Baptist HealthTalk

Why Exercise Prescriptions are Good Medicine

January 18, 2022 Baptist Health South Florida, Dr. Jonathan Fialkow, Dr. Eli Friedman
Baptist HealthTalk
Why Exercise Prescriptions are Good Medicine
Show Notes Transcript

Getting a prescription for a medication is nothing new. Neither is getting your doctor’s advice to exercise regularly. When that advice takes the form of a detailed plan tailored to your individual health goals it’s called an exercise prescription.

It’s a relatively new term that’s gaining traction across disease states – from diabetes to osteoarthritis to depression to cancer – and it’s particularly well suited to the treatment of cardiovascular disease.

Host, Jonathan Fialkow, M.D., a cardiologist and lipidologist with Baptist Health’s Miami Cardiac & Vascular Institute welcomes Eli Friedman, M.D., the Institute’s director of sports cardiology, to talk about the ins and outs of exercise prescriptions.

Speaker 1:

At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.

Dr. Fialkow:

Welcome Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health. If one thinks about it for tens of thousands of years, mankind's main needs were food and water and to find sufficient food and water, we were active. We walked and ran and sometimes for very long distances. It's only been a few generations where we've had refrigerated units in our homes. We can open a door and there are thousands of calories waiting for us. We can turn on a faucet and clean and safe water comes out. Additionally, with cars and escalators and elevators, moving walkways, and food aggregated in supermarkets, we're able to function by getting from place to place with even less activity than what we've been exposed to for thousands of years. This ability to function without being active is felt to be a major driver of obesity, diabetes, hypertension, and subsequent heart disease, strokes, cancers, and other deaths.

Dr. Fialkow:

Getting a prescription for a medication is nothing new, neither is getting your doctor's advice to exercise regularly. But what if that advice came in the form of an actual prescription? Today, we're going to talk about exercise prescriptions. It's a relatively new term that's gaining traction across disease states from diabetes to osteoarthritis, to depression, to cancer and it's particularly applicable as mentioned to cardiovascular disease. I've got the perfect guest here to explain more about what exercise prescriptions are and how they're used. And that's Dr. Eli Friedman. Eli is the medical director of sports cardiology at the Miami Cardiac and Vascular Institute. Welcome to the podcast, Eli.

Dr. Friedman:

John, thanks so much, really. Always exciting to be with you in person and on the podcast. So thanks so much for having me back again.

Dr. Fialkow:

Well, you've been a wonderful guest so far, so I'm not looking to put any pressure on you, but we're expecting a good dialogue here today as well. Always good with a level set before we start getting into the concept of exercise prescriptions and evaluating one's exercise abilities and needs. But just a little bit again, what is sports cardiology? How would you define in your medical directorship role and bringing this high level of skill towards our system?

Dr. Friedman:

Yeah, so perhaps maybe a little bit different theme than what we'll end up talking about today, but sports cardiology is the dedicated care of those who are already exercising and doing so pretty much at high levels. It's really anybody to whom sport and exercise is important, so that can be your weekend warriors. Certainly professional, amateur, sanction athletes, Olympic level athletes, and beyond. So really again, to anyone to whom exercise is important and then also their cardiovascular health as well.

Dr. Fialkow:

But certainly, with that experience and sub subspecialty and high end performance in the cardiovascular space, you're also very well adapt at assessing general exercise and its benefits towards medical and cardiovascular health, as well as which is what we're going to have to talk about, how people can get started, what advice they can be given. What are some of the push backs? So let's talk about exercise as medicine, this concept of various other medications we may give people or lifestyle adjustments, how is this concept evolving? And what's the information that supports exercise and our physical activity as being part of our medical benefit? Part of a medical treatment, if you will, towards the treatment of, if not avoiding, a lot of disease states?

Dr. Friedman:

I would hope at this time that it's pretty well established to most people and to certainly those of us in care, that exercise is a medicine. It's not even thought of as it could be, but in fact, that it's fact. That exercise certainly is medicine and it can help us to treat or manage many of these different conditions. And so in our space, in the cardiovascular space and in yours in particular cardio metabolic, I think we're all pretty comfortable at this point in time that those who engage regularly in exercise of any sort, and we'll get into those details, that it can help us to control our blood pressure, our blood glucoses, our cholesterol, our body mass, and helps us to manage just the daily stressors of life a lot better than those who don't. So really, we need to be having these discussions on a daily basis with our patients. And as you alluded to, as someone who works with athletes particularly, I'm spending the majority of my day thinking of exercise on a personal level, as well as a professional level.

Dr. Fialkow:

So when we're assessing exercise for an individual as part of their medical evaluation, I guess we could put into the category as someone who's not doing enough, someone who's doing enough, and maybe someone who for various reasons of pleasure might be doing more than enough. Where are we at now in defining enough? How do you approach and how are we moving towards approaching the individual's case towards how much activity should they do? And I guess the question would be, is it 10,000 steps? Is it 150 minutes? How do we take these broad recommendations? But how do we apply them to an individual? Where are we moving towards in this area?

Dr. Friedman:

So I think you bring up a really good point, which is the individualization of all of this. So we don't want a one size fits all policy for everybody because each individual is going to bring his or her own unique concerns and abilities to the exercise table. So number one, where I look to in terms of guidelines for exercising when we're writing that prescription that you mentioned , is what are our goals of exercise. And for the vast majority of people, it's going to be what we call 150 minutes of moderate intensity exercise per week or 75 minutes of high intensity.

Dr. Friedman:

So Eli, break that down. How do you break that down? 150 minutes of moderate intensity exercise would be John, if you and I go for a walk and we're able to have a conversation amongst each other at that point in time. That we're able to answer in more yes or no's, that I can ask you how the weather is, how's your family? And you can give me full sentences, whether we're walking, cycling, on an elliptical, whatever exercise we're choosing to do, we're conversational at that point, if we're trying to hit that higher intensity, that 75 minutes that we mentioned, now we're at a point where we're huffing and puffing a little bit more, and our answers really are yes or no at that point. Go ahead, you had a question.

Dr. Fialkow:

No, I was going to follow up, which is what you just said. So 150 minutes per week is a broad recommendation, but you sit with an individual, you go over their blood pressure, their cholesterol and sleep and all those other things. And part of it is, how much activity do you do? And we'll talk about again, push backs in a second, but 150 minutes per week could be 30 minutes, five times a week. It could be 50 minutes, three times a week. It could be 15 minutes in the morning, 15 minutes in the evening, five times a week, right? So that's an added up accumulative type of recommendation. Is that how you approach it?

Dr. Friedman:

That's exactly right, yeah. And that's how we want to break it down. I think these sessions are best done, and I think evidence would suggest as well, that it's best if you do it in 20 or 30 minute sessions. That really, you don't want to do anything less than 20 minutes in terms of that sustainable pace, because that's where the cardiovascular benefits really start to kick in and you want to do it and make it sustainable. That somebody who's really doing nothing, and now is trying to get into exercise that perhaps doing 45 minutes, consecutively is going to limit them in their ability to do it further on. So 20, 30 minute sessions, conversational, breaking it down to reach that 150 minutes. Now again, that's the goal. For somebody who's doing nothing, we just want to get them to start doing something.

Dr. Friedman:

And in your point initially, when you said there are those who are doing nothing, those who are doing something, and those who may be overachievers, the biggest health benefit we are going to find are going to be those whom we can get for who are doing nothing, to doing something.

Dr. Fialkow:

Yeah.

Dr. Friedman:

And that's where a lot of these things come from. If you look at somebody who goes from doing absolutely nothing to hitting the health goals of exercise, that 150 minutes or 75 minutes, there will be profound benefit. Now, if you get that person to then start running 5Ks and doing marathons or half marathons, yeah there will be some tangibility in terms of their health benefit, but really where they're going to hit the sweet spot is going from doing nothing to something. And that's really the group that we want to focus the most on when we're talking about population based, look at all of this to really improve health from the individual perspective, as well as the population based.

Dr. Fialkow:

So let's dive into that group a little bit more. And I appreciate you bringing that to the attention because part of that assessment is if we say, you should be doing 150 minutes per week, and someone's doing 140, are they, oh my God, I'm a failure, I can't do this? And of course the answer is no, that's fantastic and it's certainly better than nothing. So when you're meeting with a patient and whatever the reason for their coming in, and you're starting to discuss exercise and they have not incorporated regular activity into their lifestyle for reasons I mentioned in the introduction, we can function quite well without exercise. First, what clinical outcomes do you tie to the benefits of exercise? What's the motivation in terms of what they will see in whether other medical components or other aspects of their health?

Dr. Friedman:

Yeah. So to two points to that, number one, understanding why the person's in the office and what brought them there, what comorbidities or risk factors do they have? Do they have high blood pressure, high cholesterol, diabetes? Is their family history... So what they bring to the table that way. But then also, what are their goals? Where are they trying to get to? And then you may say that, yes, we can function quite well because we have the refrigerator and all of these food delivery services and grocery delivery services. That's great. But I would actually argue that we don't function so well if we are simply reliant on that, because our bodies are meant to move. And as you discussed very eloquently in the intro, we are a subgroup of species that has developed through movement, through exercise, through maybe not eating five meals per day, but by being hunters and gatherers. And I think our bodies wants to move.

Dr. Friedman:

So I would argue against that, that the more we rely on things being brought to us, as opposed to us moving our bodies and getting out there and doing it, our bodies begin to function better the more that we do. So I think individualizing that within the context of what we just spoke about, individualizing what does the person bring to the table in terms of their risk factors? What are their goals in terms of their own health? And then also understanding maybe some of the limitations that society has on them. So do they have access to playgrounds and gyms and sidewalks? Safe spaces to be able to do this within. Are they constrained by working two jobs and just trying to make ends meet? How can we work with individuals to bring exercise to them, as opposed to just expecting them to go find exercise themselves?

Dr. Friedman:

And this is an ongoing process, right? It's a not just once and done here to go do 150 minutes. This needs to be part of an ongoing dialogue and discussion where we're helping patients to exercise and teaching them how to do a lot, because for a lot of people, this will be something completely foreign to them and we have to help them with it.

Dr. Fialkow:

So how do you get started? You're sitting with a patient, like you said, of course, first assessment is why they're seeing you as a cardiologist, but it certainly applies towards primary care and various other preventive services, family practice, et cetera. So part of the assessment is, how much activity are you doing? What should you be doing based on your desires and your goals and your state? So what's the next step? How do you get people... Let me rephrase that. How would you motivate people who have... They'd like to exercise, they're tired. Like you said, they work two jobs. How do you get them started? And again, part of that is the understanding that a little is better than nothing. So what are the techniques you would use and what are the obstacles that you see that you would then help them get past?

Dr. Friedman:

So I always try to set realistic expectations, number one. And those realistic expectations are a two-way street. What is it realistic for me to expect that the patient can do? And what is it realistic that the patient can expect that they can do for themselves? So in that example, where somebody's working two jobs per week, trying to make ends meet and just trying to be as health conscious as possible, I'm really asking for no more than 20 minutes, three times a week. And frankly, that's what I'm asking for, for most people who aren't doing anything. To just go out and go for a walk, whether that's early in the morning, later at night, during lunchtime, their lunch break, where they can get out and just move their body for 20 minutes. That's the starting point that I think is accessible for most people.

Dr. Friedman:

As we progress and go from there, yes we would like to dial up the intensity to a certain respect and the quantity as well, doing a little bit more. But again, I'm realistic with people and tell them that as you engage in more intense activity, it's going to be hard. It won't be easy at first. The first two to three weeks may be hard. You may notice your heart rate goes up. That may be uncomfortable. You may notice your breathing gets harder, that you be uncomfortable. And certainly we're counseling on the red flag signs and symptoms there, but it's really helping to be a partner in that exercise, making ourselves accessible and guiding them through what's accessible and available to them as they progress on their exercise journey.

Dr. Fialkow:

Are there medical conditions or if we will, objective physical condition, which would change your approach to a patient?

Dr. Friedman:

100%. So in our world, yes, we're worried about significant coronary artery blockages in the heart's arteries that could pose a risk to exercise, weak hearts that aren't as strong for various causes. Perhaps arrhythmias as well, that could be exacerbated by getting out there and moving the body. So again, our job to understand the individual in front of us and individualize their treatment plan in that respect. But being cardiologists, we can't forget about all the other issues out there, like the orthopedic issues, neurologic issues as well. And so again, being part of a treatment plan and being part of a treatment team, working with our colleagues in all these other spaces to develop programs for these people, to help them. And understanding that perhaps somebody with severe osteoarthritis, maybe getting out and high impact exercise like walking or a bike may be hard. Maybe we need to do water aerobics in that setting. Again, working as part of the multidisciplinary team is very helpful. And we do a good job of that at Baptist, I think.

Dr. Fialkow:

And then, how important, and this is an open question so I apologize if I'm putting you on the spot, but how important is positive reinforcement? How important is, will the patient see something or should the patient expect to see something as they start this process? And again, I would think that part of the physician role is to review it and give them positive reinforcement as they move forward towards instituting and escalating this. So how important do you find that as part of the process?

Dr. Friedman:

I think positive reinforcement is great. The reason why I'm smiling and laughing is because I remember a specific story when I was probably 13 or 14.

Dr. Fialkow:

Well, this is an audio podcast.

Dr. Friedman:

No, it's an audio podcast. So I've got a face for radio, so it helps. But when I was 13 or 14 got out and started lifting for the first time ever, lifted a couple weights. Met up with a friend later and he said, "Eli, do you feel bigger and stronger afterwards?" I was like, "Yeah, I feel great". But the reality was that nothing had happened yet at that point and like anything, it just takes time. There are very few medicines we give that have an instantaneous impact, that it takes time and it requires repetition over and over again. So again, setting realistic expectations for somebody who's not exercising and starting, it may be hard for those first couple weeks, but we always hope that they catch that bug and begin to do it more and more, that they begin to feel better. And then, we can tangibly show them things later on by showing them their cholesterol, their blood glucoses, their blood pressures, their weight, and how it's really beyond a downward trajectory. And that is complimented, if not reinforced significantly, by the benefits of the medicine of exercise.

Dr. Fialkow:

I really do see almost like we'll have a booklet of offerings as part of the evaluation is okay, let's talk about exercise. How much are you doing? Or how much would you like to do? What do you like doing? Walking, rowing, swimming, et cetera. And we actually give them a prescription with a gradual increase, every three times a week, start with five minutes, go to six minutes. And wouldn't you think that following something like that would be of great benefit? And that's something that we are working towards in the cardiovascular space?

Dr. Friedman:

I definitely think so. And if you look at personal trainers, when they are working with their clients, they give workout plans. Well, we should be doing the same exact thing in our offices of setting the goals and then meeting again, how are you hitting these goals? How are you doing? And then, setting new goals and constantly reevaluating, same with what we do with medications on a regular basis. Are the medicines that we giving, are they treating the condition? Are they effective? If they are, great. Should we increase the dose? Should we decrease? Same thing with exercise. Okay, are we hitting the goals? Can we increase the intensity? Can we continue to squeeze more juice out of this fruit and get more benefit?

Dr. Fialkow:

Eli, this is really exciting. And I think, like I said, the superficial level is yes, you should exercise. We all do that and we all know that. But really getting into a detail, addressing it with the individual, customizing the recommendation, tailoring the specific approach and kind of exercise towards what they can benefit from and what they can tolerate is really very unique and appreciate it. And I think one take-home point, if nothing else is, something is better than nothing. You don't have to jump into a marathon or a 5K. It's just taking a few minute walk or even just doing some jumping jacks in your home, or whatever is better than nothing and people can start planning that. Great information. Any final comments or anything you want to iterate, reiterate, or any thoughts that we didn't touch on before we wind up?

Dr. Friedman:

Yeah. One other point that I think is important here, exercise and being active is a really nice time to engage in a community and you can do so hopefully outside in a safe place. We find ourselves here at the beginning of 2022, still locked within the world of COVID and trying to get outside and move our bodies more. And we find ourselves perhaps reeling for more community involvement and more interpersonal connections. Exercise is a great way to reinforce that. Joining a walking group, joining a running group, a cycling group, it doesn't even have to be anything intense and finding ways to make impacts throughout the community. What we've spoken about today is really improving one's physical health, but exercise improves one's mental health too. And the ability to connect across community-wide ranges in that respect is really broad. And maybe it's a time with family, friends to just reconnect and those social connections that we can form through exercise especially, I think have very positive impacts on our health as well.

Dr. Fialkow:

Well said. As you mentioned, it's a psychological benefit as well as a physical benefit. And people just stop and pause and just spend a minute or two and think about what they could do. Call up your neighbor, say, "Let's take a walk for five minutes". Get up five minutes earlier in your busy day and put that five minutes of exercise in, 10 minutes, 20 minutes. If you don't plan for it, it's not going to happen. But when you start recognizing its benefits and start putting it into your normal workflow and lifestyle, you'll be successful. So, great stuff. Thanks again for your expertise, your passion towards making us all healthier without the use of medications. How many things give us medical benefit without a surgery or a pill? And exercise being one of them, so I appreciate that.

Dr. Friedman:

Yeah.

Dr. Fialkow:

And before we sign off to the listeners, again, we could really use your help and feedback. Please take a moment to give this podcast a five star review on whichever platform you listen to us on. And if you have a comment or a suggestion for a future topic, email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. We'd love to hear from you. Thanks for listening and stay safe.

Speaker 1:

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