Exercise in the Age of Evidence-Based Medicine

[Guest guest]

Members may enjoy reading the following extracts:

Exercise in the Age of Evidence-Based Medicine: A Clinical Update

http://www.medscape.com/viewarticle/549398_5

Let's get to the recommendations. What should people be doing? You

both said 30 minutes a day and this comes from what I've called the

consensus public health recommendation that emerged about a decade

ago from the Surgeon General of the United States, American Heart

Centers for Disease Control and Prevention, American College of

Sports Medicine and other groups, and it is basically that. Thirty

minutes, even three 10-minute walks a day each day, at least 150

minutes a week. Tim?

DR. CHURCH: Well, I think it's about living an active lifestyle. It's

about accumulating throughout the day. It's about, you know, taking

the stairs instead of the escalator. It's little things that add up

through the day. And it just doesn't take that much.

It's a very steep curve between physical activity and benefit. And

when you do just a minimal amount of physical activity, you receive a

whole bunch of benefit.

The marathon runner who increases his mileage doesn't get that much

benefit. The person who goes from couch potato to regular walker gets

huge benefit. And that really needs to be, you know, pushed to the

patients. And even if you can't get that 150 minutes particularly,

you know, in the frail elderly, anything, anything will have benefit.

What Are the Basic Components of Resistance Exercise That Clinicians

Should Be Recommending to Their Patients?

DR. BLAIR: A few minutes ago, mentioned muscle. I was

participating in a dual interview with a reporter, a physician

reporter in Dublin a couple of years ago, and a very wise

cardiologist from the Hartford Hospital said, skeletal muscle will be

the endocrine organ of the 21st century. And the muscle, it is the

biggest organ in the body unless you're really, really fat. And

physical activity uses this organ as it was intended to be used.

Now, Tim, I know you're interested in not only aerobic exercise but

the importance of resistance training to help promote health

benefits. What can you say about that?

DR. CHURCH: Well, I like to say that, you know, we have mountains and

mountains and mountains of data showing the benefits of physical

activity. We don't have mountains related to resistance training. I

summarize it as this. We know it's beneficial. We don't know the

exact formula like we do with physical activity. But we've got a

pretty good idea what it is.

And I like to say at least 2 days a week. One day a week if you

really don't like it is probably enough. It doesn't need to be, but

it can be relatively quick. It shouldn't take you more than 15, 20

minutes. And you want to do 10 different exercises attacking large

muscle masses, 2 sets per exercise, and high reps, 10-15 to reduce

the likelihood of injury.

I think the people who really stand to benefit from strength training

are women, aging individuals, and individuals with diabetes. Because,

as you said, skeletal muscle is an endocrine organ and, to keep

skeletal muscle happy, the body does a much better job in

metabolizing glucose.

DR. BLAIR: And focusing on skeletal muscle a little bit, you not only

get the benefits probably in terms of carbohydrate metabolism, in

terms of cardiovascular disease, but in function. You can get up and

do things and move around.

DR. CHURCH: Well, I think that's a key issue actually, you know. I

think of it as the aerobic exercise to keep you alive because we've

got good evidence on that and strength training to keep you out of

the nursing home. Because you can outlive your muscle strength, and I

think that's a big issue for patients.

How Can Clinicians Be Effective in Providing Exercise Advice to Their

Patients?

DR. BLAIR: I want to come now to the final question for the both of

you. What should physicians out there in practice, what should they

be doing? How can they be part of addressing this public health

problem of physical inactivity?

Should they be talking to all of their patients? What should they say

to their patients? Tim?

DR. CHURCH: I think it's a cultural thing. I think it should be not

just the physician but all the staff. And it's simple. Ask them, " How

physically active are you? Are you getting that 30 minutes a day 5

days a week? "

And then realize your words are very powerful. Too many physicians

think these things are just lost on patients. They're not. They may

not act on it that day or next week, but those words don't go away.

And they may act on it within the next year or so. Just mentioning it

is very important.

DR. BLAIR: I've had physicians say, " you know, I can't remember what

the target heart rate should be. " And for a 50-year-old woman or man,

what should their target heart rate be? My advice is don't worry

about target heart rate. Take that 30-minute walk. , what do you

tell them?

DR. THOMPSON: Well, that's exactly what we do. What I do is that my

nurse asks everyone in the encounter form how much exercise they do.

And she doesn't ask about physical activity. She actually asks about

exercise, but she tries to find out if they're doing things around

the yard and whatever. Everybody that I see gets recommended that

they walk for a minimum of 30 minutes every single day unless they

have some orthopaedic issue about that.

In terms of people who want training heart rates, et cetera, I don't

spend a lot of time with that. What I tell them is to exercise to the

point where they start to feel short of breath, where they start to

feel some dyspnea because that's about the point where you start to

have an increased production of CO2. Your heart rate goes up, things

like that. And it's a good threshold. It's almost like the walk-and-

talk test that we used to use in the old days.

For people who are overweight, they'll say, " Well, it's hard for me

to walk. " And I'll say, " Yeah; the problem is you're overweight. How

can we use your problem to your benefit? You use more calories if

you're overweight walking than I would use walking. So let's use your

problem for your benefit. "

And, you know, you're almost a little bit like a coach. When they

come back next time, you need to ask (and you also need to

encourage), " What are you doing about the exercise? It's just like

your lipids. Your lipids are much better on that drug I put you on.

How's your exercise program? Your blood pressure is much better. "

It's one of the vital signs that you ought to be assessing.

DR. CHURCH: You know, it's interesting in that it's almost, in my

mind, malpractice not to talk to an individual about quitting

smoking. You would never think about not talking to them if you knew

they smoke. And being that physical activity, you could argue, is as

powerful as smoking, I put it in the same thing. We should be talking

to every patient about physical activity the same way we talk to them

about smoking.

DR. BLAIR: I think that would be our final advice -- that you're not

doing your job as a physician if you don't get physical activity on

the patient's agenda and give them the encouragement. And this simple

advice is to try to get at least three 10-minute walks 5 days a week,

preferably every day during the week.

And if every physician in America did that and their staff supported

it, you know, we could actually have quite an effect on this big

public health problem.

So I hope that you've enjoyed listening to this conversation with my

colleagues, who are truly experts in the area. I hope you will take

this information, bring it into your practices, and encourage your

patients to become -- and, hopefully with your encouragement, stay --

more physically active. It's one of the best things they can do for

their health.

STEVE N. BLAIR, PED: I'm Steve Blair. I'm a professor in the Arnold

School of Public Health at the University of South Carolina. Our

guests today are Dr. , who is Director of Cardiology at

Hartford Hospital, and Dr. Tim Church, who is a professor at the

Pennington Biomedical Research Center in Baton Rouge, Louisiana.

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Carruthers

Wakefield, UK