Fit for Three: Protecting Heart, Kidneys and Blood vessels

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode of For Kidneys Sake, Dr Andrew Frankel and Prof Jeremy Levy are joined by Dr Tony Willis, a GP and clinical lead in diabetes and chronic kidney disease prevention. Together, they examine the evidence supporting the role of physical activity in enhancing outcomes for individuals with cardio-renal metabolic disease. Dr Willis shares findings from large-scale studies, including one involving over 120,000 participants, which showed that increased cardiorespiratory fitness is linked to significantly lower mortality. He highlights that the greatest health gains come from simply moving out of the least active group.

The conversation also covers the physiological effects of exercise, including improved blood glucose control, reduced inflammation, and the preservation of muscle mass, as well as the slowing of frailty. Dr Willis outlines practical advice for recommending physical activity, emphasising that both aerobic and resistance exercises are important and can be done without a gym. He also discusses behavioural techniques that support long-term change, helping clinicians guide patients to build sustainable, active routines.

Key Takeaways:

• Modest increases in activity yield significant health benefits, even in high-risk groups.
• Exercise is safe and beneficial at any age, with no known upper limit to its positive effects.
• Combining aerobic and resistance exercises offers the greatest physiological benefit.
• Simple behaviour change strategies, such as habit stacking, make new routines more sustainable.
• Clinicians should use motivational conversations rather than directives to encourage change.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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Transcript

Andrew Frankel
Hello and welcome, I'm Dr Andrew Frankel, Consultant Kidney Doctor from Imperial College Healthcare NHS Trust.

Jeremy Levy
Hello, I'm Jeremy Levy. I'm a consultant nephrologist also from Imperial College Healthcare NHS Trust and I'm really excited about today's conversation that we're going to be having. We're going to be joined by Dr Tony Willis, who's a local GP here in North West London and he seems to have done everything in the last few years. He's been clinical lead for diabetes care, for diabetes prevention, for chronic kidney disease prevention, for personalised care, but what strikes me about him is he's been really passionate over the years about personalised care, the power of lifestyle interventions and exercise. And so that's what we're to be talking about today. Tony, welcome.

Tony Willis
Thank you so much, Jeremy and Andrew, really lovely to be here and yeah, we're really delighted to be able to share some of what I'm passionate about. Thank you.

Andrew Frankel
So Tony, today we want to talk about the power of exercise for everyone but especially for people with Cardio Renal Metabolic Disease.

Jeremy Levy
That's right, Andrew. And as you know, we've known each other for a long time. I bang on about exercise all the time, not just with patients actually, but in all my conversations with patients. And today what we want to do is to encourage our colleagues to try and do the same and to explain to really why this is important, how important it is, because there's more and more evidence about this, Andrew, not just in chronic kidney disease, but actually, as you said, in all aspects of cardiorenal metabolic disorders.

And in my view, exercise is massively underrated as an intervention. It's mostly completely free and it's so powerful. So that's what we're going to talk about, isn't it?

Andrew Frankel
Well yes, I think we better get Tony in because I know you, you won't stop talking about exercise. We want to talk about the why, how it works, what benefits we can hope to see, and then perhaps most importantly, how to discuss this with patients to actually get behaviour changes. So Tony, let's start with what we know about the benefits of exercise in cardio-renal metabolic states.

Tony Willis
Yeah, what do we know? We know quite a lot and I'm going to need to shut me up if I talk for too long because this is, as I said, something I'm very passionate about and it's really so important. everybody is too sedentary at the moment. Exercise levels on the whole have gone down very significantly and in almost all studies, exercise reduces the risk of heart failure, stroke, cardiovascular events in people at high risk and secondary cardiovascular events in people with disease.

And there's one source that I refer to quite a lot over the last year or two, and that was published in the Journal of the American Medical Association. 122,000 people, really big study. Average age 53, so a little bit younger than me, and probably you guys as well. And the study team looked at the VO2 max, which is a measure of cardio respiratory fitness. Those in the top 5%, that's the elite group, that's what they call them, had a 10 year mortality risk, roughly 80 % lower than those in the lowest 25%. So this is a modifiable risk factor, a modifier indicator of long-term mortality. And interestingly, there's no observed upper limit of benefit. So getting out of the bottom 25 % is the most important thing. 

And that reduces risk by nearly 50%. So that's bigger than the difference that you'd see from risk factors like smoking, diabetes, existing coronary artery disease and it's relatively easy to achieve. There's a wonderful whiteboard animated video on YouTube certainly worth looking it up and it's called 23 and a half hours by Dr Mike Evans which spells out some of the other benefits of exercise it's not just cardiorespiratory disease it's knee arthritis, pain and disability, reducing progression to dementia by 50 % reducing progression from prediabetes or non-diabetic hypoglycemia to type 2 diabetes by 58 % and various risks that it reduces. Hip fractures in postmenopausal women, anxiety, depression by nearly 50%, improving quality of life. 

So that, you know, there aren't tablets that do this and this is free and you don't need to go and see your doctor for this. And also it reduces the risk of cancer, particularly things like breast and bowel cancers. From a sort of cellular perspective, we know that exercise improves insulin sensitivity, glucose uptake to muscle cells, reduces insulin resistance, lowers LDL cholesterol and triglycerides, systematic or systemic inflammation, contributes to weight loss, balances fat loss with muscle mass preservation, reduces the risk of progression to increasing amounts of frailty.

Along with other risk factors, can reduce your risk of long-term conditions by about 80%. There isn't any drug, medicine, herb, supplement or anything like that that can do this. So what's not to like?

Jeremy Levy
I'm with you completely, Tony. That was a list of things that I wasn't aware was as extensive as it was. And I bang on about it to my patients with kidney disease. And I know in kidney disease, for example, that preserving muscle mass has been particularly important for people who are getting worse kidney disease. But everything you've said works across the board. Do we know actually though why this happens? The mechanisms underlying it.

Tony Willis
Yeah, I mean, this is where I get into slightly deep water being a non specialist, but ⁓ exercise enhances function in heart and muscle cells, improves vascular health, restores vascular endothelial function, reduces arterial stiffness, improves heart muscle function, enhances coronary artery blood flow, stimulates the release of hormone-like substances from muscles that support heart health.

It lowers blood pressure on average by about seven millimeters of mercury systolic. It lowers blood glucose, improves glucose uptake and so on. and there are various impacts that it has on cytokines. So, TNF and reducing CRP and other things like that. But as I said, I'm not a specialist in these things.

Andrew Frankel
So it clearly does have an effect on the body. I am convinced about the need to try and increase the exercise in the patients I care for and indeed in myself. But there is so much advice out there that's so different. Almost every day you read on the web or in the papers about these are the exercises you should be doing.

It's overwhelming. So what form of exercise should we be doing, Tony?

Tony Willis
Great, okay. I mean, there's basically two main types of exercise that we should be doing. One is aerobic, and that would be things like walking fast, increasingly fast, running, cycling, swimming. That will help your heart and cardiovascular system and its anti-inflammatory. And the key message here is something is better than nothing. Remember, getting out of that bottom 25 % has the biggest impact. And ultimately, the more that you do, the better and there's no observed upper limit of benefit as I said before. The other type of exercise that's really important to do is weight bearing or resistance training. So things like using weights, resistant bands, that maintains muscle and bone strength, it reduces and prevents osteoporosis. And some studies have shown that it actually will reverse frailty in people who are starting to develop frailty. You don't have to go to the gym for it.

It could be carrying shopping, lifting tins of beans, doing squats while you're waiting for the kettle to boil, or even chair exercises for those with reduced mobility. Rangan Chatterjee, who's a UK GP who's written a number of books, including The Four Pillar Plan and various other things. He's got a great podcast and YouTube channel, and he's got some really great things like kitchen exercises that you can do, squats, things that will increase your gluteal.

⁓ function and those are the biggest muscles in the body so working those out is really important. And then there's other things like flexibility and balance exercise like yoga and Tai Chi which help reduce the risk of falls.

Jeremy Levy
That's really helpful. It's the aerobic combined with weight bearing, which is really, really critical as you get older. Some of those flexibility things. Yeah, I like the Chatterjee YouTube things as well, because people just get obsessed and they have to join the gym. You don't have to join the gym. You can do all sorts of things in other ways that are really, really important. But people sometimes worry it's safe. And I hate that bloody message where people say talk to your GP first before you start, which unless you've just had a heart attack strikes me as a completely insane use of GP time.

Tony Willis
That's right.

Jeremy Levy
But actually, tell me that this is safe for 99 % of people. They don't need to go to their GP, do they? Or am I wrong?

Tony Willis
You're quite right, Jeremy. We've all heard the scare stories, haven't we, of somebody who started doing some exercise and drops down. But there are some big studies, there are some reviews that aim to answer exact question. There was a large meta-analysis, in other words, a pooling of studies in the British Journal of Sports Medicine, which looked at the impact of increasing activity levels in people who'd been previously inactive and overall they saw a 22 % reduction in all-cause mortality. So that to me is quite reassuring. And there was also that study that I referred to previously of the 122,000 people, and they looked specifically at the elite top 5 % versus the high fitness level in various subgroups. So people with existing coronary artery disease, diabetes, hypertension, high cholesterol.

And there were no groups where exercise brought worse outcomes in that highest elite group. And there were some subgroups, particularly those over 60 and those with hypertension. And that actually the over 60 group is also true over 70 as well. So there doesn't appear to be an upper age limit as well where exercise becomes increasingly beneficial. So I think the evidence is pretty clear. Anything is better than nothing.

The more you do, the bigger the benefit with no observed downside. I'd say though, if you're starting off, start small and gradually increase and watch out for anything like chest pain or dizziness. And in that case, absolutely go and see your doctor.

Andrew Frankel
So we're clear about the benefits. You've helped describe which type of exercise, i.e. it doesn't really matter. And you've told us that it's safe generally. I try and tell my patients to exercise probably very briskly and quickly in the consultation. I might even give them a leaflet. You've been doing this for years. How do you actually then communicate with the patient to affect a change?

Tony Willis
Yeah, I mean, it's interesting. So I'm probably my own sort of control study here in that I've recently started increasing my level of activity. so I'll talk through some of the principles, but also a little bit about what I did. So for every four people you recommend to start exercising, one will make that change. So saying something is actually important as a first step.

Behavioural science tells us quite a bit about how to do it. There are a couple of books that I refer to, so Atomic Habits and Tiny Habits, they're sort of pop psychology books. But both of them pull together quite a lot of science about behavioural change. Key messages, number one, start small. When I started exercising, my first step was just to get into exercise clothes for about a week before I actually started doing the exercise. And that was enough.

to give me that sort of sense that I could actually do something. So the important thing is celebrating small successes. You build confidence that you can begin to make a change. Start with the smallest version of the new behaviour. As I said, it could be putting on exercise gear, not actually exercising to start for the first week. And the other things that are really helpful, stacking habits. So using existing habit, like getting up in the morning or having an alarm clock.

which helps bring in the new habit into an existing habit that you're doing. Planning your environment is really important. So putting out exercise gear the night before. So when you wake up in the morning all bleary eyed and reluctant to get going, you've got that reminder, that visual reminder to get you going. Making it social is really important. So joining a group, getting a family or friends to help you.

Find a community where exercise is normal. Celebrate, we have dopamine in our brains that rewards us when we do fun things. So some kind of instant gratification. I mean, exercise itself helps release brain dopamine, but an additional well done me or a coffee or something which helps, you know, provide that reward is also good. That's the natural brain reward chemistry, keeps you coming back for more. If you miss a little bit of planned exercise, don't beat yourself up. This is something that I talk about quite a lot with diabetes patients. know, people are so quick to beat themselves up, but the important thing is to shrug it off, plan how to avoid that happening again, and try and keep that activity streak going. And the other thing that of course we've got now is technology. So mobile phones to help remind us, alarms. I've got about six alarms in the morning to sort of keep me going with the various habits that I want to do in the morning. two years ago, I bought a Garmin. It doesn't need to be as expensive as that, but something that sort of tracks your activity, allows you to see progress is really important. The Couch to 5K app is great for making exercise fun, taking you up from couch up to being able to run a 5K over about a couple of months period. Ultimately you want to be aiming for about 150 minutes of moderate intensity activity per week and ideally some of that exercise would be after a meal because that helps reduce blood sugar levels.

Jeremy Levy
Tony, that's really, really helpful. ⁓ I don't think I do all of that when talking to patients, but the stacking I really like and the building around your life. You we can't suddenly say to people, change your life dramatically. I talk about how they get to work if they're working. What's their journey and can they change their journey? Get off a bus, you know, two stops early and briskly the last two stops. If people working canary wharf in a tablock, why are they always using the lift? Use the staircase. These are small bits of things that can really drive change.

When I take medical students, I always walk to the seventh floor of the towerblock at Charing Cross and they hate it. They all want to use the lift and they can't keep a conversation going to the end. I'm not very popular amongst the consultants at Charing Cross. I've always liked the idea of the prescribing of exercise. I've seen it done quite a lot across Scandinavia. know, giving patients almost a prescription pad, a written thing from the GP that says some exercise things. Is that a good thing or a bad thing? I've not seen it rolled out across the UK.

Tony Willis
Yeah, I mean, good question, Jeremy. I think the evidence for exercise prescriptions is quite weak, to be honest. I think with most things, and I'm probably the worst one at this, if we're told to do something, we'll tend to do the opposite. And we're much more likely to do something if we own it and make the decision ourselves. So I think a prescription can be helpful if it comes after a collaborative discussion which invites change. using coaching and motivational interviewing techniques where we go, well, you what would you like to see happen? How are you going to achieve this? And getting the patient to own that change themselves and realise how important the change is to them will be the most motivating thing. After that, you know, it's sort of jotting down some notes of what the discussion was about, will help remind them of what they've committed to.

Andrew Frankel
Sadly we are going to have to draw this to a close. So final thoughts Tony.

Tony Willis
Well, at risk of repetition, getting active has massive benefits for health. I'm not sure whether you got that message. Did you? so start small, the more you do and the more intensive you make it, for example, running, cycling or swimming, the greater the benefit, celebrate the small wins and find someone to encourage you and cheer you.

Jeremy Levy
We can't stop now. We haven't talked about how exercise boosts the immune system. It improves your gut microbiota, improves autonomic nervous function, which is what helps blood pressure, improves your life expectancy, boosts social engagement. It saves you money in the long run. It saves the NHS money. We can't stop, surely.

Andrew Frankel
I'm afraid, Jeremy, all good things come to an end and the two of you I know not stop on this subject. I really have got to stop because I'm actually going to genuinely go for a run. But I wanted to summarise my key takeaways. That is, exercise has a dramatic effect on almost all aspects of physiology to improve health and wellbeing and it's especially important with people with CRM syndromes. It reduces all the harms that we see and there really is no one who cannot benefit. So if we are looking to improve health, it's a no-brainer. All forms of exercise are helpful and useful and we can encourage diversity with both cardiovascular and weight-bearing or resistance exercise, trying eventually to get people to aim for 150 minutes a week.

And we've got to be much better as health professionals about how we actually affect that change. And I'm going to go back and listen again to Tony's description of his conversation and really start to think how I can focus that down to a short discussion with my patients exactly as you do, Jeremy, in your consultations to try and really get people to do things differently and move forward with exercise.

Jeremy Levy
They were great takeaways, Andrew, but you've to stop saying takeaways. We talked about that in the gout episode. You've got takeaways on the brain. They're bad for you, takeaways. Anyway, they were great summaries. Well done. Get people moving. That was brilliant. Tony, thank you so much for joining us. I think that's been a great conversation.

Tony Willis
My pleasure. Thank you so much for the invitation.