Episode 95 - Exercise Medicine

Episode 95: Exercise Medicine. 

Exercise can be used as medicine if given at the right dose and frequency. Sapna and Danish explain some principles of exercise medicine. 

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Introduction: Is the monkeypox a hoax?   
By Hector Arreaza, MD.  

Today is May 27, 2022. Before we dig into exercise, I want to share some information about a trending topic.

I remember my lectures on public health in medical school in the late 90s when my teachers taught me about the tremendous accomplishment of humanity in eradicating smallpox. The last natural outbreak of smallpox in the United States occurred in 1949, and the last case of smallpox was recorded in Somalia (Africa) in 1977. Until it was wiped out, smallpox had plagued humanity for at least 3000 years, killing 300 million people in the 20th century alone, but the World Health Organization declared smallpox eradicated in 1980. No cases of natural smallpox have happened ever since, and if you discovered a case of smallpox, I was told by my teachers, you would be awarded one million dollars by the WHO. I did my research online and I could not confirm that information, but I learned that the variola virus (smallpox virus) is kept only in two locations in the planet: the CDC in Atlanta, Georgia, United States and the VECTOR Institute in Koltsovo, Russia.  

Why am I talking about smallpox? Because the monkeypox is a new trending topic in the media. Now as the COVID-19 panorama starts to look somehow comforting, monkeypox is starting to gain more attention in the media. Even the name “monkeypox” sounds terrifying. The CDC issued a health alert on May 20, 2022, about the most recent confirmed case of monkeypox in the United States, but this is not the first case of monkeypox in the US. In 2021 there were two travel-associated cases, and in 2003 there was an outbreak of 47 cases associated with imported small mammals. Cases of monkeypox have been identified in several non-endemic countries since early May 2022; many of the cases have involved men who have sex with men (MSM) without a history of travel to an endemic country. Cases of monkeypox outside of Western and Central Africa are extremely rare, and we hope they continue to be rare. 

Is monkeypox a hoax? Is it real? Only time will tell. For now, let’s be optimistic and hope for a world free of dangerous pandemics. Whether monkeypox will continue to spread or not is still unknown. 

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

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This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

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Exercise Medicine. 
By Danish Khalid, MS4, and Sapna Patel, MS4, Ross University School of Medicine

Today is May 12, 2022.

D: Welcome back to our Nutrition Series! Thank you for joining us again! Nutrition is such a big part of medicine, it’s the answer to many chronic diseases and yet it’s the most neglected subject in medicine. Our goal here is to educate not only ourselves but our patients and bring awareness of this discrepancy we’ve created in medicine.

S: If you’re new to this series, I suggest you pause this and listen to the first few episodes as we build upon them each time. In our previous episode, we discussed how the term “diet” brings upon a negative connotation as well as explored various popular meal plans. 

A: Exercise prescription. FITTE (Obesity Medicine Association): Frequency, Intensity, Time, Type, Enjoyment. 

D: As healthcare professionals, time and time again we advise our patients “diet and exercise,” because that’s what we were taught and research has backed for many years. It’s so easily said, yet the words carry such weight. But what does that really mean? Well, that’s what we’re here to explore. At least the latter part, exercise.  

S: extra fries?

D:Or shall I say, “physical activity?” Again, just like the word “diet,” “exercise” has similar negative connotations. Thus, let’s avoid saying “exercise” and resort to words such as “physical activity or workout.” Disclaimer: What we discuss here today is focused directly towards those who are beginners. For those of you who are more experienced, this may benefit as a reminder of the foundations.  

A: Screen your patients. 95% of patients will benefit from exercise, and most do not need a special test. Only 5% of your patients may require additional testing. 

S: So what is the best workout for me, you, or our listeners? Well, as simple as that sounds, it’s not that simple. Especially nowadays, where information is at the tips of our fingers, it is so easy to get confused on how to start. But let’s start by establishing your fitness goals. Do you want to lose fat, gain muscle, or gain muscle while losing fat?  

S: Once you’ve figured that out, then it's all about small steps and achievable goals. Oftentimes, individuals start their journey to healthy living with unrealistic goals, hoping to achieve them within a few weeks or months when in actuality it takes longer. This often leads to falling off or reverting back to their unhealthy habits. But small tricks such as reducing the amount of sedentary behavior can do wonders. With technology ruling over our lives, we’ve adapted to this sedentary lifestyle, became comfortable and left physical activity behind. In fact, the National Center of Health Statistics found that only 26% of men, 19% of women, and 20% of adolescents meet sufficient activity levels. 

D: So the first step: Move more, sit less. And for those with a busy lifestyle, some physical activity is better than none. According to the Physical Activity Guidelines published by the US Department of Health and Human Services, for substantial health benefits, adults should do: 

At least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity aerobic physical activity.

Or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity. 

And muscle-strength training of moderate or greater intensity that involved all major muscle groups on 2 or more days a week. 

S: How many of you understood that? What does this all mean? Let's break it down. The amount of time for exercise is self-explanatory, but what does moderate or vigorous intensity aerobic physical activity mean? Putting it in simple terms, aerobic physical activity means “cardio”. The level of intensity varies based on the activity you perform. Moderate-intensity activities include a brisk walk or walking on the treadmill at 2.5 to 4mph, playing double tennis, or raking the yard. Whereas, vigorous or high-intensity activities include jogging, running, carrying heavy groceries or objects upstairs, shoveling snow, or participating in a strenuous fitness class. You may have heard of the terms of: low-intensity steady state (LISS) cardio and high-intensity interval training (HIIT) cardio. 

A: In general, if you’re doing moderate-intensity activity, you can talk but not sing during the activity. Vigorous-intensity activity, you will not be able to say more than a few words without pausing for a breath.

D: So what’s the best cardio routine? LISS or HIIT? Well, there’s a lot of potential options. In terms of the best form of cardio for fat burning, there’s one thing you need to prioritize, that is preventing muscle loss. This enables your physique to dramatically improve as you lose weight. 

S: Ok, give us the evidence.

D: One study claimed that HIIT cardio workouts should be included due to its potential muscle sparing properties. HITT training can be done in a fraction of a time as LISS and is a great cardio workout to burn fat. Furthermore, the study  recommended performing lower body cardio workouts, rating bicycling as the most effective method of HIIT. However, HIIT is very demanding on the body as it may cause potential muscle recovery issues, which is why you should also combine it with a few LISS sessions per week as well. And one of the best methods of LISS include doing the stairmaster at 2.5 speed to 4. Furthermore, those looking for a fat burning effect should aim for an effective heart rate level during cardio. To keep it simple, those performing HIIT should aim to keep the heart rate 140-160 beats per minute and for LISS should aim for 110-130 beats per minute, keeping your heart rate elevated will optimize fat-burning effects from cardio. 

S: When should you perform cardio? What’s the best time? Well, studies have shown that the best time to perform cardio sessions should be when you’re not strength training or right after. It was found that participants who performed cardio before strength training experienced greater muscle loss than those who performed it after, or when not strength training. 

And while we’re on this topic, let’s address a myth regarding cardio: Sweating more does not equal more calories burnt. Each individual has a temperature setpoint for sweating. Once you meet that body temperature limit, you start to sweat as your body’s way of cooling down. For example, those from the midwest or east coast deal with a colder climate. Their setpoint is lower than those on the west coast or where the climate is hotter year-round. Thus, these people sweat more than others and easier.

D: How about those whose goals are to gain muscle? Is it the same or different? Don’t worry we haven’t forgotten about you guys. Although, going on a jog, or run, or riding a bike, is an effective way to help you burn some additional calories, and help you get into that hypocaloric state. It doesn’t allow you to build lean muscle tissue to achieve the desired physique many of us want.  The only way to obtain that is by incorporating strength training into your regular exercise regimen. This is why the guideline, as mentioned earlier, recommends strength training in addition to cardio, notice the “AND”. Yes, I’m talking about hitting the weight on a regular basis. 

S: Show me some more evidence.

D: Multiple studies have compared diet alone versus diet + weight training and diet + weight lifting + cardio after. And every single time, those with weight training wins out, especially if it’s the muscular physique you are looking to build. Now, don’t overlook this subtle difference that all exercises are created equal, because it’s not. Well, what training split should I follow then? Does it matter? The total body split, or push pull legs, or the “bro split”? You see, oftentimes people get confused as to which to choose, and that confusion can lead to no choice at all. Do whichever you like, but just make sure you’re doing this, and here’s the key: progressive overload. Adding more weight to allow more strength to build from workout to workout, or phase to phase. Or increasing metabolic overload or demand by keeping the rest time shorter and getting more work accomplished from workout to workout. Whatever strategy you choose, as long as you are striving to push yourself to a higher level of fitness and strength. That’s going to do the job.  

A: Use PT to assist you to design a good physical activity plan, depending on disability or limitations of movements. 

S: Yup I agree, personally I choose to increase each set by at least 10-15lbs, and rest for 30 secs to 1 mins since my goal is to increase my strength and endurance.  

You know what I’ve noticed, Danish? A lot of women refused to lift weights. They want to get fit and toned, but they don’t want to look “bulky”. So, they skip the weights, and perform hours of cardio, or worse - they avoid exercising all together. A common misconception about heavy weight training, especially among women, is that lifting heavy weight will lead to a bulky looking physique. It’s true that lifting heavy will promote hypertrophy in muscles leading to a size increase. However, the idea that it leads to a “bulky” look is untrue.

The true culprit that leads to bulky physiques is fat accumulation. Excessive body fat is what causes both men and women to look bulky. The most important aspect of someone’s physique is his or her body fat percentage. A good physique nearly always requires a fairly low body fat percentage to achieve. Lifting heavy can help accomplish this.

D: What about the hormones? 

S: Testosterone, or the lack thereof, is one of the main reasons that women won’t get bulky from lifting weights. Testosterone is a natural anabolic steroid, which directly stimulates muscle growth. And, on average, women only have one seventh the amount of testosterone as men. So, as usual, that means women have to work harder. But it also means you don’t really need to worry about bulking up. Heavy weight training has a plethora of benefits that can help develop muscle, shed fat, increase metabolism and ultimately lead to anyone’s desired physique.

D:Another question that gets asked a lot: which workouts will help me lose my belly fat? Should I do a lot more abdominal workouts? Although there’s so much more to this question. The simple answer: None. You cannot specifically target belly fat. Your body has its own way of allocating fat distribution, different areas in men and women. Similarly, when you lose fat, you’ll oftentimes notice different areas losing more fat first. Don’t get discouraged and be patient. As the results will come. One advise, take weekly pictures for comparison. It is said and accepted by many that it takes 4 weeks for you to see your body change, 8 weeks for friends and family to notice, and 12 weeks for the rest of the world. So keep grinding. 

And last but not least, it’s important that we reiterate: physical activity only supports and aids your eating lifestyle. It will not combat a poor eating lifestyle. Proper eating habits are 80% (relative number). So keep your eating habits in check. 

S:Well, that’s all we’ve got for today. If you liked this and found this helpful, feel free to reach out and let us know. It’s always a pleasure to hear from our listeners and motivates us to do more. And before we end this episode, we’d like to know: What do you want to hear about next? What questions do you have? Or something you don’t completely understand? Let us know and we’d be happy to learn with you. Till next time. Take care!

A: Email [email protected] 

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[Music to end: Your Choice]

Now we conclude our episode number 95 “Exercise Medicine.” Sapna and Danish reminded us that the US Department of Health & Human Services recommends 150-300 minutes a week of MODERATE-intensity aerobic exercise AND  muscle-strength training 2 or more days a week. Most of your patients will benefit from exercise, only a minority may have contraindications to exercise, in such cases, make sure you perform a proper evaluation, even a cardiology referral, before sending them to the gym.

This week we thank Hector Arreaza, Danish Khalid, and Sapna Patel. 

Audio edition: Suraj Amrutia. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

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Wisloff, Ulrik; Ellingsen, Oyvind; Kemi, Ole J.High-Intensity Interval Training to Maximize Cardiac Benefits of Exercise Training?, Exercise and Sport Sciences Reviews: July 2009 - Volume 37 - Issue 3 - p 139-146.

Ratamess NA, Kang J, Porfido TM, Ismaili CP, Selamie SN, Williams BD, Kuper JD, Bush JA, Faigenbaum AD. Acute Resistance Exercise Performance Is Negatively Impacted by Prior Aerobic Endurance Exercise. J Strength Cond Res. 2016 Oct;30(10):2667-2681.

Foster C, Farland CV, Guidotti F, Harbin M, Roberts B, Schuette J, Tuuri A, Doberstein ST, Porcari JP. The Effects of High Intensity Interval Training vs Steady State Training on Aerobic and Anaerobic Capacity. J Sports Sci Med. 2015 Nov 24;14(4):747-55.

Michael A. Wewege, Imtiaz Desai, Cameron Honey, Brandon Coorie, Matthew D. Jones, Briana K. Clifford, Hayley B. Leake, Amanda D. Hagstrom. The Effect of Resistance Training in Healthy Adults on Body Fat Percentage, Fat Mass and Visceral Fat: A Systematic Review and Meta-Analysis. Sports Medicine, 2021.

Demco, Sonja. “Why Women Will Not Get Bulky Lifting Weights.” Demcofitness, 21 Oct. 2019, https://www.demcofitness.com/single-post/Why-Women-Will-Not-Get-Bulky-Lifting-Weights.