Dr. Christopher Suhar details how good lifestyle choices such as proper diet and exercise reduce cardiovascular disease risk.
Okay, welcome back from the short break is my pleasure to introduce my co director and colleague, Dr Chris Sahar. Um He has really been a fantastic co director with me at this conference and I think a visionary and kind of he's become a thought leader in the integrated cardiology space. He's also just a wonderful colleague clinically to work with and he's really become a sought after speaker and has become you know, really among the panel, one of the one of the doctors dr there's several on this panel today and you know a lot of lot of colleagues go see him clinically. They trust him so much and that's really, obviously really a compliment to him and what he's achieved in his career overall. He's an integrated cardiologist with an expertise in general cardiology as well as integrative Medicine. Um He really has a passion for using evidence based therapies including evidence based alternative therapies to treat patients with coronary disease and coronary risk factors, including display academia and his really passionate prevention. It's exciting to take a tour with him of the Integrative Cardiology Center, encouraged to do so someday. Where he directs that. He's also involved uh is one of our cardiology fellowship directors. And you know, I'm really looking forward to hearing his talk and exercising cardiovascular risk. Thanks dr Sahar, Thank you very much. Doctor Cork really looking forward to this talk. Uh Dr Cork mentioned again that I I run the Center for, I'm the Medical director for the Center for Integrative Medicine. And with everything that integrated medicine encompasses lifestyle medicine is my biggest passion. And with that exercise again, I'm super passionate about it. I'm going to jump right in because we are limited on time. 30 minutes is not a lot of time to talk. So I have nothing to disclose. All right. So, I thought I'd start my talk off with a a story, a true story actually. It was about myself, like I moved out to California from Ohio in 2000 and um, and had this chance to rent a very inexpensive room from a retired psychiatrist named Socrates. That was his real name. I'm not making that up. And uh, he, I got so jazzed to be on the pacific coast to pacific ocean and run every morning on the beach. And I did this all summer long. I ran, ran, ran and everyday Socrates will be sitting on the back patio, just people watching. So one day I stopped and I asked, I said, hey man, like why are you not exercising? Why aren't you enjoying this opportunity, you know, to, to go for a run on the, on the boardwalk. And, and he looks at me, guys chris, I'll tell you what, sit down and observe with me for 10 minutes before I answer that question. And so I sat there and I observed and what I saw after about 10 minutes, he asked me, he said, what did you what did you witness? Or would you observe? And I said, well, gosh, I observe pain. I observed exhaustion. I observed sweating and people really out of breath, you know, just not happy people. And he looked at me and he goes, why would I ever want to do that? You know? And that is stuck with me in my career. You know, I think exercise is probably the single most impactful thing a patient can do to better the outcomes for their health and and and just better their outlook on life. Actually, there's tons of research research showing this yet a number of our patients that we try to get to exercise. Look at exercise this way. They don't like exercise is painful. So how do we where do we go with that? Well, what what gives me hope is that, you know, I love to exercise. I enjoy it. I get that natural endorsement rush. And I do have a number of patients that also feel the same way they feel better when they exercise their happier. You know, they feel like they are actively engaged in doing something with their patients. So the real challenge is how do we tap into this side of the love for exercise? The benefits of exercise in our patients? What we do know is what we do know is that we are losing the battle. The numbers for heart disease continue to rise. And despite the best of what we have in Western medicine, with all of our medical therapies and medicines and testing, our numbers continue to rise and it's not looking good. We are in the middle of a public health crisis. At least a quarter of the us population has more than one chronic disease. Multi morbidity, multi morbidity accounts for 83% of healthcare spending. It's only on the rise. And what has been unfortunate is we in medicine have been very quick to the pill. We have become very dependent on prescribing medications. Could we be doing more to maybe not have to be as dependent on medications? Um So so the C. D. C. Published a study a number of years ago. There's many like this. Um This was one of the largest I found on more than 50,000 U. S. Adults for over 20 years. They looked at seven standard health metrics and these, if you look at them are pretty attainable. These are pretty reasonable health metrics Whether you smoked if you were active, meaning you exercise, you know five or more times a week at a moderate mild to moderate level or a little higher intensity three times a week, fairly healthy diet. You know, uh controlling your blood sugars, blood pressure, cholesterol and obesity, reasonable numbers. So they looked at those seven health metrics and what they found was there, it was a 51% difference in all cause mortality between patients that could accomplish six or more of those metrics versus people who accomplished only one or less, uh, one or zero of those metrics. So a big, profound difference in people who are getting reaching those healthy goals versus the ones that were not modifying lifestyle continues to show the largest improvements in cardiovascular health. Unfortunately though physicians haven't really been the best at guiding their patients in in a in in surveys, there's reports that physicians spend an average of only eight minutes in a one hour consult. Now, one hour consult is a dream. Most of us don't have that. But this, this survey looked at physicians that actually had an hour with their patients eight minutes total, spend a lifestyle change. And that included canceling about tobacco and alcohol, which tends to be the things most commonly addressed if you're going to address lifestyle. Um, you know, we're missing the boat and unfortunately, a lot of us haven't really been trained in motivational interviewing, trained on how to get people to exercise, how to get people to eat better and manage their stress levels better. So, um, we are, the reality is most Americans have little or no physical activity in their daily lives. The number one excuse for not exercising is not enough time. What I like to point out is that the average America watches 30 hours of television per week and I often talk to my patients about this. Um, what we do know is there's an estimated 200,000,000 deaths annually in the us related to a sedentary lifestyle. Exercise is beneficial and a number of ways it reduces the risk of all cause mortality and morbidity promote psychological health and prevents and eliminates the risk factors of chronic disease through improvements in cardiovascular and metabolic health. Uh, now, to look at the data on exercise, there is a lot of common sense to exercise, but there's actually a fair amount of research. The largest studies to look at this was the Harvard Alumni Health Study, the Women's Health Initiative in the in Haines study, um, where they had the largest groups of patients and looked at exercise outcomes. And across the board every study shows a profound benefit in outcomes when you when you when in patients who accomplish exercise versus the ones that do not accomplish it. However, these studies reliance self reported data and can have significant bias. Unfortunately to date, there are no large randomized controlled studies on exercise. They just don't exist. They're too expensive. We're looking for very few events. And so the numbers of these studies are too large to be able to really accomplish randomized controlled studies. Now, that being said, there are a number of randomized controlled trials that I I just listed just a number of them where they use surrogate markers, things like cholesterol lowering blood pressure, lowering crp level, lowering uh and weight decreases. And again across the board, profound improvements in these surrogate markers when you are looking at randomized controlled trials and um and studies on research. So um what I really, really point out to my pain when I really point out to my patient is patience is that exercise is the single best method to stay young as you get older. And this tends to resonate with a lot of people, especially with our older population. Unfortunately, this is what a lot of our are, a lot of what people perceive exercise as this is actually. I think this is a pretty common picture shown in a lot of these talks now, but this is a real picture here in SAn Diego from Point Loma. This is not Photoshop All right, so how do you define exercise Now? There is, what I wanted to do is really point out the difference between physical activity and exercise. Uh physical activity is any bodily movement produced by contraction of muscle that increases your energy. Now the difference with exercises that exercise is actually physical activity that is planned, structured, repetitive and purposeful and with the main objective in improving or maintaining one or more components of physical fitness. So a big difference there. Um what we know is as you increase your physical activity as you increase your actual exercise or cardio respiratory fitness, there is continued improvement in relative risk reduction with the more you do that applies to not only exercise but also to people being physically active. We know that exercise is not just on or off. It is definitely a spectrum from the sedentary patient to the patients who do physical activity that is considered more light to the moderate levels of exercise into the more moderate and vigorous exercisers. Um What uh what what we what we used to think about with exercises. We used to think they were either sedentary patients or exercisers. Uh this was a clever study where they put predominant predominance on patients and accelerometers. And they found here in the middle uh that there is actually a big difference between sedentary patients is which is really a lack of activity versus active patients versus exercises. More color, the more active you are. Um, there is this spectrum where you get as you increase those levels of activity, you get, you gain benefit from that as far as health outcomes. All right, so what are the four pillars of exercise? These are flexibility, strength, cardiovascular, and you're a murder your own murder as a cardiologist. One of the things I tend to always focus on is cardiovascular, but what I've had to remind myself throughout the years of my clinical practice is that all four of these pillars of exercise are key to guiding your patients towards the path of exercising. Um now, what I um when I found out what Dr. Cork and I negotiated, we only allowed 30 minutes for our talks. I took out the meat of these pillars. And what I did was I took my slides and I put him at the end of my talk. I'm not going to go into each individual pillar as far as the nuances of how to encourage your patients to do each one. I'm going to go more into kind of the prescription of exercise and how to really reckon what to really recommend for your patients. But what I want to encourage you, you have access to the slides, you can skip, you can go down to the bottom of the talk after my thank you slide in. The meat of these pillars are going to be listed there, so that hopefully will be good information for you. So what about the optimal exercise prescription for our patients? Um It's really the way I look at it is it's really an approach. Uh you know, it's really you've got to really um uh it's very individualized and we need to basically partner with our patients on helping our goals of getting them to exercise more. I love this cartoon here, the doctors asking his His patient, what did your busy schedule better, exercising one hour a day are being dead 24 hours a day. I always thought that was humorous. So, um what the underlying theme here is that we must actively engage our patients, asking a patient if they exercise and moving on is not good enough. It needs to be a conversation and it needs to be a repetitive accomplished conversation at every visit exercises you must understand is exercise is very personal, patients have different beliefs about exercise. A lot of them are educated on the different pillars, are not educated on the benefits, patients have different interests. I love to run, that's my thing. Another patient may hate running, but you start tapping into different options. You find out well they love to swim and maybe we can come up with the different strategies for that. Uh And always remember never let up. You must motivate and keep pushing, emphasize and courage and engage otherwise it won't happen and it will not work if the exercise is not fun, you've got to find a strategy to help your patients enjoy their exercise. So the optimal exercise approach, it consists of five components mode intensity, duration, frequency and the progression of physical activity. These five components apply to everyone regardless of age, fitness level and health status. So for mode it's those four pillars. Each pillar has certain exercises that maximize the benefit. Um You gotta you must encourage exercise that the patient actually enjoys and choose the exercise that works within their physical limitations. Some patients, based on their physical limitations may benefit from different pillars. You know, more flexibility if they struggle with joints and muscles um you know, they're older, more of the neuro motor exercises, et cetera. Uh For intensity, intensity and duration of exercise determines the total caloric expenditure. It should be tailored according to the patient and their health problems. Now this is the biggest what I think the biggest component of exercise that people struggle with providers struggle with when we're recommending exercise when you um are just looking at my time, making sure my mindful when you when you ask somebody if they walk or they run or whatever it is and they say yes, it's kind of like a lot of, a lot of providers check and they move on. What you really need to do is dig into the intensity. What are they really putting into their exercise? Give them goals for that intensity. So it becomes meaningful. Now there's different ways to measure intensity and I'm not gonna go over these for time. There's the heart rate calculation, heart rate reserved, the traditional heart rate calculation based on your age, there's heart rate reserve, which tends to be more accurate. Again, I'm not going to spend the time I've got the equations there that you can work on. Um what I like to use is rating of perceived exertion. This is basically asking a patient, you know, if they feel like they're getting a good workout, it really doesn't have to be more complex than that. In fact, I actually don't give heart rate goes to a lot of my patients because I think it takes the fun away for your exercise. There is an objective way to quantify this and exercise physiologists do this and cardiac rehab. They have a scale and based on a patient and what their, what they tell the physiologist, exercise physiologist about their level of what they're feeling their symptoms. You can give a number to it and then they can follow that number and see progression on how they're improving. Um, but really, you know, is the patient's writing a little bit, are they a little out of breath when they're talking or walking? Um, you know, do they feel like they're getting a workout or they feel like they're lollygagging? You know, we've all seen those patients at the gym on the elliptical where they're kind of just move in and they're, they're flipping the page on the magazine and you're looking at him like come on, that's not really exercise. So again, really diving into this is an important piece of encouraging a meaningful work out. So duration this correlates with intensity. As an intensity increases. You can tend to decrease your duration, Scientific evidence is lacking to support the health benefits of high intensity short duration exercise. Um most guidelines recommend that's the hit, that's the hits. I'm gonna get into here in a second, that's the hit exercise. Most guidelines recommend moderate intensity, moderate duration which is about 30 minutes and the healthy individual to improve aerobic capacity. Um speaking of hit. Um so so hit training is this high intensity interval training. Um This is something where a lot of patients get attracted to this, they They are interested in saving time. It's this typically a super hard burst of exertion for a few minutes, anywhere from 10 to 10 minutes. And then you take a break and maybe repeated another time. Or you do some kind of recipe for about 10 minutes of this super intense off, super intense off. And um the thought is you can get a lot more of a workout in in a very short amount of time. There's very questionable safety on this. Uh There's not good research proving the safety. Uh And so I do I do caution you if you have patients with hit to really have an open discussion about what they're doing. Are they really trained for it? I find that this is this is kind of like fad diets in a way where I'm excited to hear dr meta and his talk on nutrition, you know, fat diets often don't last people start it and then they go away. You know, diets or something you can stop unfortunately. Um you know hit training these patients, my experience, they start with this but it never is this long term solution for continuing exercise throughout their life. Um What I try to encourage is a different kind of interval training. This is where you're at a baseline level and you have your patients exercise at a baseline level for a period of time, you increase for a minute for a period of time and then you actually go below your baseline for a minute but you don't stop and that's like a recovery and then you go back up to your baseline. This can be incorporated on treadmills, ellipticals outside when you're on a walk with a stopwatch. A lot of the equipment, cardio equipment has these programs already built in that already have the intervals figured out. This cannot really help a patient improve their stamina. And then as far as frequency we must, it's paramount that we encourage our patients to exercise seven days a week. Some of the guidelines say five days, some say seven. I always believe that a patient will never quite get to what you're recommending. So if you're saying five days they're going to come in under that. So I say start at the max, let's go seven days a week. And then if they come in under that, hopefully they'll come close Every day a week, seven days a week, at least 30 minutes a day. So progression never let exercise get stagnant, encourage new exercises. I love cross training um the uh helps to prevent overuse injury and then really having that discussion every visit and asking what they're doing and then ask for ways to increase over time. So let's put it all together. So if a cardiac for the four pillars cardio respiratory, it's seven days a week of moderate intensity, that's what I always recommend. Um And modern intensity could be a brisk walk or other aerobic activity. Patients always asked me well what does that mean? I give them a benchmark of a 15 minute walk, it's four MPH in a treadmill. That's a pretty brisk walk. But I give them that benchmark. So if they're hitting 24 minute miles I start getting them to measure that at least they know where they're at. And then you can slowly encourage them to get to 23 minute miles, 12 then to 22 you kind of work out at that And I always tell my patients if you have only 30 minutes in the day to exercise, cardio respiratory gives you the greatest benefit and always choose that over the other pillars. There are many excuses, but there's always some form of cardio exercise the patient can accomplish. You got to try to open your comeback list as far as when patients say, oh hey, I can't exercise because my knees hurt. Well why don't you swim? Well the pool is cold here in California. Well, wear a wet suit. You know, you can always come with different ways. Come back to encourage a patient to come up with different strategies uh for flexibility. Um uh 2 to 3 days a week. Um should be performed to the point of mild discomfort within the natural range of motion. I really encourage working with the physical therapy or therapist. Ical therapist or personal trainer to learn these techniques. Resistance training. 2 to 3 days a week. Um I'm a big fan of, most of us are not bodybuilders. I'm a big fan of starting low weight and increasing reps. Again, this is another thing when a person goes to the gym for the first time. I was encouraged them to hire a trainer for 4-8 sessions just to learn the gym, learn the equipment, the machines and learn how to kind of incorporate a resistance training program And then for your motor. This is also incorporated 2-3 days per week and more as you get order. You know, over the age of 80, fall prevention becomes a huge thing. And so I really do focus more on this on on my patients over 80. Uh, and again, this is really best accomplished with uh physical therapist or a number of classes that can be focused on this. There's some great senior classes that really work on no neuro motor exercises. So exercise order cardio respiratory exercises. Always first. Uh This uh this actually this. I lost my train of thought here. This study that I have listed was a very clever study. Um on looking at the order. Actually they actually looked at the order for exercise. And what we found what they found, they looked at the four pillars and what they found was cardio respiratory um was uh patients were more compliant with cardio respiratory if they put that first before resistance training. And it didn't really matter where you put flexibility and you're a more motor. I'm a big fan personally with doing a lot of flexibility. I do before and after most exercise physiologists really encourage it at flexibility after you do some kind of warm up exercise that's kind of been validated to be better as far as getting a good stretch in. Uh So exercise dose um uh You know again what you have to find where your patients at and wherever they're at slowly increase and try to get them to move up that scale. This has been looked at and there is no level of exercise that you can do more that won't continue to give you added benefit as you increase hours of of exercise per week. All cause mortality goes down the more and more you're able to accomplish. However, when you get over about 2.5 hours per week, you start getting diminishing returns. So you're bang for the buck is in the 1st 2.5 hours of the week. After that, I always encourage more. Um but you do you do risk um you do risk more injuries. If you do more, you also risk, you know, compliance. If people start getting tired of it, that kind of thing. But anyways, if patients asking for more, God bless, it's going to get more outcome. You're just the first bang for your buck. Is that 1st 2.5 hours of the week? So, um, the biggest, biggest multiple studies have shown that the biggest risk of for cardiovascular outcomes of sedentary behavior. Um uh, this sedentary behaviour increases all cause mortality, cardiovascular disease and diabetes. Two biggest culprits are television and the workplace. There are a number of things we can do. We've experienced this recently in Covid. I've seen people now doing more meetings outside. Uh, we can now incorporate different types of equipment. I remember when I did my mayor board review. They had these treadmill desks there. Um, and it was great because super slow. But it kind of gets you moving here at, at our center. We have a number of staff, they just sit there. They do check in. They they don't move much. So we get, we got stand up, sit down deaths for for them, another great thing to incorporate the workplace. Um wearables. There's been an explosion on wearables. Uh the uh you know, there is some controversy over this, but I think this does drive the conversation and it does work for certain people, a lot of money in this business and I think the technology is getting better. Um I did have a kind of a fun thing here. I don't have a lot of time. All I can tell you is that The 10,000 mark for steps is what everybody quotes. That was based on marketing. There was actually no research that was put into that. However, when I went out and tested it with my own pedometer in order for me to get to 10,000 steps, I pretty much have to exercise. So. So I have found anecdotally 10,000 steps is actually a pretty good thing to recommend if a person really wants that recommendation. So I think it's actually okay even though the research is not there, I think it's okay to use 10,000 steps as your benchmark for whether a person can reach that exercise that doesn't go over exertion level. So again you'll kind of take that with a grain of salt. So um I exercise resistant patients. There are a lot of them. I use my five minutes exercise program. This is where we we start with only five minutes of exercise every day. You know they're not allowed to increase. They can only do five minutes a day for 30 days, then they go to 10 minutes a day for 30 days, then they go to 15, it's at any pace. They just can't skip. This has been highly successful for my patients. Um and so just a clever way to do it. And I always get these patients that come back with their spouse and after they We talk about it they turned they always turn to their spouse and they say see Dr. Sahar only said five minutes. Yeah a spouse always struggles with the fact that I told them only five minutes. But what I'm trying to do is five minutes is better than zero. And these are my patients that aren't doing any. So um I'm gonna skip that side. Okay so what about cardiovascular risk? I only have a few minutes to go over this just recently in the Euro Cup. We we saw christian eriksen collapse miracle. That, I mean it was great to see the medical, the team and the medical staff save him. He ended up getting a defibrillator. But this catches all the news and it reminds people that there is some risk associated with exercise. Um the research is convincing if exercise is done right, it is very safe. Exercise is known to acutely, albeit transient lee increase absolute risk or increase increased relative risk for sudden cardiac death. And in mind The absolute risk for acute events that are still very rare. It's about .3-2.1 uh for sudden cardiac sudden cardiac deaths per 100,000 person years, so very rare. Um and there is differences in age. The older individuals over 35, there is a higher estimated risk, but again, still rare, competitive is slightly more risk than non competitive and men is more risk than women. Although I think the studies are very poor. Um looking at women and this risk, I think most of the studies have been done on men. So uh you know, as far as causes, whether it's competitive or non competitive for people over the age of 35 individuals over the age of 35 C. A. D. Is the predominant cost cause for under 35. We used to think Hokum and coronary anomalies with the predominant cause. More recent studies have suggested that actually non identifiable causes are the most common. Hokum and coronary is still very important causes, but they're actually not the most common. A lot of patients in this group have structurally normal hearts. Uh what about extreme exercise? This is like marathon runners, Triathletes. The biggest risk is inappropriate training and the risk also appears to be lower in women. This is really getting looked at a lot, a lot of by a number of groups. Um uh marathon risk is about one in 100,000 participants and for triathletes is a little higher at 1.7 per 100,000 participants. Um There is seems to be a U shaped curve looking for intense training at intense training. The Copenhagen City Heart study was the first to highlight this as you start to get to extreme levels. There's this question of loss of health benefits, there's very questionable data and the that in this specific study there was very small deaths, there's a lot of overlapping, wide and overlapping confidence intervals. So the data was questionable. There was follow up studies showing that actually they're questioning really whether that risk was truly there at those high levels. Um So I know I'm right at the end of my time, so I'm just gonna finish on a couple slides here. Um We all know about the athlete's heart, that's enlargement of all cardiac chambers uh in the setting of a improved cardiac functioning cardio and compliance. Electro electrical remodeling has also seen these patients. Sinus bradycardia, sinus arrhythmia, first degree A. B. Block. These things have been uh have been seen over and over again. And we know this is a real entity. We also know that reverses after patients stops doing the extreme exercise. We really don't know the outcome of this. It's not been shown that this is actually harmful. Um We also see an increased incidence of a fib cornea, atherosclerosis and mild cardio fibrosis scene with increased late gadolinium enhancement seen in athletes on M. R. I. Um So um these can happen in the patients that are do extreme exercise for all patients. What's interesting is moderate levels of exercise improve these areas. It's not until you get to the extreme levels where you start seeing these increased risk. So again patients should be aware of the possibility of these these issues. So what about screening? Um I take a very individualized approach. Um Getting routine BCG or stress testing is not universally recommended. Uh It's also very controversial for screening high school and college athletes. Although here at scripts we have an amazing program called the eric parities Save a Life program where we go out to local high schools and we do screen them with health screening E. C. G. S and then some patients go on to echo screening as well. It's been a very successful program that's free to the community. I think the big controversy is the cost to benefit ratio. We took the cost out of it. We were we've raised money to support this. Um I think this uh this will be in my slides, this calculator are this risk category. Uh kind of graph here shows a really good approach. You have to look at the patient's individual level of activity and whether they are symptomatic or not when you're discussing the safety or or risk of exercise and if they're trying to accomplish light to moderate levels of exercise and they're asymptomatic, I say go for it. You do not need to do any kind of screening. If they're trying to go for that high risk kind of exercise like marathon, high elevation exercise, triathlons, etcetera, then you need to have that discussion about the risks versus the benefits and proper training. Uh I don't have time to go over where wearable health technology. Um so what I will just end with as far as the summary is that exercise continues to be the single best method to stay young as you get older. Uh We must actively engage our patients Uh include all four pillars and it's definitely you can choose your battle on which one you go with with your patients if you only have so much time. But cardio respiratory would be my preference more is better. Although diminishing returns at higher levels, exercise is safe. However, there is some risk if not properly managed um and we should encourage our expectations to exercise seven days a week. Thank you very much. Sorry when a few minutes over. But again I really appreciate your attention dr Sahar. Thank you so much. Great talk. Very comprehensive. I think one of the the goals today was to really be better counselor for patients and your strategies you suggest are nice and are going to improve my ability to counsel patients. I think you've got some creative approaches there. I'm glad you covered the four pillars of exercise and the benefits of each. So Great talk. Thank you so much.
