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The Role of Exercise in Integrative Preventive Medicine 

The Role of Exercise in Integrative Preventive Medicine
Chapter:
The Role of Exercise in Integrative Preventive Medicine
Author(s):

Michael F. Roizen

and Jeffrey D. Roizen

DOI:
10.1093/med/9780190241254.003.0011
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date: 29 November 2020

Since the dawn of recorded time, habitual exercise and sport participation were prescribed to promote a healthy body and a healthy mind.1 Eighty observational association studies (many of which are prospective) and a few controlled trials provide compelling evidence that physical activity makes your body and cells act as if they are many years younger.2,3,4,5,6,7 The physiological effect—that is, the effect of physical activity alone (independent of its effects on weight, blood pressure, LDL cholesterol, hs-C-reactive protein, TMAO, and other biomarkers of health and inflammation)—of all four physical activities advocated in the prescription in this chapter makes a 55-year-old woman have a relative risk of death more like someone who is 9 years younger than the typical 55-year-old American woman, and makes a 55-year-old man have a relative risk of death more like someone who is 8.1 years younger than the typical 55-year-old American man.8,9,10,11 (The RealAge metric has been validated by prospective independent analysis by Hobbs and Fowler, 2014.)8,9,10,11 This chapter summarizes the available evidence so that healthcare providers can write a rational prescription for physical activity that allows minimal activity for maximum health benefit.

Prescription of Exercise for Wellness: Why, How Much, and How Little

In our culture there are two extremes for exercise; most Americans get less than 1 hour of even moderate exercise a week, but, for those who exercise more than this 1 hour, they often get more than 1 hour of the same activity each day 6 or 7 days a week. It turns out that both of these extremes (no exercise and more than an hour a day, 7 days a week of the same exercise) are not optimal for health.12,13,14,15,16 For optimum health—to maximally prevent morbidity and mortality (for weight control, for longevity, for preventing cancer and arterial diseases, for keeping up sex drive and sex ability, for maintaining brain health, for feeling strong and happy).

Currently, there are no randomized-controlled studies of sufficient duration to precisely identify the ideal amount and kind of exercise with this gold-standard approach. However, the below recommendations to do four kinds of exercise weekly are based on formal and informal meta-analyses of the largest available datasets (Cooper Clinic Studies,7,19 Cleveland Clinic Studies,20 Harvard,21,22,23,24 and Penn Alumni Studies,25 Jerusalem Longevity Studies,26,27,28 and others29,30,31,32,33,34,35).17,18 Specifically, four different types of exercise—(1) any kind, (2) strength building, (3) bone strengthening (jumping), and (4) stamina building—are needed and are all that are needed for maximize longevity and to minimize morbidity and mortality.7,19-35 Doing these exercises increases longevity and has multisystem benefits; specifically it increases ability to do daily functions requiring muscular activity like moving to and from a job; it improves metabolic functions and decreases risks of obesity, osteoarthritis, bone fractures, and type 2 diabetes; it increases mental alertness and ability to function in daily activities requiring thinking, it increases hippocampal size36,37 and improves both short-term and long-term memory; it increases your immune function to ward off cancers and infections and increases disability-free survival if those occur; it even changes the microbiome.38 Perhaps the most important reason to recommend and stress the importance of exercise to patients is that it can help prevent patients from gaining something unwanted, abdominal fat. Patients increase their risk of heart disease in two ways if seriously overweight (a body mass index [BMI] of above 35—for example, being 5 feet 8 inches and 230 pounds) or if the waist size is greater than 40 inches for men or 37 inches or greater for women (measure around the belly button while you suck in your gut). That waist carries two important risks. First, patients are much more likely to have or develop other risky conditions like high blood pressure, diabetes, lipid disorders like high LDL levels, sleep apnea, or arthritis, which will inhibit their desire to exercise. Second, that extra weight that’s carried around the patient’s waist places each at an even higher risk, because the fat cells in abdominal fat secrete substances that directly increase inflammation in blood vessels.39 A weight loss of even 5% of body weight will significantly improve overall and cardiovascular health. Another way exercise can help is by reducing stress, which is one of the greatest agers of your patient’s body. And just four types of physical activities have been shown to provide all these benefits. But when recommending that a patient start a new exercise program four questions often arise:

  1. 1. Does the patient need an assessment before exercising (and if so, what assessment and why)?

  2. 2. What’s the specific prescription for minimal effort to get maximal health benefit (and are there limitations in what is advised and for whom)?

  3. 3. How does someone who has not been formally exercising start to exercise?

  4. 4. What about the other extreme: Can healthy patients do too much exercise?

The answers the literature allows are described in the following sections.

What Assessments Are Needed Before a Patient Starts an Exercise Program?

The conservative caregiver might argue that testing before starting provides an extra measure of safety, but no randomized controlled data supports the point that just starting with activity that is usual and done pain free, for example a slow walk, and increasing gradually, is safer with than without tests first.40

Some groups of patients—those with unstable angina (chest pain on walking or at rest, without doing any activity); those with chest heaviness or shortness of breath without doing any activity; or those who are unstable, lose balance, or get dizzy when they walk—should start and advance a physical activity program in a closely supervised environment, such as a cardiac or type 2 diabetes, or kidney or neurologic disease prevention or rehabilitation set of shared medical appointments.

To ensure physical activity is started and done safely by the patient, some tests are needed prior to starting, but others (numbers one to five in the next section) can be delayed until the patient advances from walking to more intense exercise, or before adding resistance exercise (the first 10 in the next section). In the 1960s and prior, the presence of heart disease, whether in the valve structure, muscle structure or force, or arteries and veins of the heart, triggered a prescription of a sedentary lifestyle and recommendation to avoid almost all physical activity and sport. Yet compelling evidence has accumulated that regular and increasing physical activity, even in this group with cardiac disease, reduces all cause mortality and disability rates, and improves quality of life. Even in the face of, and perhaps especially in the presence of, high blood pressure, or type 2 diabetes, or high blood lipid risk, or increased inflammation risk, or prior heart attack or stroke or heart failure, regular and increasing physical activity improves quality of life and reduces disability risk.41,42,43,44,45,46,47,48 Because doing physical activities decreases risk of disabilities, it could be argued that neither testing nor an assessment is necessary before writing an exercise prescription.

Other rationales for the 16 tests below are they can (1) help judge current status, (2) guide the prescription for speed in advancing, and (3) possibly provide a metric (for the patient) in how far they have come. Engaging in physical activity without a clear starting point may make it more difficult for a patient to maintain motivation; when weight loss is slow or ceases, but healthy benefit is still accruing, having evidence of that benefit will hopefully provide a nonweight motivation. For some patients, seeing improvement in LDL, HDL, blood pressure, or in other areas, and thus in risks for serious and possibly sudden disability or death, is vital to continuing to work (please assume we use “her” to mean “her or him” in each use when appropriate).41,42,43,44

Ascertaining baseline information about a patient’s fitness status, family history, heart, cancer, and brain status can be used to develop a personalized physical activity program that is safe, effective and lets the healthcare provider and the patient evaluate progress.

Many patients on blood pressure medications, cholesterol management medications, and pain medications will likely be able to reduce or stop one or more of their medications, including antidepressants, and in time these may not be needed at all.41,42,43,44 But this should not be rushed. These changes usually start after 90 days and do not progress to full effect to well after 6 months.

What Assessments to Get?

Before the patient starts, or within the first week of starting a walking program:

  1. 1.Blood Pressure: It should be under 120/80 with or without medications before a patient advances past a walking program.49

  2. 2.Resting Heart Rate: This should be taken when lying down or sitting quietly and not talking for 5 minutes, preferably first thing in the morning. As long as your patient’s heart rate is regular or controlled and is between 40 and 96 when resting, beginning a walking program is totally appropriate. (If it is above 96 or below 40, the cause of such abnormal readings should be sought before prescribing an exercise program.)

  3. 3.Height.

  4. 4.Waist size and weight (ideally first thing in the morning): Measure the patient’s waist size with a tape measure parallel to the floor at the belly button while the patient sucks in the gut.50

  5. 5.Recommend that the patient buy a pedometer or use one on a smartphone, have the patient record the steps they walk each day for 3 days: Average the steps taken in the first 3 days and then advance by 5% of that total every day for the next week. For example, if the patient walked 6,000 steps on average each of the 3 days, then the next week do 5% more per day (6,300 steps a day) and advance by 5% again each day for the next week (6,630 steps per day).

Early in the walking program, take and record the following measurement:

  1. 6.Speed of walking 1 mile (or 6-min walk distance): This measure is simply how fast can the patient walk a mile.51,52 All the patient needs for this test is a watch or smartphone with a watch function with a second hand and a level surface on which to walk 1 mile or 8 city blocks, assuming the city is built at 8 blocks to the mile. If not, the patient should find a track at a local high school (the tracks around football fields are usually one-quarter of a mile). Have the patient follow these instructions:

    1. 6.1 Warm up by walking at a moderate pace for 5 minutes.

    2. 6.2 Walk 1 mile as quickly as possible without causing yourself pain or discomfort. (Do not run on this test, even if you can do so).

    3. 6.3 Immediately after completing the walk, take your pulse for 10 seconds. Multiply the number you get by six to obtain your 1-minute heart rate or measure your heart rate with one of the strap-watch monitors. This enables you to obtain your heart rate in the last few seconds of exercise, rather than in the recovery period after exercise. If you do the finger on the pulse method, it is important to do the 10 seconds immediately at the end of the exercise, not after 10 or 20 seconds of recovery.

    4. 6.4 Record your walk time, and your 1-minute heart rate.

    5. 6.5 Cool down by walking at a moderate pace for another 5 minutes.

    6. 6.6 Keep track of your progress.

The patient can be her own goal setter for changes in time and heart rate over time. Over the course of several weeks, if her time on the 1-mile walk decreases without a rise in her heart rate, she has become more fit. If her time on the mile walk stays the same but her heart rate drops, she has also improved her fitness level and reduced her risk of some key chronic diseases.

For comparison purposes, if your patient’s physiological age (her physiological condition where her relative risk of death is equivalent to that of someone at that age—we call it her RealAge8,9,10,11) is 40 to 50 years old, she should be able to walk the mile in 20 minutes with a heart rate below 135. If her physiological age is 51 to 60 years old, she should be able to walk the mile in 23 minutes with a heart rate below 140. If her physiological age is 61 to 70 years old, she should be able to walk the mile in 26 minutes with a heart rate below 140. If her physiological age is 71 to 80 years old, she should be able to walk the mile in 29 minutes with a heart rate below 140. If her physiological age is 81 to 90 years old, she should be able to walk the mile in 32 minutes with a heart rate below 140. If her physiological age is 91 to 100 years old, she should be able to walk the mile in 36 minutes with a heart rate below 140. Your patient will see this time shorten (or the heart rate improve, or both) as her health from physical exercise improves.11

Do Tests 7–10 Before Recommending That the Patient Advance to Resistance Exercises

There are many tests of maximum exercise capacity for strength and for cardio activity, to help you determine where the patient is (Point A) and help the patient set goals for where she wants to go (Point B).

  1. 7.One Leg Standing Times: Under supervision (and timing in seconds) and in a room that is padded to protect the patient from injury in case of a fall, and with a person who can catch the patient if the patient starts to fall, have the patient stand on her right leg, close her eyes, and see how long she can stand on one leg. Repeat three times and record the best time of the three attempts. Repeat with other leg. Times less than 15 seconds indicate the patient’s balance may be that of a person older than 45.

  2. 8.Grip Strength: This is measured by a grip strength meter, which most physical rehab offices and many physician offices have. The grip strength correlates with the patient’s physiological age (see Figure 11.1).53,54,55

Figure 11.1 Grip Strength and Physiological Age

Figure 11.1 Grip Strength and Physiological Age

References 53–55.

  1. 9.The Push-Up Test (push-ups in 1 minute): The push-up test evaluates upper-body muscular endurance. Men should perform the test in the standard push-up position, in which only the toes and hands have contact with the floor. Women should assume a modified position, in which the knees also rest on the floor.

    Whether the patient is male or female, remind each to keep his or her (as earlier, “her” shall refer to “his or her”) spine straight and her head in line with her spine and to place her hands directly under her shoulders. Have the patient lower her chest toward the floor until it comes within 3 or 4 inches of the floor, and then push herself back up. She should inhale as she lowers and exhale as she pushes back up.

    Have the patient follow these instructions:

    1. 9.1 Perform a 5-minute warm-up (i.e., walk at a moderate pace and do a few standing push-ups against the wall).

    2. 9.2 Assume the gender-appropriate push-up position.

    3. 9.3 Count the number of push-ups you can perform with proper technique. (You may rest during the test but only in the “up” position.)

    4. 9.4 Record the number of push-ups completed. This is her score.

The patient’s results can be compared to the population norms in Table 11.111

Table 11.1 Push-ups

Men

Women

If your patient’s physiological age is

>20 and <29

your patient can do

>35 or

>18

If your patient’s physiological age is

>30 and <39

your patient can do

25-29 or

13-19

If your patient’s physiological age is

>40 and <49

your patient can do

20-24 or

11-14

If your patient’s physiological age is

>50 and <59

your patient can do

15-19 or

7-10

If your patient’s physiological age is

>60 and <69

your patient can do

10-14 or

5-10

If your patient’s physiological age is

>70 and <79

your patient can do

6-9 or

4-10

If your patient’s physiological age is

>80 and <89

your patient can do

3-5 or

2-6

If your patient’s physiological age is

>90

your patient can do

1-3 or

1-4

(gender adjusted . . . modified knee for women):

  1. 10.Curl-up Test: (curl-ups in 1 minute) The curl-up test evaluates abdominal muscular endurance. Both men and women perform the exercise in the same manner. Have the patient follow these instructions:

    1. 10.1 Warm up for 5 minutes by walking at a moderate pace and tightening your abdominal muscles a few times.

    2. 10.2 Lie on your back with your knees bent 90 degrees and your feet flat on the floor. Place your arms at your sides, palms down.

    3. 10.3 Flatten your lower back and curl your head, shoulders, and shoulder blades up off the floor for 4 to 6 inches. Return to the starting position.

    4. 10.4 Perform as many curl-ups as possible in a minute.

    5. 10.5 Record the number of curl-ups completed.

If the patient has been doing curl-ups for a while, they can take a more advanced test. In order to perform this test, each will need a mat or padded floor, masking tape, a tape measure or ruler, and a metronome. Have the patient follow these instructions:

    1. 10.11 Warm up for 5 minutes by walking at a moderate pace and tightening your abdominal muscles a few times.

    2. 10.12 Place a line of masking tape width-wise across the mat, about a foot from the end, or on the padded floor. Just beyond that tape, place another line of masking tape parallel to the first. The strips of tape should be 4 inches apart if you are 45 years of age or older and 12 inches apart if you are under 45.

    3. 10.13 Lie on your back with your knees bent 90 degrees and your feet flat on the floor. Place your arms at your sides, palms down, with the tips of your fingers touching the first piece of masking tape.

    4. 10.14 Set your metronome to a cadence of 40 beats per minute. This will allow for 20 steady curl-ups per minute.

    5. 10.15 In time with the metronome, flatten your lower back and curl your head, shoulders, and shoulder blades up off the floor until your fingertips touch the second piece of tape. Return to the starting position. Each complete curl-up should take two beats of the metronome.

    6. 10.16 Perform as many curl-ups as possible (75 at the most) until you cannot keep time with the metronome or you can no longer consistently reach the second piece of tape. (Some people naturally slide backward while performing this test. If that is your case, forget the tape and focus instead on lifting your shoulder blades off of the floor.)

    7. 10.17 Record the number of curl-ups completed. This is your score.

The patient’s results can be compared to the population norms in Table 11.2:11

Table 11.2 Curls

Men

Women

If your patient’s physiological age is

>20 and <29

your patient can do

>45 or

>35

If your patient’s physiological age is

>30 and <39

your patient can do

30-34 or

25-29

If your patient’s physiological age is

>40 and <49

your patient can do

25-29 or

20-24

If your patient’s physiological age is

>50 and <59

your patient can do

20-24 or

15-19

If your patient’s physiological age is

>60 and <69

your patient can do

15-19 or

10-14

If your patient’s physiological age is

>70 and <79

your patient can do

10-14 or

7-9

If your patient’s physiological age is

>80 and <89

your patient can do

6-9 or

4-6

If your patient’s physiological age is

>90

your patient can do

2-5 or

1-3

If the patient’s usual maximum physical activity fits into a general category like walking or gardening, or if she does not do maximum physical activity like running, jogging, or elliptical training regularly, you should have her do a walk test and the muscular strength tests first.

If the patient does a stamina or aerobic activity like running, jogging, elliptical training, squash, or basketball near her maximum capacity, she should do the maximum activity test and the muscular strength tests.

  1. 11-13.Cardio Tests: What the patient records seems straightforward (see references 7, 10, 19, and 20 to learn how to do these if questions arise):

    1. 11. Maximum Mets with Treadmill or Schwinn Bike or Elliptical

    2. 12. Maximum heart rate you achieve

    3. 13. Two-minute recovery heart rate and the difference in your maximum heart rate and 2-minute recovery heart rate.

  2. 14-16.Flexibility Tests: Flexibility corresponds to the capacity to move each joint through a full and normal range of motion. Adequate flexibility is essential for optimal functioning, while excessive flexibility can lead to unstable, injury-prone joints. We have selected a few important joints to evaluate in patients (or to have them evaluate with instruction). Before they undertake these tests, have the patient perform an aerobic warm-up, such as a brisk 5-minute walk or ride on a stationary bike.

  3. 14.Trunk Flexion: Low Back

Have the patient follow these instructions:

    1. 14.1 Sit on the floor with your feet about a foot apart and legs straight out in front of you.11

    2. 14.2 Place one hand on top of the other with your fingertips lined up together.

    3. 14.3 Exhale and lean forward, extending your hands between your feet, with your fingertips almost touching the floor. (Keep your knees straight.)

  • Women: Age 45 and under: She should be able to reach 2 to 4 inches past her feet.

  • Age 46 and older: She should be able to reach to the soles of her feet.

  • Men: Age 45 and under: He should be able to reach to the soles of his feet.

  • Age 46 and older: He should be able to come within three to four inches of the soles of his feet.

If the patient has less than the desired flexibility, recommend that she incorporate low-back stretches into a morning routine.

  1. 15.Trunk Extension:

Have the patient follow these instructions:

    1. 15.1 Lie on your stomach with your hands in pre-push-up position.

    2. 15.2 Trying to maintain contact between your hip bones and the floor, slowly press your chest off the floor. Do not force yourself into any discomfort. Stop pressing upward once the hip bones begin to leave the floor.

The patient should come close to straightening her arms with the hips still in contact with the floor. If the patient has less than the desired flexibility, recommend that she incorporate the abdominal stretches into her routine.

  1. 16.Hip-flexion Test:

Have the patient follow these instructions:

    1. 16.1 Lie flat on your back with your arms down at your sides and your legs straight out on the floor.

    2. 16.2 Without moving your hips or pelvis, lift your right leg up toward the ceiling, keeping the knee straight.

    3. 16.3 Repeat on the other side.

The patient should be able to lift her leg until it is almost pointing directly toward the ceiling (about 85–90 degrees of hip flexion).11 If your patient has less than the desired flexibility, incorporate hamstring stretches into her routine.

Ten thousand steps is what we start with.57 Not many extra tests are needed for that. But other tests you may consider depending on your patient’s risk factors, age, and other conditions include an exercise or echo stress test, LDL cholesterol and cholesterol particle size, Lipoprotein A, hsCRP, TMAO, fasting insulin and glucose levels, eye tests, and tests for gene function.-58 These tests may have important implications for your exercise prescription.

What is the Least Exercise to Recommend to Patients to Get Them Maximum Health Benefits? The Exercise Prescription

What patients need as the minimum physical activity for maximum health is:

  1. 1. 10,000 steps every day

  2. 2. 30 minutes of resistance exercise a week, including some for hand and for core strength

  3. 3. 20 jumps a day, and

  4. 4. 20 minutes of cardio (at a heart rate of 80% or greater than her age adjusted maximum—220 minus calendar age) three times a week.

More physical activity than this will not make patients healthier; yes, they can improve performance, but more exercise than this does not cause any benefit in morbidity and mortality. Let us review these in turn:

1. 10 k a day, every day: 10 k a day gives the patient about half of the total benefit of maximum physical activity for her health, 9 years physiologically younger for a woman and 8.1 years physiologically younger for a man who does the average of all other healthy choices.8 In addition to the outsize benefit that this recommendation has on health (relative to time investment), it has the added benefit of being a recommendation that people mostly follow through on. That is, when patients are told to do any of a specific exercise they are more likely to consistently do 10,000 steps than almost any other recommendation.

Ten thousand steps is approximately 5 miles for most adults. These steps can be done throughout the day and do not need to be in one chunk. In fact, if it takes longer than 2 hours in one chunk to do it, it is better to not do it in one chunk. We do not totally understand the physiology, but 10,000 seems to be the minimum number that provides the most health benefit. For instance, 10 k a day improves insulin resistance much better than 8 k, but 12 k does not help more than 10 k does (yes, she may get more fit, but her health doesn’t get better for the long term). Walking those 10,000 steps is the limit at which insulin resistance seems to decrease substantially, allowing you to reverse the fat accumulation—inflammation—desire to eat more cycle.59 Because it is such a simple strategy with such major health benefits, 10 k a day is the first thing I prescribe my patients and the people I coach or am a buddy to—for weight loss; for smoking cessation; for diabetes control; for blood pressure control; for decreasing the risks of heart disease, stroke, and certain cancers; for treating immune-related issues; for better sex; for better kidney, liver, and lung function; for greater resiliency in the face of stress; for better sleep—in fact, for just about everything.

In addition to improving insulin resistance, walking (and exercise in general) increases the size of the brain’s memory center, your hippocampus, by up to 2% in a year (the only part of the human body where size really matters).36,37,38,60 But stay on the couch, and this key region may shrink 0.5% per year, adding to memory lapses. One reason? Exercise increases levels of brain-derived neurotrophic factor (BDNF), a “brain fertilizer” that helps you grow those new cells and encourages better memory formation. You do not have to be a race walker to get more brainpower, but it helps. The people studied in this research who got their brain’s hippocampus measured via a magnetic resonance imaging (MRI) scan started out walking just 10 to 15 minutes at a stretch, building up slowly.60 And I probably do not need to even tell you what a great stress relief and antidepressant effect walking can have. A big study from Harvard in 201061 looked at more than 13,000 women to see who reached or passed age 70 in “super-healthful” condition: no cancer, diabetes, heart attacks, cognitive impairment, or physical or mental health limitations. What these super healthy had in common was physical activity. Those who did the most activity in their 60s (and that was nearly 10 k a day) were roughly twice as likely to be super healthful after age 70 as people who did the least activity.25,26,27,28 If you are not convinced by now, just do this: ask yourself or a patient to make a commitment to try it for 30 days. Every day, do what you can to get in those steps. Will you lose 50 pounds in that time? Of course not. Will you resolve all of your health problems? No, biology does take a little more time than that. But I guarantee that you and your patients will feel better, feel stronger, be more motivated, lose a few pounds, decrease your blood pressure, and create new habits that will provide the foundation to make all of the changes you want in your life.

George Matthew Schilling is said to be the first person to walk around the world—he did it from 1897 to 1904. And according to Guinness World Records, the first verified global transperambulation was by David Kunst from June 20, 1970, to October 5, 1974. He walked 14,450 miles through four continents.62 But patients do not have to go to all that effort to get the amazing benefits of regular walking.

Getting a pedometer, a walking buddy, and good shoes, and heading out for 10,000 steps a day, 5 to 7 days a week, can dramatically diminish or eliminate the effects of weight-gain promoting genes,63,64 and can mute the desire for sugary snacks.

If your patient is unable to walk due to a leg issue or balance issue she can substitute other activity for some of the steps. (This is where data tracking becomes especially important.) The general rule is that 1 minute of moderate activity equals a hundred steps (and 1 minute of intense activity can count as 200 steps). If the patient does 20 minutes of moderate swimming, she can count that as 2,000 steps.

2. Show Some Resistance: Ignoring resistance training is ignoring the patient’s health.

To get optimal benefit from resistance exercise a patient only needs to do it 2 days a week, for about 15 to 20 minutes each session. To get the most benefit, she should aim to do exercises that work her largest muscle groups, such as those in her legs and back, as well as all the muscles in her “core” (abdominal muscles, as well as those in the hips and especially her butt). She can do this with formal weights (e.g., dumbbells), resistance bands or medicine balls or with water or cans of soup, or even with her own body weight (e.g., squats or pushups). Recommend that your patient start with a weight (or suitable substitute) that she can use to do twelve repetitions with no problem. How does she know when she is ready to add weight? If she can do an exercise more than 12 times without feeling fatigued in the muscle area she is working, it is time to graduate to a higher weight. If she cannot perform the move at least eight times, she needs a lighter weight.

Please recommend to patients that they not try to combine resistance exercise with things like walking: carrying weights while walking dramatically increases the risk of rotator cuff injury. When the patient gets tired or starts focusing on dodging potholes, she forgets about proper technique with those weights and increases her odds of meeting someone specializing in rotator-cuff rehabilitation.

There was a time when people thought that training with dumbbells or barbells should be reserved only for bodybuilders and dumbbells; not even football or basketball players were allowed in the weight room. Many people, especially women, shied away from weights because they thought they would beef up to have muscle exploding from every part of their bodies. While weights can certainly help a patient get bigger and stronger in that sense, the tide has turned, and working out with weights is no longer looked at as something that only specific athletes should use. More experts acknowledge that one of the secrets to a healthier body is doing some sort of resistance training, in which you move some kind of weight (even your body) against gravity to put muscles under tension, as opposed to cardiovascular exercises such as running or swimming that are more to work the heart.

To be fair, weight exercises can be cardiovascular, and cardiovascular exercise does involve muscles other than your patient’s heart muscles. But moving a weight against gravity is almost always how resistance is separated from cardio—or how they are traditionally distinguished. And by “some,” we mean a short routine twice a week to get maximum health benefit. Here is why: when doing resistance training, the patient is breaking down muscle fibers. In the days that follow, the fibers rebuild the muscle stronger. So over time, the patient is adding muscle to her body. Why do people need to add muscle? For one, adding muscle helps protect your joints when you walk or perform other cardiovascular activity. Resistance exercises for the muscles above and below the knee, for example, are the best way to prevent and maybe even quiet the symptoms of knee arthritis. They act as shock absorbers. More muscle means fewer injuries, which means your patient is more likely to stick to her routine and stay healthy.

Second, building muscle burns calories and breaks insulin resistance, just as walking 10,000 steps does. So by improving the process of insulin delivering glucose to her body’s cells, the patient is decreasing the potential damage that glucose can do to her genes, her proteins, and her circulatory system, and the chances that she will store fat that causes inflammation.

Best of all, to do resistance exercise, she does not need to join a gym or invest in any fancy equipment. She can use anything. To put her muscles under some type of resistance requires pushing or pulling some weight—that is where the tension is created, and that is where the process of growing muscle begins. But here is the greatest thing: there are a million different ways to do that. She can do it with traditional methods, like barbells, dumbbells, and exercise machines she would find at the gym. She can do it with medicine balls. She can do it with resistance bands, which are small and light enough to pack so that she can have her own gym-on-the-go. She can do it with household items such as unopened cans of soup, jugs of water, and many other things that can double as equipment. She can also do it with her own body weight. Yes, squatting in place is a form of resistance exercise, as are push-ups. Your patient needs to do it only 2 days a week, for about 15 to 20 minutes each session. To get the most benefit, your patient should aim to do exercises that work her largest muscle groups, such as those in her legs and back, as well as all the muscles in her core. The core consists of the abdominal muscles, as well as those in her hips and especially her butt. Strengthening her core is about providing a sort of anatomical back brace—to improve her posture and prevent injury. A strong core may help keep her safe if she slips on the ice— not because a six-pack of abs can break a fall, but because a strong core may help her keep her balance so that she does not land nose-first on the sidewalk.

Additionally we recommend not ignoring the resistance exercise for the hands. Do not ignore the hands. Building grip strength in midlife can protect patients from inability to do activities of daily living. Several studies53,54,55 indicate that grip strength predicts disability risk and death. It is not clear why grip strength is such a good predictor of disability and death, but it is even a better predictor that overall muscle mass, blood pressure, or LDL cholesterol level. However, there are not any studies that show that making your grip stronger in and of itself alters morbidity or mortality. Exercises that you can recommend to your patients to improve her grip strength are to pop bubble wrap, play with clay, squeeze a ball, or even just gently push against a wall (a stretch that can also help prevent carpal tunnel syndrome).

3. Buy a Jump Rope: All your patients need to gain maximum increase in hip bone strength is 40 jumps a day.67 Using a jump rope and doing more will provide an aerobic exercise. Regarding jumping technique: recommend to the patient that she keep her back straight and her head up and turn the rope from her wrists.

4. Sweat three times a week: A major way for your patient to improve her cardiovascular fitness is to do continuous exercise to the point where it makes her sweat and raises her heart rate 80% or more of its age-adjusted maximum (220 minus her age) for an extended period of time.67 Your patients should aim for a minimum of 60 minutes per week of aerobic activity—ideally in three 20-minute sessions. We recommend low-impact activities like swimming, cycling, or using an elliptical trainer to get her heart rate up without compromising the quality of the joints in the process (and to change activities, so they do not get repetitive use injuries from doing the same activity over and over). We also recommend interval training (alternating periods of maximum effort with periods of recovery)—for the maximum cardiovascular benefit. Even doing 1 minute at the end of every 10 minutes with maximum effort can be beneficial.

Use your best judgment to identify patients who you want to try it in the controlled setting of a stress test first.

How Does Someone Who Has Not Been Formally Exercising Start to Exercise?

Simply get them to walk and e-mail you or a friend (buddy) every day as to how much they have walked. Ask them not to exceed a 10% increase in steps any day of the week but to gradually increase to 10,000 steps a day. (See item #5 in assessments, earlier.) Once the patient hits 10 k a day for 30 days, then add resistance exercise (described earlier).

What About the Other Extreme: Can Healthy Patients Do Too Much Exercise?

Blood samples from extreme exercisers before and after ultra-exercise reveal deficits in gut barrier integrity.69 Long-term, excessive endurance exercise (e.g., marathons, ultramarathons, ironman triathlons, etc.), can actually damage the joints, the heart, and arteries. Every time your patient pushes her body to excess it causes transient (but measurable) damage. If she does this once and gives her heart a rest, its function and arterial reactivity returns to normal within a week. Similarly, doing more than 2 hours consecutively of the same exercise predisposes toward overuse injury. Doing more than 1 consecutive hour a day of the same activity 7 days a week predisposes toward overuse injury.

It Is Not Only Exercise: Avoid Too Much Sitting

Several articles showing the harm of too much sitting (that is not mitigated by exercise at other times) have been highlighted in the lay press. One shows a huge benefit of standing, but others show no great benefit of standing. Data is still emerging, but at this point the best data is that walking for 2 minutes to interrupt each hour of sitting mitigates most of the harm from sitting.

Summary

Physical activity is key for the integrative medicine practitioner to prescribe. There is clear evidence that for most diseases and for most individuals, any physical activity is better than none. Walking is the best way to start and can be started safely for most individuals without preactivity tests. The data also are clear that 10,000 steps a day seems to be the minimum for maximum metabolic health. As you advance your patients to greater physical activity for greater benefit, there is greater risk that may be mitigated by assessment of specific tests. We recommend a prescription with the following action steps that you can add to your patient’s integrative prescriptions to help her get healthier (you can duplicate the italics below to give the patient):

  • Buy two pedometers (so you’ll always have one),

  • Some great walking shoes,

  • And find a walking buddy. Just start walking. You can do it.

  • Start scheduling physical activity into your daily calendar—Do it, and keep doing it!

  • Start seeing if you are hitting the 10 k a day minimum for maximum health. If not, increase walking by 10 more each week (each day of the week should be 10 minutes or 5% more than the previous week’s average) until you get to 10 k.

  • Buy a jump rope and start learning how to do 20 jumps every morning before you start your car.

  • Get up from your desk and walk for 2 minutes every hour.

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