list is occupational health which came up on other lists, and based on the amount of time I spend at my job with my awesome coworkers seemed deserving of mention. In my opinion, your job absolutely impacts your health and overall well-being.

And so, without further ado, "The six types of health that make up who we are":

https://edu.glogster.com/glog/the-6-types-of-health/29w1xegudiu

1) Physical Health

2) Mental Health

3) Emotional Health 

4) Environmental Health

5) Spiritual Health

6) Social Health

Physical health came immediately to me when I was thinking about this concept.  Do you feel sick or healthy?  Are you able to use your body to function in the ways in which you desire?  Do you have any broken bones or wounds?  This is the easiest one, in my opinion, because to some extent - it's able to be seen.  You can see someone who looks pale or sweaty or tired.  You can see someone limping, in a boot or sling or on crutches. You can see injuries - incisions, bruises, atypical movement patterns.  This is what I spend the majority of my day helping my patients work on, so naturally this is what would pop into my head when asked about the types of health.  This is what so many people spend considerable amounts of time working on - with diets, gym memberships, yoga punch cards, rec sports leagues.  It's also what I work on when I cook myself dinner, working to ensure I receive adequate nutrition and hydration.

Mental health has been on my mind a lot more recently (ha!). I've written about it a little bit here and here as well as in my posts that explore chronic pain.   I'm going to group this together with emotional health because they are similar  Mental health deals with your ability to process emotions, feelings, and thoughts while emotional health is your ability to express those same things.  I don't feel like I learned nearly enough about psychology or mental health during PT School, but I've been learning more about them and recognizing that taking a mental health day - or even just an hour - to pay attention to your personal needs is essential to your overall health.  Last week I was scheduled to work a shift as an on-call PT and they canceled just a little while before I was meant to arrive.  The sun was shining and instead of wasting the afternoon, or even being productive with some things I've had sitting on my to-do list, I hopped on a ferry, enjoyed the sunshine, caught a few great photos of Mt. Rainier, and gave myself some alone time to think.  I needed it. A lot. And in my opinion, recognizing the need to take care of myself is a huge part of the battle for mental health.  I don't think it's easy to recognize when you need to take better care of yourself, sometimes until it's too late.  I do think it's easy to help others recognize this issue, though.

Mt. Rainier from the Edmonds-Kingston Ferry, Washington 1/14/2019

Environmental health was not something that I had considered, though when I looked into this idea further, it did include occupational health, along with home environment and the natural space you live in.  From an occupational perspective, if you've ever had a job you disliked or worked in a toxic environment, I'm sure you can releate to the impact your job has on your health.  You spend so much time at your job and with your coworkers that it makes sense how much of an impact that could have.  I'm so grateful that I love my job!  What about your home environment?  The people you live with, the space in which you live, are you nessy or meat, is it quiet or a bit more crazy?  There are pros and cons to having roommates or people coming and going from your home that impact your overall feeling of well-being.

Then there's the natural environment in which you live. I grew up in Connecticut which holds a special place in my heart, but I absolutely hate the snow.  Every year when I go home in March, I cringe thinking that I might end up in a snow storm.  I feel my body tensing up in the brutal cold and the runny nose and watery eyes and needing to wear hat, gloves, boots, scarves and 37 layers of sweaters is just not what I enjoy.  Additionally, I have known for a really long tiem that I need to be near the water.  When I graduated from PT school I only applied for jobs in Rhode Island until Seattle came up as a possibility.  I wanted to be able to breathe in the salty air of the ocean and get to the coastline as much as possible.  Large bodies of water provide me with a sense of calm and a change in perspective because the ocean is so vast and makes you feel smaller, in a good way.  When I spent 16 weeks in the middle of the country where I couldn't get to a big body of water, I felt unnerved and trapped.  I live so close now that I almost take it for granted that I can see the coastline on a daily basis.  I often drive the wrong way to get to the highway in the mornings before work so I can see the Puget Sound and have that extra moment of calm.

Spiritual health is an area that made complete sense to me as being important in overall health.  I've only written about religion once on the blog, here, but as a person who embraces my religion in my own ways, I can say that my spiritual health has gone through hills and valleys throughout my life.  I think this applies to all these areas of health - they're not static.  Mental health ebbs and flows.  People who have anxiety or depression can have happy days or weeks.  People who have a great work environment can have increased stress with a new project or temporary conflict. These change by the day or by what's going on in life.  Some days you just don't feel well and your physical health is poor.  That influences all the other areas of your life.  Spiritual health goes beyond religion and could include values and beliefs and practices such as meditation.  For myself,  I find medidation unnerving.  I don't really like to sit alone with my thoughts.  But for some it is what centers them and is essential to their health.

And last, but certainly not least, is social health - the people you surround yourself with and the relationships you maintain.  With the way of social media, people are basically able to connect to the planet and have millions of strangers impact their social health.  We can choose to keep the circle tighter, limiting it to the people we know and love.  Our family, friends, and significant others who are closest to us - as well as our coworkers, patients, neighbors, and those who you cross paths with and can impact your day. 

It does not seem possible to me that a person who is physically healthy but not healthy in the other areas can be a well person.  As healthcare providers, is it our responsibility to consider these other areas?  Overwhelmingly I'm thinking that we need to give it a little more attention than we have in the past, or guide our patients and family members to providers who can help in the other areas when we recognize issues.  I feel that I sometimes don't recognize in myself when I need to give my own health some attention - but that others can see it fairly easily.  I had a headache at work yesterday and my coworker was quickly offering me hydration, probiotics, anti-inflammatories, a granola bar, a quiet space to take a minute... we have the opportunity to impact each other's health.

I really needed this reminder that physical health is not everything... for both myself and for the patients I'm working with.  And I like the idea that we have to take care of ourselves, but that we can of course help each other more.  Be kind to yourselves and to those around you.  It's good for your health. 

"Just an Ankle Sprain..."

Let's talk about ankle sprains.

I've recently had a few patients come through the clinic with ankle sprains that needed to be evaluated.  It's basketball season!  My first question to any new patient is usually "what brings you into physical therapy today?" Any of my fellow PTs also experience teenagers coming in and answering this question with "just an ankle sprain?" They usually shrug while they say it and sigh in exasperation, maybe even a hint of an eye roll.  It's a completely different presentation from the kid in a sling who broke their arm and tells you all about the huge tree they were climbing or the other kids who were on the monkey bars when they slipped and who got the teacher for help and whether or not they cried. It's a different presentation from someone who just tore their ACL and feels like the future of their sport seems impossible - or at best a million years way.  Those are real injuries, right?  A broken arm or a torn ACL are a big deal... but an ankle sprain is no big thing, they think.

From a physical therapist perspective, an ankle sprain is a bit of a double-edged sword.  On the one hand, they're pretty easy to evaluate and they overall recover fairly quickly - at least back to baseline function.  On the other hand, they usually feel really good long before they have made an effort to reduce the risk factors that contributed to their injury in the first place.  Said another way, sometimes these athletes feel like they're back to normal, but normal is at risk for getting injured again.  As a physical therapist, I sometimes have to convince these patients that just because they feel like they should be playing their sport without any restrictions, it doesn't mean physical therapy or strength training has ended.

So who says this?  Sometimes it's a young athlete who wants to look tough after an injury that shouldn't seem like a big deal. Sometimes it's an athlete who really didn't have that much pain a day or two after the injury but couldn't get into physical therapy so they're almost back to playing sports.  These athletes have already gone to practice but their coach won't let them play in a game until someone clears them, so they come in for their first visit hoping that I'll be the one to do that.  This very rarely happens, though I won't say never. Sometimes they've noticed that half of their teammates have had the same injury and it's really common.  When you're at physical therapy and your teammates are there with you, something could be very wrong with your team training program. 

Here's why it is, in fact, a big deal:

Ankle sprains are really common.  In my graduate thesis that surveyed 246 high-level women's basketball players about their injury history, 70% had experienced an ankle sprain.  So not only are they really common - but athletes also recover from them and get back to playing their sport at a high level.  You can sprain your ankle and recover in such a short period of time that it would be possible to experience the same injury repeatedly throughout a season or career, though with each subsequent injury, the recovery is generally longer and the tissue damage gets worse.

When someone sprains their ankle, about 40% of the time, the ankle becomes chronically unstable.  According to this 2017 paper by Miklovic et al, this chronic instability affects range of motion, strength, movement patterns, and postural control.  Basically your nervous system recognizes that something has occurred and tries to protect you by moving in different ways.  An unstable ankle can get better with strengthening and balance - though it doesn't generally go back to it's original state.  The other way an unstable ankle gets better is through surgery... which is what happened to me.

The BIGGEST RISK FACTOR for an injury is a previous injury.  (Sorry PTs who have heard this before!  The general population just doesn't know this is a fact!) So if 70% of athletes on your team are having ankle sprains, that means 70% of athletes on your team are at risk for another injury and next time it may be another ankle sprain, or it could potentially be something that takes them off the field or court for a much longer duration.

Here are three key concepts with regard to ankle sprains that are really important for you to know if you're an athlete or a parent of a youth athlete or a youth sports coach or a person with an ankle - because these happen to non-athletes, too!:

First: When an ankle sprain occurs, it can be classified into one of three grades. This grading system is used for all sprains and strains in the body, but we're talking specifically about the ankle today.  There are many references that outline this, so here's one:

Grade I: the ankle feels stable, you can probably walk on it, there likely isn't any bruising but maybe some swelling.  There may not be any damage or a few ligament fibers are injured, which is painful, but these generally recover very quickly in about 1-2 weeks and often they are not treated in physical therapy.  In my opinion, this is a mistake!  Get it checked, get a home exercise program, and reduce risk of re-injury particularly when you're only missing a short period of time from sports or activities.

Grade II: the ankle probably has a little bit of bruising and swelling, it's painful to walk on, and may or may not feel unstable.  Usually people with a grade II sprain are given crutches and sometimes a boot for a short period of time.  There is partial tearing of a ligament with this injury.  These take a little longer to recover, more like 4-6 weeks.  These are more frequently seen in the PT clinic, but still many people don't come get treated for these until they've had multiple episodes.  Again, I believe this is a mistake. 

Grade III: the ankle will have much more bruising, usually also going into the foot and lots of swelling.  Generally you won't be able to walk with this and there is full rupture of a ligament or more than one ligament.  Sometimes these are also accompanied by fractures to the ankle bones, so these people typicall need XRAYS to determine the severity of their injury. These are the injuries that get a boot and crutches for a longer period of time.  The ankle feels unstable, even after the extended period of immobilization.  Generally these do not require surgery but take closer to 6-12 weeks for full recovery and almost always are recommended to have physical therapy.

(Of course - recovery times vary and it depends on the anatomical structures involved in the injury.)

Second: It seems pretty obvious to some, but in case you haven't noticed, in a standing  sport, the foot is the first place that the body interacts with the environment. The foot strikes the ground and that interaction directs human movement.  When I treat patients in the clinic with pain in their low back - I must choose to treat them from the ground moving upwards or from their head moving downwards.  Sometimes the symptoms are driven from above- othertimes from below - and sometimes the symptoms are sandwiched between dysfunctions and you treat from both directions.  When it comes to the foot - there isn't really anything to consider below it because that's the ground.  I of course need to make sure the toes are all moving, but overwhelmingly, when you are looking at someone who experienced an ankle sprain, you're going to treat the ankle injury and give focus higher up the chain to the hip which controls the leg in space.

After an ankle sprain occurs, the most common deficits to the athlete following the injury are: Limited dorsiflexion ROM, decreased balance/proprioception, decreased strength which translates into decreased power to push off or jump.  This is a long list of things that are affected from "just an ankle sprain."  So if you play a sport in which you jump, after an ankle sprain you're likely jumping differently than beforehand.  And squatting differently.  And walking differently.  And rebounding differently. And pushing off of first base differently... got the idea?  Your movement changes after the injury - and physical therapy helps guide you to exercises that will improve this.  Moving differently may not be a problem - but it might contribute to your risk for another injury.

If you just treat these deficits and don't consider what could have been going on BEFORE the injury, you might entirely miss the need to assess and strengthen their hips and the way they move as a whole unit.  The body moves as a whole and needs to be treated as a whole.

Third: What you can do about it:
I've previously written about injury prevention programs.  Ideally everyone would do a better job of preventing ankle sprains from happening in the first place. Here's where I've written about those in the past for ACL injuries as well as this post using dynamic warm ups as a way to incoporate injury prevention into daily practices.  Start with a program for everyone on your team and find a physical therapist in your area to screen your athletes for risk factors and then get individualized exercises to add in for each person.  There is evidence available showing that injury prevention programs help reduce ankle sprains.

If you are a parent to an athlete who experiences an ankle sprain or a youth coach who has an athlete experience this injury, SEND THE KID TO PHYSICAL THERAPY!  Once the injury occurs, get them screened, get them a home exercise program that you incorporate for all your athletes.  They will probably benefit from some mobility work, some strengthening to their ankle, hips, and core, some training on how to move with control, and some balance exercises.  If I've said it before, I've said it a million times: Injury Prevention = Performance Enhancement. 

Don't end up like me, in the photo above, having had so many ankle sprains that I did nothing about and ultimately ending up in the operating room.  Prevent things from getting worse, and Get PT 1st.  It might even make you a better athlete!

Breaking Up With My FitBit

My Only Half Marathon

Towards the end of 2017, a friend asked me if I would be willing to commit to running 1000 miles in 2018 as a motivator for her training for some half marathons.  She's a good friend... like really good... like one of my favorite people on the planet... but that was an easy question. Heck no!

I'm not a runner.  In fact I think I hate running.  I can run. As in, if a bear was chasing me or I happen to be facing oncoming traffic, I could get out of the way at a faster pace than my usual walk.  I have run road races in the past - including running our first half marathon together.  There's a chance I'll run a 5K again... those are fun.  But after we ran the half marathon, she just continued running them.  She's probably past 30 half marathons by now.  I didn't run another... and I can't imagine I would.

There are so many ways to exercise that it's not a big deal that running isn't on my list of choices.  Occasionally at the gym I choose the treadmill and get in an interval training session instead of a bike or elliptical, but in general I choose lifting weights and a class whenever possible.  I think the only time I really choose to run is when the weather is nice and I can be outside or I'm exploring a new place.

So I agreed to completing 1000 miles on foot with the goal being to walk that many miles in a year... and she would run them.  I got a FitBit that I wore pretty much every day for 2018 to track my progress and it was really fun.  The FitBit app lets you cheer others on and does some fun things when you meet your daily goals.  I completed 1000 miles towards the end of September and felt like wearing the FitBit tracker definitely motivated me to go a little bit further.  If I was wrapping up my day and it said anything over 9,000 steps, I almost always found a way to wander the house to hit that 10,000 step milestone.  I jogged in place reading a book that was resting on top of the laundry machine or paced the hallway back and forth listening to a Podcast just to finish that last 1,000.

There were certainly a few days where I did next to nothing... but overwhelmingly it increased my motivation to move.  When I looked back, there were only 5 days in 2018 where I walked less than 1 mile.   There were also a few days when I walked more than 10 miles in a day hiking.  So those are balanced out, right?  I started walking on my lunch hour a few times per week and when my job relocated to a much larger building, my step count increased just by having the bathroom and lunch room considerably farther away.  I really liked seeing how the tracker affected me and how the job change affected my movement.

But now it's 2019, and the FitBit is no longer on my wrist.  There's two reasons for this change.

First - I've decided it's time for my body to tell me when it wants to move... not a machine.  Some days after work I'm just downright tired and don't want to go to the gym.  I'm tired of making myself feel guilty for taking a day - or even a few days in a row - off from exercising.  I think I may have been torturing myself a little last year to make myself move more than felt good for me.  And... when you're on the stair climber or the elliptical at the gym, if you don't move your arms enough, the Fitbit didn't register it so it's like you didn't work out, and then a stupid machine was making me feel bad.  I'm not into that.  Funny enough, if I type aggressively enough during the work day, the FitBit also recorded key strokes as movement...and that's just ridiculous.  Sometimes I just type with purpose!

"A Beautiful Mind"

Second - I tracked everything I did last year.  Every mile I walked.  The food I was eating.  Workout days, stairs trained, progress towards personal goals, even the books I read. There's a beautiful thing about tracking in that it shows a lot of accomplishment and completion of tasks.  There's also the opposite effect - I was intimately aware of all my failures.  I set some goals that were not reasonable and every time I noticed how far I was from achieving them, I felt bad.  My 2018 planner looks like John Nash's office in "A Beautiful Mind."  Circles and lines and random numbers with symbols for workouts everywhere.  The tracking needs to go.

So... if I go for a long hike with my friends this year, I'll probably grab the FitBit to see what the daily mileage looked like.  If I can find it and was prepared enough to charge it. But it'll be because I'm choosing to move and curious to know how much.  If I need a day on the couch... which doesn't happen that often... I'm going to embrace it instead of feeling bad about it.  And maybe the sun will come back out in Seattle, and I'll chose to go for a run.  Or go kayaking... because I love that far more.

As always... if you have a FitBit or other kind of tracker... you should use it how you like.  You do you.  I'll do me.  

SUGAR!

It was recently recommended to me that I watch the movie “That Sugar Film” which also has a book, "That Sugar Book" which I also read.  I’ve spent many periods in my life avoiding sugar or carbohydrates or dairy. I always feel better without these things in my diet, but tend to have a backlash after they find their way back into my meals. I'm not currently restricting anything, but I always like to learn about nutrition to make more informed choices about what I'm eating, so I figured I'd check them out.  I've previously written about nutrition here and with the Whole 30 here. I'm DEFINITELY NOT recommending anyone restrict sugar or try these diets - but if you're interested in learning the science behind how sugars interact with your body, these are entertaining and eye-opening resources you can check out.  I've spoiled the story a little bit here, but the details and imagery were worth it if the topic interests you.

Australian movie actor and writer Damon Gameau met a girl and took refined sugar out of his diet to get healthier... plus that's how she ate and cooked.  He later decided to do a self experiment eating the average daily sugar intake for 60 days to see how his body reacted. He filmed the experience - making the movie- and kept a diary which he then used to write the book.  In summary, the addition of 40 teaspoons of sugar (about 160 grams per day) made him sick, but here are some of the highlights.  

• If you removed all the items containing sugar from a supermarket, only 20% of items would remain.  That's because it's added to pretty much all processed foods.  
• In the 1970's, there was a sugar versus fat battle around the world and ultimately it was decided to remove fats from the diet, resulting in a sugar boom. Low fat everything became available, but to make better flavor once fat was removed, sugar was needed.  It was suggested throughout both of these resources that the negative outlook towards fat was created by the sugar industry.  This ultimately led to massive creation of fad diets, like the Atkins diet, which believed the opposite was true and restricted sugar and carbohydrates instead.
• One teaspoon of sugar is roughly 4 grams.  So you can figure out by looking at nutrition labels how many teaspoons of sugar you're consuming based on the grams listed. 
• Sugar has a long list of alternative names on labels which sometimes make it easier for manufacturing companies to hide it.  Fruit juice concentrate = sugar.  High fructose corn syrup = sugar.  Agave = sugar.  Nutrition labels list ingredients in order from highest content in the product to lowest.  By using a variety of these (and fake sugars like maltodextrin), the concentration of each one is lowered so the ingredient gets bumped later in the list.  Tricky.

So the narrator, who has been off sugar, starts consuming sugar with a team of supporters including physicians and dieticians to watch his blood levels, body weight, and nutrition. He does this challenge without touching any candy, baked goods, soda, or chocolate.  He only consumes foods marked as healthy like yogurt, cereal bars, and juice and chooses low fat options whenever possible. He gets blood markers taken before, during, and after the experiment monitoring for changes of the heart and liver as well as tracking his blood pressure and heart rate. 

Different types of sugar are explored in these resources and the basic science of how the body processes sugars is outlined.  For example, glucose is the sugar that is used by the brain, cells, and organs for energy.  Lactose is the sugar that is found in dairy product. Sucrose is table sugar that is added to numerous foods we easily have access to.  It is composed of two different sugars - half glucose (the one I just mentioned is used as energy by the body) and half fructose. Fructose is the sugar in fruit and vegetables, including from corn as high fructose corn syrup and was previously very rare as fruit was not available year-round and to acquire honey, you'd have to fight the bees.  Fructose makes food very sweet, and it is considered to be the problem sugar because we have made it so much more readily accessible.

So Damon starts his sixty day journey of 40 tsp of sugar that are primarily fructose and sucrose.  He maintained his same exercise routine and overall had a consistent caloric intake from his non-sugar diet.  Some people he met along the way would say that his experimental diet looked healthier than their own typical diet.  Based on his study - that's a problem.  

It was obscenely easy to hit the target of 40 tsp per day. Cereal with yogurt and apple juice for breakfast on the first day totaled 20g (5 tsp) at breakfast. A 12 oz glass of apple juice has 33g of sugar (about 8 tsp).  Serving sizes really mattered because usually packages were multiple servings and could be far more sugar than he expected.  He noted many times throughout the experiment that beverages were a huge source of sugar intake and how this could impact your health in a variety of ways. 

After 12 days, he went to get a check up.  He had gained 3.2 kg (7 pounds!) and it was all in his belly. Visceral fat around the organs rather than distributed around his body.  Three weeks in, watching the movie, he looked ill. His blood tests showed changes in his liver enzymes with fatty infiltration.  He was feeling moody, lethargic, and like an addict waiting on his next sugar dose.  Twenty one days of sugar and it was obvious that it was making him sick.

One area that I found really interesting was that he explored the history of the aborigines and their health changes as they started eating processed foods and sugars.  He went to visit a community that had eliminated coca cola and the health of the community dramatically improved. 

One experiment he tried was to swap out the sugary food choices for a non-sugary option and add the actual amount of sugar to the plate.  This had a dramatic visual effect.  AKA it looked really disgusting. For example, he had planned to eat some teriyaki chicken where the sauce packaging said it had the equivalent of 4 tsp of sugar in it. Instead he had chicken without sauce on it and poured 4 tsp of sugar over the chicken and consumed that. Instead of drinking a bottle of Powerade that had 8 tsp of sugar, he drank warm water with 8 tsp of sugar. Ultimately he still had the 40 tsp for the day but as straight up white table sugar. This made him throw up. 

A month into the experiment, Damon comes to America. (side note: if you haven't seen the movie Coming to America, you MUST!  Here's the trailer.)

Upon his arrival to the USA, he gets a Jamba juice that has 34 tsp (136 grams) of sugar in it. He then shows all the fruit he would have had to consume to make that smoothie and shows how it would be impossible to eat that many whole pieces of fruit.  I've never tried to eat four apples in one sitting... but I definitely don't think I could...and then throw in a banana and some berries and limes?  No way!

He realized quickly it would be super difficult to stay under 40 tsp sugar per day because of all the high fructose corn syrup in the USA, which is not produced in Australia. He meets with an Appalachian region of Kentucky dentist who does mobile home treatments educating kids on how much sugar and caffeine are in Mountain Dew and Pepsi (or Coke). They have considerable tooth decay and start drinking soda at age 2-3 out of their baby bottles! An almost 18-year old has a mouth full of rotten teeth and they plan to extract many of them on the movie.  Damon reached out to Pepsi who said, "In moderation, Mountain Dew is part of a balanced healthy diet." 

He meets with researchers and undergoes various tests. One test was to get his brain studied under fMRI so while sugar is fed to him, they monitor the effects in the brain and then they teach him the science of sugar on the brain and hormones. He also can see what happens to his brain when he is simply shown a picture of a milkshake.  After having so much sugar, even the image of a sugar intake lit up his brain like a Christmas tree.  The researches told him about a study that showed rats worked harder for sugar than for cocaine... it's that addictive!

At the end of 60 days, Damon completes the journey and goes for follow up tests. I won't go into the details... but all of them were bad.  He had a body weight increase of 8.5 kg (18.7 pounds), 7 percent body fat increase and 10 cm increase at waistline.  And the whole time he's eating foods marketed as  "healthy." The calorie intake was virtually the same, but the source of the calories was the problem. 

Then he goes through the change back to his healthy diet. The first week he felt withdrawals and horrible sleep.  It took almost a month to get over the addiction/cravings.  He quickly lost 6 kg just by changing back his diet. Blood tests also restored. Good news: this is a reversible problem! The palate took a while to readjust, but overwhelmingly his body recovered (in the short term).

The recommendations from the movie and book are to limit to 6 tsp of sugar per day which is 24 grams.  Some people are more sensitive and should restrict to less because it triggers them, others can probably tolerate more.  According to the book, in 2003, the World Health Organization was preparing to recommend limits of 10% of caloric intake be from sugar. The sugar industry attacked the WHO and threatened congressional acts that would pull $260 million in funding if they did it. That recommendation was never made public, which suggests that the government and politics interfere with health policies... isn't that sweet?

Happy 2019, everyone.  Stay healthy.