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Reference topic 40: The Handrail I: Move, Eat, Drink

How to move, eat and drink for the body you evolved

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.22 sources11 graded recommendationsTopic hub: MovementTopic hub: Strength and boneTopic hub: Food

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Starting in 2011, thousands of older American women in the Women's Health Study wore a small accelerometer, a motion sensor that counts steps, through the waking hours of a single week. Nobody asked them to walk more, or faster, or at all. The device only counted.1

Over the next four years or so, about 500 of the women died. Sorted by how much they had moved in that one week, their risk of death took a shape worth memorizing. The least active quarter took about 2,700 steps a day. The next quarter, at about 4,400, already had a lower risk. Risk kept falling as the steps rose, then flattened at about 7,500 a day. How briskly the women walked added nothing once total steps were counted.1

Mismatch card

The system

Skeletal muscle, heart and lungs, the gut and the thirst reflex, all of them signal-driven.

What it expects

Several hours a day of unremarkable movement, occasional hard bursts, loads carried, food that spoils, and water when thirsty.

What it gets

About 5,100 steps, chairs, engines, food engineered to be eaten quickly, and a hydration industry.

What happens in the gap

Systems tuned by use drift downward in their sleep, and the drift shows up decades later as disease.

The handrail

7,000 to 8,000 steps, 150 to 300 weekly minutes, a few vigorous bursts a day, 30 to 60 minutes of strength work a week, less ultra-processed food, water to thirst (●●○)

Strength of evidence

●●○ The individual doses rest on large, consistent cohorts and a few feeding trials, but the package as a whole has never been randomized.

What this topic covers

  • ·The Shape of the Curve
  • ·Counting in Minutes
  • ·The Stairs You Already Climb
  • ·Enough Strength, Not the Most
  • ·Eat: The Negative Instruction Comes First
  • ·Drink: The Signal Still Works

The practical version is in the book: Chapter 1, The Short Version.

The handrail

None of this asks you to hunt anything. It asks for about 30 minutes most days, two sessions with something heavy, a few minutes of hard breathing, most of your calories from food that was recently an ingredient, and a glass of water when you want one. The next chapter takes the signals you cannot chew: light, darkness, temperature and the green world outside.

Each recommendation carries the strength of the evidence behind it. How the grades work.

  1. Walk, and aim at a range rather than a floor

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Evidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for the shape of the curve·Evidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for any single number

    Benefit rises steeply from a few thousand steps a day and flattens somewhere around 7,000 to 8,000 in the best-studied groups, earlier in older adults.13 If you are starting low, build gradually; sore feet and shins are the usual price of a sudden jump.

  2. Bank the weekly minutes

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    150 to 300 minutes a week of moderate activity, or 75 to 150 vigorous, is the guideline; mortality was lowest at roughly double that.678 Anything counts that raises your breathing, including gardening, cycling to work and carrying children.

  3. Use the bursts you already have

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    Three or four short bursts a day, a minute or two each, hard enough that talking gets awkward: stairs taken fast, a hill walked hard, a heavy bag carried quickly.10 If you have diagnosed heart disease, or stairs bring on chest pain or breathlessness, ask your clinician before adding hard efforts.

  4. Lift twice a week, and stop counting hours

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    About 30 to 60 minutes a week across the major muscle groups is the best-supported dose for mortality and major disease, not a minimum to build past.611 If you are new to it, learn form with supervision where you can, and add load slowly.

  5. Load your bones on purpose

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    Evidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for supervised resistance and impact training·Evidence grade: Emerging. Early, small, animal-only, or actively contested. for everyday carrying

    Progressive, heavier training twice a week is the best-evidenced bone signal (Topic 6).12 With osteoporosis or a past fragility fracture, start under supervision.

  6. Rest actively between sessions

    EmergingEvidence grade: Emerging. Early, small, animal-only, or actively contested.

    Short spells sitting on the floor, kneeling or squatting, and carrying rather than wheeling (Topic 6).14 With knee osteoarthritis avoid long deep squatting, and after a hip replacement follow your surgeon's precautions.

  7. Cut the ultra-processed share first

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Evidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. that it drives intake in controlled feeding·Evidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for long-term outcomes

    This single change outranks every superfood in this chapter (Topic 11).15

  8. Eat many kinds of plant, and some live-culture fermented food

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    Build up slowly; expect some bloating at first (Topic 12).16

  9. If you want a pattern, the Mediterranean one has the best trial record

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    with its 2018 retraction and republication understood as part of the record.17

  10. Treat an eating window as a tool, not a mechanism

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    Use it if it helps you eat less; expect nothing extra from the clock.1819 Skip it if you are pregnant or have a history of disordered eating. Never begin one while taking glucose-lowering medication without your clinician's adjustment, because of the risk of hypoglycemia (dangerously low blood sugar).

  11. Drink to thirst

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    More in heat and during long exercise; during endurance events, do not drink past thirst (Topic 17).202223

The skeptic's corner

The case against this topic, from the research itself.

Almost everything in this chapter is observational: it compares people who already live differently rather than assigning them at random. People who walk 8,000 steps, take stairs at speed and lift twice a week differ from people who do none of those things in income, illness, optimism and a hundred unmeasured ways. Randomized trials of exercise exist in quantity, but they run for months and measure blood pressure or fitness, not decades and death. The direction is consistent enough to act on. The precision is not what the round numbers imply.

The 10,000-step target is folklore, and its pedometer origin story is repeated far more often than it is sourced. The real curve plateaus lower, at a point that depends on how old you are.13

VILPA is a headline finding from a single cohort, and the people who give UK Biobank their wrist data are healthier and wealthier than the general population. Reverse causation, illness driving inactivity rather than the other way round, is the live worry. It earns ●●○, not ●●●, until other cohorts reproduce it.10

The J-shaped curve for strength training is a caution against slogans in one direction, not license for laziness in the other. It covers death and major disease in pooled cohorts. It says nothing about strength, function, bone or injury prevention; the extra hours were simply not shown to extend life.11

On diet, the popular wars are noisier than the evidence. Time-restricted eating has a plausible mechanism and two decent trials, and in neither did the window beat the simpler comparison it was tested against.1819 This chapter names no supplement at all. Where the book discusses one, it does so in the chapter that owns the trial, so the caveats travel with the dose (Topics 8 and 19).

Terms this topic defines

Related topics

Sources cited above

  1. 1.Lee, I-M., Shiroma, E.J., Kamada, M., Bassett, D.R., et al. (2019). "Association of step volume and intensity with all-cause mortality in older women." JAMA Internal Medicine, 179(8), 1105-1112. https://doi.org/10.1001/jamainternmed.2019.0899 (18,289 women agreed to wear an accelerometer during waking hours for 7 days, 2011-2015; 16,741 met the wear-time criterion and were analyzed, mean age 72.0; 504 deaths over a mean 4.3 years; quartile medians 2,718 / 4,363 / 5,905 / 8,442 steps a day; the quoted sentence opens the Importance section. The exact numbers apply to older women and should not be transferred to young adults.) (the women averaged 5,499 steps a day)
  2. 2.Aguiar, E.J., Ducharme, S.W., and Thomas, D.M. (2019). "Is 4400 steps per day the new 10 000 steps per day?" JAMA Internal Medicine, 179(11), 1601. https://doi.org/10.1001/jamainternmed.2019.4704 (correspondence; reply by Lee, I-M., and Shiroma, E.J., JAMA Internal Medicine, 179(11), 1602, https://doi.org/10.1001/jamainternmed.2019.4701. Cited here for the framing of the debate, not for new data.)
  3. 3.Paluch, A.E., Bajpai, S., Bassett, D.R., Carnethon, M.R., et al. (2022). "Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts." The Lancet Public Health, 7(3), e219-e228. https://doi.org/10.1016/S2468-2667(21)00302-9 (pooled analysis of 15 cohorts, about 47,000 adults; the plateau varies by age group)
  4. 10.Stamatakis, E., Ahmadi, M.N., Gill, J.M.R., Thøgersen-Ntoumani, C., et al. (2022). "Association of wearable device-measured vigorous intermittent lifestyle physical activity with mortality." Nature Medicine, 28(12), 2521-2529. https://doi.org/10.1038/s41591-022-02100-x (25,241 nonexercisers, mean age 61.8, mean follow-up 6.9 years, 852 deaths; the paper reports the sample median VILPA frequency, 3 bouts a day of 1 or 2 minutes, separately from the sample median VILPA duration, 4.4 minutes a day, hence the two sets of figures) (14,178 women and 11,063 men; against no VILPA, the median daily duration of 4.4 minutes was associated with about 26% to 30% lower all-cause and cancer mortality and about 32% to 34% lower cardiovascular mortality; at the median frequency of three bouts a day, 38% to 40% and 48% to 49%; the association was close to linear; a parallel analysis of 62,344 people who did exercise found similar associations for structured vigorous activity)
  5. 11.Momma, H., Kawakami, R., Honda, T., and Sawada, S.S. (2022). "Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies." British Journal of Sports Medicine, 56(13), 755-763. https://doi.org/10.1136/bjsports-2021-105061 (16 prospective cohort studies; observational, not trials) (for all-cause mortality, cardiovascular disease and total cancer, the largest risk reduction, around 10% to 20%, came at about 30 to 60 minutes a week; for diabetes, benefit rose to about 60 minutes a week and then flattened; the authors write that "the influence of a higher volume of muscle-strengthening activities on all-cause mortality, CVD and total cancer is unclear when considering the observed J-shaped associations"; doing both strength and aerobic work, rather than neither, was associated with lower all-cause, cardiovascular and cancer mortality)
  6. 18.Lowe, D.A., Wu, N., Rohdin-Bibby, L., Moore, A.H., et al. (2020). "Effects of time-restricted eating on weight loss and other metabolic parameters in women and men with overweight and obesity: the TREAT randomized clinical trial." JAMA Internal Medicine, 180(11), 1491-1499. https://doi.org/10.1001/jamainternmed.2020.4153 (n=116, 12 weeks; weight change -0.94 kg with the eating window, -0.68 kg with consistent meal timing, between-group difference -0.26 kg, 95% CI -1.30 to 0.78, p=0.63) (mean age 46.5; weight loss was the primary outcome; the window group lost a little weight, and the structured-meals group's loss was not statistically significant)
  7. 19.Liu, D., Huang, Y., Huang, C., Yang, S., et al. (2022). "Calorie restriction with or without time-restricted eating in weight loss." New England Journal of Medicine, 386(16), 1495-1504. https://doi.org/10.1056/NEJMoa2114833 (n=139, 12 months, 118 completers; between-group difference -1.8 kg, 95% CI -4.0 to 0.4, p=0.11) (calorie targets 1,500 to 1,800 kcal a day for men and 1,200 to 1,500 for women; waist circumference, body mass index, body fat, lean mass, blood pressure and metabolic markers showed no added benefit from the eating window)
  8. 6.Bull, F.C., Al-Ansari, S.S., Biddle, S., Borodulin, K., et al. (2020). "World Health Organization 2020 guidelines on physical activity and sedentary behaviour." British Journal of Sports Medicine, 54(24), 1451-1462. https://doi.org/10.1136/bjsports-2020-102955
  9. 7.Lee, D.H., Rezende, L.F.M., Joh, H.K., Keum, N., et al. (2022). "Long-term leisure-time physical activity intensity and all-cause and cause-specific mortality: a prospective cohort of US adults." Circulation, 146(7), 523-534. https://doi.org/10.1161/CIRCULATIONAHA.121.058162 (n=116,221)
  10. 8.Garcia, L., Pearce, M., Abbas, A., Mok, A., et al. (2023). "Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies." British Journal of Sports Medicine, 57(15), 979-989. https://doi.org/10.1136/bjsports-2022-105669 (196 articles, more than 30 million participants)
  11. 12.Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., et al. (2018). "High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial." Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/10.1002/jbmr.3284
  12. 14.Raichlen, D.A., Pontzer, H., Zderic, T.W., Harris, J.A., et al. (2020). "Sitting, squatting, and the evolutionary biology of human inactivity." PNAS, 117(13), 7115-7121. https://doi.org/10.1073/pnas.1911868117
  13. 15.Hall, K.D., Ayuketah, A., Brychta, R., Cai, H., et al. (2019). "Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake." Cell Metabolism, 30(1), 67-77.e3. https://doi.org/10.1016/j.cmet.2019.05.008
  14. 16.Wastyk, H.C., Fragiadakis, G.K., Perelman, D., Dahan, D., et al. (2021). "Gut-microbiota-targeted diets modulate human immune status." Cell, 184(16), 4137-4153.e14. https://doi.org/10.1016/j.cell.2021.06.019 (17-week study, 18 participants per arm; the primary outcome, a cytokine response score, was unchanged in both arms)
  15. 17.Estruch, R., Ros, E., Salas-Salvadó, J., Covas, M.I., et al. (2018). "Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine, 378(25), e34. https://doi.org/10.1056/NEJMoa1800389 (the 2018 reanalysis and republication: 7,447 participants aged 55-80 at high cardiovascular risk; hazard ratios 0.69 for olive oil and 0.72 for nuts against the control diet; results similar after omitting 1,588 participants whose assignment departed or may have departed from the protocol. Retraction and republication notice: New England Journal of Medicine, 378(25), 2441-2442, https://doi.org/10.1056/NEJMc1806491. Cite this version, not the original 2013 paper.) (the protocol deviations: household members enrolled without randomization, and irregular randomization at two of the sites)
  16. 20.Pontzer, H., Brown, M.H., Wood, B.M., Raichlen, D.A., et al. (2021). "Evolution of water conservation in humans." Current Biology, 31(8), 1804-1810.e5. https://doi.org/10.1016/j.cub.2021.02.045
  17. 22.Valtin, H. (2002). "'Drink at least eight glasses of water a day.' Really? Is there scientific evidence for '8 x 8'?" American Journal of Physiology: Regulatory, Integrative and Comparative Physiology, 283(5), R993-R1004. https://doi.org/10.1152/ajpregu.00365.2002 ; the 1945 wording is from Food and Nutrition Board, National Research Council (1945). Recommended Dietary Allowances, Revised 1945. Reprint and Circular Series No. 122.
  18. 23.Almond, C.S., Shin, A.Y., Fortescue, E.B., Mannix, R.C., et al. (2005). "Hyponatremia among runners in the Boston Marathon." New England Journal of Medicine, 352(15), 1550-1556. https://doi.org/10.1056/NEJMoa043901 (488 of 766 enrolled runners gave blood at the finish; 13% had a sodium level of 135 mmol/L or less)

This topic carries 22 notes in the research manuscript; the 18 above are those behind the material on this page. Full source register.