Back Pain Made Simple: Just the Facts

The Cleveland Clinic Journal of Medicine has a helpful, authoritative review of back pain, its causes, and advised treatments. Back pain is the second most common reason for doctor visits (after the common cold). I recommend sending it to anyone dealing with back pain.

Some of the key points:

  • Most back pain has no recognizable cause and is therefore termed “mechanical” or “musculoskeletal.” Underlying systemic disease is rare.

  • Most episodes of back pain are not preventable.

  • Confounding psychosocial issues are common.

  • A careful, informed history and physical examination are invaluable; diagnostic studies, however sophisticated, are never a substitute. Defer them for specific indications.

  • Encouragement of activity is benign and perhaps salutary for back pain and is desirable for general physical and mental health. Evidence to support bed rest is scant.

  • Few if any treatments have been proven effective for low back pain.

  • Low back pain should be understood as a remittent, intermittent predicament of life. Its cause is indeterminate, but its course is predictable. Its link to work-related injury is tenuous and confounded by psychosocial issues, including workers’ compensation. It challenges function, compromises performance, and calls for empathy and understanding.

I would highlight the fact that exercise is helpful. (You should also exercise when you have the common cold, by the way.)

The last point about empathy and understanding rings true. Last October I woke up one morning with searing, unexplainable lower back pain. It dominated my existence for a couple weeks and I was able to do almost nothing else. I grew more understanding of what some must deal with on a daily basis.

Also, I never do exercises in the gym that come anywhere close to hurting my back. This includes squats. Unless you're extremely well instructed on how to use the weights, avoid back-related movement and stick with bodyweight exercises.

(h/t Andy McKenzie for the pointer)

The Keys to Life: Running and Reading

Will Smith, one of my favorite actors and rappers, tells the audience at the 2005 Kid's Choice Awards that the keys to life are running and reading. The two minute YouTube clip is embedded below. Running because when you run you get tired and want to quit and have to train yourself to fight through the pain and be resilient, and reading because through books you can learn from the people who have lived before you. It's inspirational to hear this message delivered by Smith to a rap beat and interspersed with some riffs on hard work.

(hat tip: Max Marmer)

Three Things I'm Doing to Become Healthier and Smarter

1. I take four Kirkland Natural Fish Oil Omega 3 pills a day. Each pill has 1000 mg of total fish oil with 300 mg of DHA and EPA each. 1200 mg/day seems to be a good target amount. Here's a page comparing fish oil to flaxseed oil. Here are all of Seth Roberts' posts on Omega-3. Here is Tyler Cowen on his flaxseed oil supplement which he calls "good for his heart, brain, and gums" and says "the Omega-3 ingredient has a scientific consensus in its favor, with no evidence for negative side effects."

2. I'm tracking personal metrics. I'm starting with sleep and exercise. I record in Excel when I went to bed, when I woke up, and how many minutes I exercised. See the article titled You Are Your Data to learn about the burgeoning Quantified Self movement. I hope to track nutrition soon. And maybe one day I will be able to carefully track my time spent on different activities.

3. I'm interviewing local neuro-psychologists to see if they can help me understand how I learn. I am still unsure how I process information best. People with learning disabilities work with these folks. I don't think I have a learning disability but I do think I could do a better job at taking in information in ways that are optimal for my cognitive makeup. I'm also researching SPECT scans, but these have its critics and are expensive.

I'm not a self-improvement maniac. But I am on the lookout for ways to become healthier, happier, and smarter, and all these things seem likely to help in one or all of these fronts.

Thanks to Seth Roberts, Andy McKenzie, Tyler Cowen, and a Child of the Kemp for their direct or indirect advice.

Bodyweight Exercises and Perfect Pushups

Growing up, exercise equaled sports. I played tennis, baseball, basketball, football, ping-pong, roller-hockey, home-run derby, and others. I eventually realized that if I wanted to get good I had to focus on one and I chose basketball. I started playing year-round, participated on elite traveling teams, dragged my ass out of bed at early hours to do agility and plyometric exercises, and worked near-daily on improving all aspects of my game. Playing basketball I learned a tremendous amount about teamwork, giving and receiving feedback, the importance and limits of hard work, channeling competitive instincts toward a firm goal, and mental focus. After my senior year season of high school I felt burnt out and stopped playing for a couple years.

With the built-in structure and commitment of basketball gone, I had to think about physical fitness in a context other than team sports. It's not uncommon for athletes to stop exercising altogether when the whip of a coach is absent, but I had no problem jumping into a new self-designed program that would keep me in shape. I went to the gym every day and pursued various cardio and weight exercises. Here's my post on diversity in your workout routine. Here's my post on pushups and crunches.

For exercise I think about two things: cardio and strength training. For cardio I do 10-15 mins on the bike (I read light fiction or magazines) and then 20-25 mins on the treadmill (I listen to music and try to just chill out). My strength training is more experimental. Since I'm no longer playing basketball there's no external need to build muscle mass, so my motivation / interest fluctuates. On its own, increased strength just feels good, lifting weights uniquely relieves stress, and there are aesthetic / attractiveness benefits, too. Due to my frame and biology, I can put on significant upper body muscle mass within a few months if I keep a routine. But it can be a hassle screwing around with the machines.

A few months ago I started up a more vigorous strength training effort. However, instead of going into familiar free weights and machines, I focused exclusively on pushups, crunches, and pull-ups: bodyweight exercises. Because of my weight, these types of exercises have always been hard -- ie the more you weigh, the more weight you're pushing up. My question was: Can I actually get bigger this way or will I just maintain current strength?

My goal was to do 100 pushups a day, every day, and as many crunches and pull-ups as I could do. Within a few weeks I was doing three sets of pushups (35, 35, 30) in 10-15 mins and within a couple months I could do 50-60 pushups consecutively no problem. (There's a whole movement around doing 100 pushups consecutively.) I felt / observed significant gains in upper body muscle mass. Most important I had no problem doing them daily because anytime I had some time to kill and a floor I could drop down and get it done. Much harder to invent excuses not to do it!

For Christmas my brother got me Perfect Pushup -- two circular disks with handles that you put on the floor and they twist as you go down and push up. It stresses slightly different muscles and supposedly is better for your elbows. At the least using them keeps the basic pushup interesting. Again -- avoid boredom by introducing variety into your workout.

Nutrition-wise, my basic operating principle is as it's always been: "Eat as much food as I can." I'm always hungry. I try to pre-eat before restaurant meals, I try to go to restaurants with known small eaters so I can finish whatever they don't eat, and I snack / eat Clif bars throughout the day. So quantity hasn't changed but quality has. Specifically, I have tried to eat more cottage cheese and nuts (solid sources of protein) and move my PB&J's to wheat instead of white bread (if you eat PB&J every day like me this makes a difference).

So, after three months of a pushup-centric workout routine combined with a little more focus on my intake, I feel as fit as ever. The numbers bear it out. When I stopped playing ball my weight crept up to 220, even 225 pounds, which at 6' 4" I could manage but it still felt a little heavy. Now I'm down to 215 lbs which feels more comfortable. My physique is more cut. This involved no weight machines! Granted, bodyweight exercises will only take you so far -- to re-introduce variety and push above my weight, I'm for the moment moving back to machines and free weights -- but for the casual fitness person I strongly recommend keeping it simple and doing push-ups, crunches, and pull-ups.

Bottom Line: I highly recommend bodyweight exercises if you want a simple, easy, anywhere way to increase overall strength.

Cities and Restorative Effect of Nature

Jonah Lehrer has an interesting piece in the Boston Globe titled How the city hurts your brain...and what you can do about it.

He cites research that says "
just being in an urban environment... impairs our basic mental processes. After spending a few minutes on a crowded city street, the brain is less able to hold things in memory, and suffers from reduced self-control." Constant stimuli -- signs, noises, sights -- leave us depleted. What to do? One psychologist says that immersion in nature can have a restorative effect. Walking through a quiet forest area can replenish the focus and attention that city life drained. Even spending time in nature within an urban area -- say, a city park -- can achieve a similar effect.

Thanks to growing up in the West, I've been lucky to spend a significant amount of time in nature and my personal experience matches this article all the way. I love the hustle-bustle of big cities but crave regular doses of open space, forests, and fresh mountain air. When I'm there -- when I'm gaping at the spectacular red canyons of Utah, or on the peak of a mountain in Colorado, or hiking around the Sequoias of California, or simply letting the desert heart swirl around me in New Mexico, heat that comes out of the ground for miles on end, those open plains -- when I'm there I enjoy myself, but I really feel the benefit when I've returned to the big city, recharged.

Day-to-day in the city, I think it's important to find those getaway nooks to relax for an hour. Golden Gate Park in SF or Central Park in NY are the obvious options, and they are wonderful. But sometimes, in San Francisco, finding a cement bench
facing the water on a deserted road, and letting the foggy odor envelope the scene, can be just the thing.

Main Side Effect of Some Drugs: Identity Confusion

It's astonishing how effective pharmaceuticals are today with only very minor side effects.

But there's one side effect yet solved and I suspect it's the most potent for some drugs: the identity confusion of whether the you on drugs is really "you."

For drugs that deal with personality issues or depression, I imagine even a successful patient must grapple with whether their newly improved state is artificial. (Artificial in a more serious way than the effect of myriad everyday things like coffee.) Am I really happy or is it just the drug that's tricking me into thinking so?

If the goal is to have people take medication that can help them while also minimizing in their own minds the fact that they're on medication, maybe these drugs could induce temporary amnesia immediately after swallowing the pill? The problem is that you need to know you've actually taken it!

Bottom Line: We've made remarkable progress in eliminating the biological side effects of anti-depressants and other mind-altering drugs, but still have to figure out how to deal with the assorted identity and self-understanding issues that can bedevil medicated patients.

(Note: I have never been on any these drugs so I'm speaking from observation not experience.)

Exercise: Push-ups, Pull-ups, Crunches

Working out has long been a part of my daily routine. I work out on average 45-60 minutes a day, 5-6 days a week. The ROI on this time is very high: by working out an hour a day I believe I reap at least an hour of productivity throughout the rest of the day, in addition to various long-term health benefits of a better cardiovascular system and less stress and so on. I feel strongest when I'm on the treadmill and listening to music.

Most people know about the overwhelming evidence connecting regular exercise and physical health. I'm also intrigued by studies which link exercise and mental / cognitive ability.

In any event, I've recently undergone a shift in my work-outs. Whereas in the past I worked with weights/machines, my current one hour workout is as follows:

  • 15 mins on the bike
  • 20 mins on the treadmill
  • 3 sets of 20 push-ups
  • 2 sets of pull-ups (as many as I can do)
  • 3 sets of 12 crunches and leg lifts

Push-ups, pull-ups, crunches, stretching, some aerobics. Simple, easy, and I feel great.

Here's an article which calls the push-up the enduring measure of fitness. And in this interview the senior VP of Westin Hotels says they have a "running concierge" at 30 of their locations who will run with you if you want to jog outside and make sure you don't get lost and point out sights. Great idea.

The Centenarian Strategy: Life / Career Issues When You Will Live to 100

David Mahoney gave a wonderful commencement speech at Rutgers University in 1996. Mahoney, then chairman of the Dana Foundation, a brain research organization, made five compelling points to young people about why they should adopt a "Centenarian Strategy" for life.

His premise is that if you're in your 20's today, you have a pretty decent shot at living till 100 years old. Not only that, thanks to advancements in brain science, you have a decent shot at enjoying an "active fourth quarter" -- that is, your 70's, 80's, and 90's won't be about wheelchairs in retirement homes and somebody reminding you what you ate for breakfast, but rather decades in which you'll remain intellectually vibrant and independent.

What do you do with this information?

I submit that you throw out all previous notions of one career followed by a lazy retirement. That was the strategy of your grandfathers and it's strictly wheelchair thinking. You need a new strategy for a lifetime of alertness that lasts a whole century.

The Centenarian Strategy delivers a swift kick in the head to the current idea of hitting the ground running, working your youth into frazzle, taking every better offer as it comes, making a pile as early as you can and then coasting on that momentum until your last downsizing company forces you into retirement.

He then issues five points of advice for centenarian living. I've included excerpts below not in blockquote because it's a bit long. My assistant typed the whole thing from a print version - there are a couple typos...I recommend reading it all.


1. Diversify your career from the very beginning.

Stop thinking of jobs in series, one after the other; instead, think of careers in parallel. That means planning your vacation along with your avocation, and keep them as separate as possible. If you want to go into business, plan an avocation of music or art; if you are inclined toward the law or the media, diversify into education or landscaping. If you want to be a poet, think about politics on the side, and study it seriously.

Don't confuse an avocation with recreation. Watching basketball on television, or surfing the Internet for the latest interactive game, can be a lively part of life, but it's not creative avocation. And don't confuse a serious avocation with a hobby; do-it-yourselfing is fund, and so are clay modeling, and gardening and fiddling with old cars. Hobbies are ways to relax and to make friends, and everybody should have some; but a real avocation is a subtext to a career, and a part of your working week to pursue with a certain dedication. Why? Not only because it gives balance to your second quarter, but because it positions you for the time that will come, in the third or fourth quarter, to switch gears. And then switch them again – you'll have the time, and public policy will change to give you incentives to keep working or avocating.

The point is to not be singleminded about career. Be double-minded, or triple-minded; to keep a pot or two on your back burners.

2. Take advantage of your opportunity to wind up a millionaire.

Financial independence will take a lot of pressure off that fourth quarter and make it something to look forward to. The Age of Entitlement is coming to an end. The baby boomers who count only on Social Security and Medicare  will be disappointed. You in the post-boomer generation should not rely on society's safety net and think more about your own personal nest egg.

The trick is to use the new tools the government is giving you to save, to avoid taxes in your IRAs and 40I (k) accounts, and to invest in broad index funds that are sure to grow. To the centenarian, credit-card living is out, leveraged saving is in. Use your tax leverage to make your savings grow exponentially. In this savings race, the tortoise beats the hare; by taking full advantage of the plans out there now, and more sure to come in the next decade, you need not be a rocket scientist to become a millionaire – in real terms – by your fourth quarter. Especially if you're part of a two-income family. About that family –

3. Invest in your family dimension.

As life gets longer, young people are getting married later. Fine; that deliberation about a big choice should ultimately reverse the divorce rate. But make a commitment early in your second quarter; the smartest thing you can do in diversifying your life is to stop playing the field.

The wave of the future, in the Centenarian Strategy, is to frame your life in traditional family settings. Do your market research in singlehood, choose for the long term and then commit to marriage; have kids; a void divorce; raise your likehood of having grandchildren. Following this course, you can expect at least a couple of great-grandchildren to enjoy, to work with, and to help as you approach the century mark. If you plan properly now to protect your wallet and your intellect, you can be a family asset, not a liability, later; and your family, with all the headaches, will enrich your life.

4. Pace yourself: it's a small world and a long life.

The centenarian thinks about success differently, with a longer view. He or she measures success in getting to personal satisfaction, which does not always mean getting to the top of the heap. Making money is important, never derogate building an estate that you and your progeny can use. But developing long –term loyalties in all the strands of your career and avocation and hobbies and recreation pays off in that satisfaction. Those loyalties also make life easier later; you can get things done across the different strands, helping someone in your avocation who has helped you in your career.

Ask yourself along the way: Whose approval is important to you? Whose is not? The centenarians do not stop to smell the flowers; they carry the flower along.

5. Plan for at least one thoroughgoing discombobulation in your life.

This can be a good shock, like meeting someone amazing, or developing a talent you never knew you had, or finding an opportunity that takes your career or avocation in a wholly new direction. Or you can find yourself, after years of success and loyal service, out on your ear in a merger or a downsizing or a hostile takeover.

It happened to me. I was running a multibillion-dollar conglomerate, doing just fine, but when I tried to take it private, somebody beat me to the punch. I wound up with a big bunch of money, which meant I got no sympathy from my friends, but I was out of a job. No airplane, no executive support system, no daily calendar full of appointments with big shots – not place to go in the morning.

Did I let it bother me? You bet I did. I plunged into the deepest blue funk imaginable. But luckily – and this was not part of any life strategy – I had an avocation to turn to. It was philanthropy, the Dana Foundation, and it had long been leading me into supporting the field of brain science. So I threw myself into that, applying what I had learned in marketing and finance to a field that needed an outsider with those credentials. And for the past ten years, I've gotten more sheer satisfaction out of marshaling the force of public opinion behind research into imaging, memory and conquering depression than anything I ever did as a boy wonder or a boardroom biggie.

But it would not have happened if I did not have that anchor to windward – the other, wholly unrelated activity to turn to. Success, or a resounding setback, in one career can lead to success, of another kind, in the parallel career.

We Juggle Five Balls in the Air

Advice from James Patterson, former advertising mogul and now mystery fiction writer:

Mr. Patterson urged her to think of life as a game in which we juggle five balls labeled Work, Family, Health, Friends and Integrity: "One day you understand Work is a rubber ball. You drop it and it bounces back. The other four balls are made of glass. Drop one of those, and it will be irrevocably marked, scuffed, nicked and maybe even shattered."

Haven't heard this before, but I believe it.

(via Harry Hurt's review of two new books)

Performance Enhancing Drugs...For Your Mind

My dear friend and loyal reader Massimo from Switzerland asks:

In the local paper today there was an article about the abuse of pharmaceuticals for the purpose of performance improvement in exams and the learning period (especially to improve the short term memory).

They claim that 25% (!) of the college students in the US take "stimulating drugs"  or cognitive enhancers such as Ritalin or Modasomil.

Is the use of those brain boosters a topic among students and in the media? Will we have to undergo an anti-doping test after our exams in the future? What are your thoughts about it?

I believe that the use of cognitive enhancing drugs in schools is one of the most underreported stories. From talking to friends and from my own observations, virtually every competitive college campus in America has a lively black market for Ritalin and Adderall and other drugs which help you focus and memorize. As someone who has never used such drugs, I'm annoyed there isn't more policing. Or at least more exploration of the ethics. There has been some chatter about the astonishing increases of high schoolers conveniently diagnosed with a learning disability right before taking the SAT -- so as to secure extra time -- but less about taking performance enhancing drugs when you don't have a clinical need.

But it's more complicated than it seems, this use of technology to gain an edge. For example, should students be able to use a laptop during a test to type out an essay? If so, does this give an unfair advantage to those who can type fast?

Anyway, the use of drugs to get an edge isn't limited to the classroom. According to this L.A. Times article and others, it appears executives and other high stressed people are catching on the wonders of cog-boosting pharma. I feel more OK about adults doing this. Maybe it's because the real world doesn't claim to create a "level playing field" of competition, as schools do.

The bottom line for me is that as mental drugs become cheaper and more effective, and as certain neuroscience technology like fMRI trickle down to the rich and eventually the masses, we're going to have a host of important ethics questions on our hands. To me, far more interesting questions than whether professional baseball or football players are taking steroids.

Heidi's New Venture: SkinnySongs

A year ago I went for a walk with Heidi Roizen around her house in Atherton. I was gearing up to head out to Colorado to hang with her Mobius partners, and she was pondering her next career move. She had various new business ideas, all fairly eccentric. A few months later I was back at her house because she was helping me with some stuff involving my book. When I asked her if she'd pursued any of her ideas -- or joined another venture capital firm or done something else -- she said she hadn't, but wanted to update me on her ideas over a workout. So we went down to her exercise room. I'll never forget the image: she, in workout clothes; me, in nice clothes (by my casual standards) sweating through it all trying to keep up both my heart rate and the conversation.

Fast forward to December, 2007 and I now see why we were chatting while working out: Heidi has taken action on her idea and launched a new company called SkinnySongs which will produce great pump-up music for women who want to lose weight. Heidi has partnered with some of the leading figures in the music industry to create professional, good natured music to listen to while exercising. Check out this fantastic Forbes profile on Heidi and SkinnySongs. This could be a great Christmas gift for a woman friend who's trying to lose weight. Available on Amazon.com (ignore the "only 1 left" message). It'll be on iTunes by Dec 15.

I've learned a lot from Heidi over the past few years and respect her a great deal, which is why I asked her to contribute a "Brain Trust" essay to My Start-Up Life (it's on page 11 for those following along at home). Succeed or fail financially, Heidi's new venture is a wonderful example to entrepreneurs of someone who's pursuing a genuine passion (music and exercise). You can feel the passion on the web site and in the songs. As the Forbes piece shows, it's also a good example of an entrepreneur scratching her own itch to understand a market and problem -- the bet is that others have the same itch and are willing to pay for it.

Congrats and good luck, Heidi!

###

I love pump-up music. Here's a list of the 10 Most Terrifyingly Inspirational 80's Songs. I agree with their picks. Excerpt:

Nearly everything is unbelievably dangerous while listening to "Eye of the Tiger." Here’s a little exercise that illustrates perfectly what this song is capable of. Think of the weakest, most pedestrian chore you can do, for example, doing laundry. Now play "Eye of the Tiger" in the background. If, by the end of that spin cycle you haven’t managed to somehow kill a grizzly bear with fabric sheets or make sweet love to every woman within 40 yards, then you need to see a coroner because you apparently died the night before.

###

Harvard Business School did a case study about Heidi awhile back. Some Berkeley researchers recently presented the case study to students but changed "Heidi" to "Howard" to see how a gender difference would change one's perceptions of her assertive style. Slate has a brief write-up halfway down the article.

###

I worked with Heidi on the Heroes project of the National Center for Women and Information Technology. We sought out some of the most interesting and successful women doing work in IT. Lucy Sanders and Larry Nelson interviewed them as podcasts. Check them out here -- loads of inspiration for any woman (or man) looking to have an impact in the field of computing.

Vassar's Silly Tips for How to Improve Self-Esteem

Ah, if only I were a Vassar College student, I could have access to their wonderful mental health clinic, where I would discover self-esteem improving tips such as:

- Identify the people you feel intimidated by. Learn to be assertive with them.

- When you fail at something, say: "That's okay. I'll do better next time."

- When you're feeling blue, say: "It's okay. I will be alright."

- If your day was rough, relax in the evening or as soon as you can.

- When you try something new and don't catch on right away, give yourself credit for trying.

How sweet! How original! How helpful!

If you want real tips for how to improve self-esteem, check out these useful thoughts.

How to Cope When You're Stressed

A friend emailed me and told me she was really stressed but that she'd gotten some great advice from another friend, which she forwarded to me. It's below and it's great advice.

My point to her was, "Stop telling yourself you're stressed." Self-talk is really important. The more you tell yourself and others how stressed you are, the more stressed you become. I extend this theory to the common cold -- when you tell people have a cold, the cold only persists.

Her friend's full email:

We all have those days Mary. You need a day of rest or a half-day of rest and a lot of sleep. Take a deep breath.

Remember, when things start falling apart, don't look at the big picture--pay attention to minute details. Get out of your head and into the world.

Look at your hands, are your nails trimmed, are your teeth brushed? What is the weather like today? What can you see new on your way to work? What is the person across from you on the train doing? When we are so caught up in our problems that we forget the rest of the world, then things really go bad. It's the details that save you.

Breathe deep, feel the quality of that breath. Taste your food. Slow down.

When you have a minute, draw up a list of the three things you have to do today and the three things that you can accomplish the most quickly.Try and knock out the three must dos and if you you have time, the three easy and quick things. Don't try to do more. You'll catch up.

Quote of the Day - Americans and Their Burgers

"My opinion is that the media is the main supporter of healthy eating. We're certainly not hearing it from our customers. And [surveys] show that while consumers say they want to eat healthier, what they actually want is a big juicy burger."

-- Andrew Puzder, who is the CEO of CKE Restaurants, the parent company of Carl's Jr. and Hardee's.

Strong Mind / Strong Body: Fitness on the Road

To continue my fledgling Health / Fitness series entitled, "A strong mind starts with a strong body," tonight I want to briefly touch on working out while traveling. (Speaking of traveling, I'm once again posting missives from my road trip on my travel blog.)

On June 1st I will have been on the road for 150 out of 365 days (excluding my time in Boulder). During this massive year of travel I have devised new strategies to keep fit.

First, use free weights over machines. If you lift weights regularly, you know that correct settings and positioning is key to safety. Instead of fiddling with machines you've never used before, just use free weights and target the same muscle groups. (Note: some machines are "standard" -- a bench press is a bench press anywhere in the world.)

Second, if you have the choice, go to a real local gym over a hotel "fitness room". Top hotels don't skimp, but most do.

Third, if you want to go for a run outside, know your way. There's nothing worse than thinking you're going to explore a city's geography and then getting lost. Have a map. Or better yet, follow Chris Sacca's advice and get Garmin GPS device. I haven't used it, but I hear good things. Although I favor a gym to outdoor running, an urban city run -- especially overseas -- can be magical if you know your way. I had a great run along a lake in Rome and through grass fields in Dresden, Germany.

Fourth, don't forget pushups and crunches. Two simple exercises which can take you a long way. Rob Urstein also recommends RipCords and jump rope as easy, portable exercise tools to bring with you.

Fifth, focus on cardio. After long plane or car travel you need to get the blood moving. If you must turn a 1.5 hour routine into 45 minutes, cut back on the beach muscles and just focus on the heart rate.

Sixth, value a free hotel breakfast. I always try to book hotels that offer a free breakfast. There's nothing worse than trying to find a breakfast joint at the start of the day. (I won't even consider the possibility of you skipping breakfast given the evidence in support of the meal!)

Any other tips for staying fit on the road?

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