Dr. Karl Nadolsky presents available evidence-based physical activity guidelines, provides personalized prescriptive exercise suggestions, and expands on nuanced exercise guidance for patients with diabetes.
dr carl model ski is going to be talking about exercise and I just wanted to add, he is particularly qualified to talk about this because he is quite an athlete. He was a big 10 wrestler, wrestling on michigan state's varsity team when he was in college. And he also while doing wrestling um really excelled academically. And the other thing I wanted to add carl is you really tugged at my heartstrings when you set soda pop my midwest roots, just like I felt so much joy for that. So, I I appreciate that because here in California, it's just key terminology there. Alright, right there. So go ahead. All right, well thank you very much. And I know on the brochure it talked about exercise for weight loss I think. But really what I want to focus on is exercise is medicine because uh there's one particular slide will, will go over where exercise maybe isn't great for weight loss per se, but it's definitely medicine for what ails our patients and that's the, you know, the animosity based disease. We talked about the complications, obviously the body composition and fat loss and muscle gain are very important for our health and that's what we actually care about what's on the inside that counts literally. So again, no disclosures objectives. Um you know, just kind of maybe re familiar, familiar, familiarize ourselves with the available evidence based physical activity guidelines um, and improve some comfort in providing personalized prescriptive exercise suggestions to patients with goals. Again, beyond the weight loss that they need to understand a lot of people just think I don't exercise enough. I know, but that's not maybe the key um and expand awareness of nuanced exercise guidance for patients with those and deposit based diseases like diabetes. And so this is uh this goes back a few years. This was actually a blog that my brother and I wrote for med page today because so many people out there, especially those trying to work against evidence based medicine and mainstream Western medicine claim, well all those doctors, they don't they don't prescribe lifestyle, I don't prescribe exercise, you know, come to see our functional medicine clinic because alternative medicine were the ones that actually care about this, but that's not true. They get their data if they're even doing evidence based medicine at all from real mainstream medicine, Every single relevant guideline evidence based guideline has exercise first when applicable. And so just to go over those a little bit and they're all basically the same just to be clear because the evidence is kind of, you know, it's pretty consistent across the board. But again, it's a personalized thing that we have to really think about. So here's the World Health Organization, just guidelines on physical activity and sedentary behavior. So they'll talk about trying to get over 150 preferably 300 minutes of moderate intensity, aerobic physical activity, which, you know, first of all, patients don't understand some of this stuff. So we just have to talk to about walking briskly um figure out where they are. And we'll go over that a little bit more. But then also, you know, more than 75 115 minutes of vigorous intensity, aerobic physical activity or some equivalent of that throughout the week. And certainly muscle strengthening activities that moderate or greater intensity. I'm a shill for for weight training. Um You know, I think it's an extremely important thing that we need to get more people doing from the time they're in their youth all the way through death because it's important for every age group. Um and it's recommended to increase moderate intensity aerobic physical activity to over 300 minutes. Um for additional health benefits or that 150 vigorous minutes. And then also, and this is now consistent in all guidelines. And we'll talk about where this is, but reducing the amount of time being sedentary. So we're all I'm sitting here right now, I see dr Harris sitting there right now, we're all sitting here right now, look at looking at these. So, you know, in between lectures, we should be up and moving, we should go to the bathroom, get a drink, do some sort of little activity and we need to find a way to help our patients do that too, because it really matters. Here is a slide. The first one on the left is from our 2016 obesity guideline. And again, very consistent with every guideline. You see we want to increase aerobic physical activity more than 100 and 50 minutes per week, preferably again that 300 minutes per week resistance training. Each muscle group at least two times per week reducing the sedentary behavior. And also, again, finding a way to individual lease. These programs for people. We have patients of all different, you know, creeds and all sorts of stuff and they have different injuries and physical limitations. So we have to find a way to personalize recommendations for all these people and that's where we should start incorporating other expertise. Have insurance would cover. That's part of the big barrier that I suspect is a recurrent theme here. But exercise physiologists, you know, if, you know, personal trainers, you you trust first of all, because you never know what's out there. So think about that. And what, what is the common theme for everything we'll talk about is that the clinical benefits are more important than the weight. I always tell patients I don't care about your weight on the scale per se, especially when we're talking about the exercise aspect. But it's literally what's on the inside that counts. So, exercise across the board improves metabolic health by CMA control lipids, blood pressure, inflammation and also functional capabilities, cardio respiratory fitness, which is a very important predictor of long term mortality, strength, vascular function and also structure structural so they lose weight. They might improve some of the actual weight related issues like arthritis and sleep apnea. And so here's just from the 2000 and 21 88 standards of care. So obesity and add a posse based Type two diabetes. Especially very important. They there's going to be this question of do we need to do any dynamic testing for these patients who are at very high cardiovascular risk. And that's a somewhat controversial and debatable. But I think if we evaluate patients correctly and give them appropriate exercises that they're able to start, then we probably really don't need to. And we'll talk about that in a little bit. Um going back again more than 100 and 50 minutes of some sort of aerobic moderate to vigorous exercise every week, 2 to 3 sessions of resistance training per week for each muscle group and reducing the sedentary time. And this is in the recommendations. Go for walks before and after meals, interrupt your sedentary time when you're working. These are evidence based guideline driven recommendations and they also throw in flexibility, balance training, yoga, tai chi, that sort of thing. And uh I kind of wish I would have done more of that back in my day. Maybe my interest would have even been even more special. All right. And so just some real basic nuggets here, meeting these aerobic and resistance training guidelines are associated with lower obesity. They're associated more importantly with cardio respiratory fitness and a lower risk of type two diabetes and a modest mean weight loss of 1 to 3% with 100 and 50 minutes weekly of modern. Too intense aerobic training is really what you can expect. And this is why I use this type of example uh, to talk to patients who say, well I know I don't exercise enough or how much I know, okay, let's find a way to exercise and lose weight. Well this this waterfall plot is what I described all my patients. So if you look at this, this is each individual in one of these trials where they were prescribed a lot of exercise and this is the weight change here. You can see some people do really well with weight loss all the way up through people who don't lose a lot of weight. Again, this is not body composition. This is wait. So hopefully some people are gaining some muscle but there's some people and this goes back to that uh, you know, the hypothalamic control of our appetite and metabolism that uh in some people overcompensates and they actually gain weight if there's no other interventions. So when we're talking about weight and actual obesity related disease, we do need to address all things. But this is just an example that when people do only exercise, they may not lose a lot of weight, they might, but they might even gain weight. And so we have better outcomes with higher intensity and increased volumes. So we got to start where the patient is not everyone can just go out and start running wind sprints and doing crossfit and running marathons, but you can start where they are and then increase their volume and intensity as they can tolerate and as they are able to do so and then again back to the inside that counts, improved glossy mia metabolic syndrome components and cardiovascular risk factors. Again, the better the higher intensity, the more volume, the better those outcomes end up. And for the actual weight loss. You know, we do know that higher amounts are really good for weight maintenance. In fact, it's one of the key components in some of the weight loss, maintaining registries that we have. And this comes to that concept of fitness versus fatness and mortality. So for so we don't use that term with patients. But um, no matter what the weight is, their fitness matters for their outcomes. And so here's just a little schematic that was recently published in the past year and a half about obesity associated type two diabetes. And and how it has this sort of Vicious cycle of reduced cardio respiratory fitness. Because if type two diabetes leads to roost cardio respiratory fitness. Well then they're not maybe going to do as much exercise, which is just, it just leads to this vicious cycle. So we have to address all the areas of that vicious cycle. And so this actually just recently got published and some of us I think commented online about it. So this goes back to that concept of well, you know, if they don't lose a lot of weight with exercise and they get frustrated, they regain their weight, then maybe it's futile when really exercise is important for what's on the inside that counts and what matters. So so this is a proposal that for obesity treatment, we don't care about their weight anymore and we only care about their fitness. Well, to some degree, that's true. But also there's no reason to completely discount all of it. You know, we should all be holistic and treat our patients holistically. So we're going to we're going to treat their weight, we're going to treat their energy balance help decrease animosity, but also make sure that they focus on their fitness and get the benefits from exercise that actually matter. And so, you know, what they talk about is this weight neutral strategy, the mortality secondary to obesity is attenuated with higher levels of cardiorespiratory fitness or physical activity and cardio metabolic markers improve the exercise training independent of weight loss. Um and then they question the intentional weight loss and mortality. But we do have data where if people intentionally lose weight and we actually get that response to therapy we discussed earlier with the far Michel's therapy especially over 10% weight loss, then we do start to see where some of these outcomes can can improve, but there's no reason we need to be mutually exclusive here. Yeah. And so I kind of cross this out. I think I shared this on social media and I said, why do we have to be mutually exclusive? Let's do both. But the point is taken and we do need to improve everyone's exercise and cardio respiratory fitness. Okay, so here's a guideline that was a couple of years ago from the european Journal preventive cardiology. The european associated of preventive cardiology. And so this is specifically for some of our highest risk patients, obesity, type two diabetes and cardiovascular disease. And I just want to run through some of these because I think it's important and it reiterates what we're talking about increased cardio respiratory fitness should be an important goal. Whether or not we assess it with the testing that gets into practicability practicality. I don't know that that's necessarily true. But for our patients with type two diabetes glycemic control should be a key target of exercise training. That's where we can see some of the real benefits. And while cardiovascular outcomes are likely improved, we have pretty good data about the microvascular outcomes and muscle strength back to being a shill for weight training and strengthening. Muscle strength is pretty well known to be prognostic and a relevant target for patients to achieve. And they say again like I've been saying, weight loss per se is not a relevant target fitness, likely serves as a better path a physiological and motivational parameter for patients. Um And certainly we can use different measurements of body composition by but not necessarily practical or enough data to use as a pragmatic target for patients per se. And I think blood pressure is a really good adjunctive target because I think anybody who knows when patients really start to put in the exercise time we see blood pressure improved triglycerides and they can de escalate some of the medications um that are needed if they are needed but maybe maybe aren't needed anymore in these cases and patients like to deescalate medications. Um And uh and to improve adherence activity needs to be carefully adapted to preferences and comorbidities and then adjusted the training progress over time type intensity duration of exercise. So again we have to personalize all these recommendations for every different patients. Okay going back to talk about duration, volume and intensity of aerobic exercise needing personalization. So high volume modern intensity for body composition and cardiovascular risk factors. So H. I. T. Stands for high intensity interval training. So that can be doing sprints weight training all sorts of different versions and how to do that for patients depending on what they want to do. Um It should be considered as an alternative. It is very good for patients to and going back to that reducing the sedentary time if we have people interrupt their sitting and taking little walks before and after meals. They have definitively shown improved glycemic control high volume resistance training very beneficial, especially when combined with aerobic exercise training again for glycemic control, body composition and strength. Now there's insufficient evidence as an alternative to aerobic exercise training. But I would like to suggest that it really depends on how you do it. Everyone knows you can lift weights in a somewhat lazy manner or you can lift weights really hard with high volume, little rest periods, high heart rate, that sort of thing. And you do need to monitor for some of the cardiac autonomic neuropathy and risk of hypoglycemia depending on the medications which I think were mentioned by like Alex when uh you know for like intermittent fasting, we want to reduce those types of medicines almost across the board. And so for every individual started a low intensity and aim at integration of regular physical activity into their daily routine. We got to make these things that have it. And so here was a trial that was published in the new England Journal of Medicine a few years ago for older patients, 70 years old Amine B. M. I. 35. And they weren't really doing that much. And so here are the different arms that they had no control arm, has the guy sitting at the couch. Um and then they had the aerobic arm, 60 minutes, three times a week Resistance training, 60 minutes, three times a week or some nice combination thereof. And over here you can see the graph the weeks of intervention and the weight change in percent. And they also included some good dietary habits and you can see it actually in this trial. A very nice uh weight loss really kind of the same for all these groups. The aerobic resistance and combination. But note again, the reason I put this in here is because they weren't just doing exercise. They were including a dietary intervention. So that there was really good weight loss with us. And then what you can see here that that splits up the weight loss is the lean body mass. So you can see this change from baseline. So obviously there's more to just fat loss and people are going to lose a little bit of everything. Um The least amount of uh lean mass loss. Of course when it was only resistance training uh the combination group lost less lean mass than the Arabic group. And uh the down here you can see the strength obviously improved when you included the strength training. Yeah. So what about the physical activity pre participation screening? Do we need to get medical clearance for these high risk patients? Do we need to do exercise stress testing. Do we need to do cardiopulmonary testing? Well, here's some thoughts. So there's really a lack of evidence that medical clearance plus exercise testing mitigate any of the risk of any exercise related cardiovascular events which are pretty rare anyways. There's really a lack of consensus regarding the extent of medical evaluation needed as part of the exercise. Pre participation participation health screening process. Uh The American College of Cardiology recommends exercise testing before engaging in moderate or vigorous intensive exercise when the risk of cardiovascular diseases increased. But they really point out that they recognize that these recommendations are based on conflicting evidence and a lot of divergent expert opinions and so this is getting busy. I know. But the physical activity guidelines advisory committee report to the secretary of HHS stated that symptomatic persons those with cardiovascular disease, diabetes or other active chronic conditions who want to begin engaging in a vigorous physical activity and you have not already developed a physical activity. Playing with their health care provider may wish to do so. But it still doesn't mandate such medical contact even. And the U. S. P. S. T. F. Recommends against routine diagnostic resting or exercise. E. K. G. For screening asymptomatic individuals at low risk of cardiovascular events prince efficient, insufficient evidence. No specific recommendations regarding the need for exercise testing for individuals that intermediate or high cardiovascular events. The american College of Sports Medicine does not recommend abandoning all medical evaluation as part of the exercise participation health screening process but to identify the highest risk for those who might succumb to exercise related acute M. I. Or sudden cardiac death referred to health care provider. Obviously for us we are the healthcare providers so we need to think about this. But I think the practicality is that it's probably not really the best thing for patients. So here on the left are just the exercise standards for testing and training. Um, and this is just a picture of it. And over on the right talking about metabolic equivalents and how it is a strong predictor of mortality. And whether or not we need to do cardio metabolic testing. I just don't know that that's the case because we should be able to get a good history from patients and know what they're capable of and where they start. But what we want to do is increase their cardiorespiratory fitness even just a little bit seems to be associated with lower rates of cardiovascular events and should and cardiorespiratory fitness should at least in theory be added to to risk models. And I certainly agree with that. I just don't know that we need to be testing and then monitoring people because it's not really pragmatic to be honest. Because there it is, I don't know that many people are doing this or if it's even necessary. And so now what about these metabolic equivalent? So when we talk about these recommendations, I'm not so sure a lot of physicians know what these are and I know patients don't know what they are. So here's just a quick slide that shows an example of, you know, very low intensity met about equivalence when you see these in the literature and recommendations all the way up through gulf walking, skiing, basketball, you know, jogging 10 minute mile. I guess it would be more like jogging. And then, uh, these higher intensity activities where you're running sprints or cross country skiing or competitive cycling certainly is pretty high intensity. So here's some pragmatic advice. Instead of doing all that stuff, let's just start low and go slow and personalize the prescriptive plans for patients. Um, well and exercise the test. Change the plan. Well, if they seem to have symptoms, then it's indicated anyhow. Um, do they really want to go from being a sedentary high risk patient to suddenly going out and running sprints and doing crossfit like in a real vigorous plant. I don't think many people can or necessarily want to do that and we shouldn't probably have them do that even if they want to. So no matter what we do or what the risk is an exercise prescription is indicated and so we need to do it regardless. So help them establish a daily habit if they really, really don't do anything. I tell patients, look, let's figure out when you might have the most likely time to do it and let's just pretend exercise for five minutes. And I kind of joke with them. But then I said, but really just just go for a walk and walk for five minutes and come back. Or maybe they can't walk and we have to do some arm exercises in the house. Or maybe we need to invest in a bike or get to the gym, but just some sort of habit. And then we can go from there, started a low duration goal like five minutes, 10 minutes. And then we can slowly increase that and same with the intensity. So again, they don't need to start running necessarily. I don't think a lot of our patients can run. So we have to have a low intensity goal, just something light and then we can crank it up from there. So here's some uh examples walking, biking, elliptical. A lot of patients might want to, you know, get into a community pool and use some swimming but also light recreation. Think about what what patients want to do. And uh and if we find something that they have fun doing then they're more likely to continue doing it. And it's all good for him. Maybe we need to do some testing prior to patients who are sedentary with high cardiovascular risk, who really really just want to suddenly start doing high intensity interval training or high intensity circuit training. But again, I'm not so sure many people are going to do that. Um now I want to go to this article just because I think it really supports what what I like to tell patients and this is our patients with obesity and capacity-based type two diabetes. And it's really talking about training them like athletes and so um you know, really coming up with a combined aerobic and resistance training program for them like an athlete because it's so good at improving these cardio metabolic risk factors and a one C levels. So I say especially if they played sports before we got to find that either tiger in them again and you know, we may not be training for a competition next year but we are training for them to improve their health their lives. And a lot of them at this point are are wanting to be around and healthy for their kids and grandkids, maybe even their great grandkids. And so these are good goals I think for patients to to really train like they are athletes now. Just a few pragmatic things to think about. So, you know, we've all done anatomy but when you're talking to patients about what kind of weight training they need to do, think about what muscle groups were using. And the big muscle groups really depend upon the most basic fundamental exercises that are good for cardio metabolic health, especially at a positive basic argument about health. So the pushing muscles, our pectorals, deltoids, triceps, our upper body pulling muscles, trapezius, lettuce in the store side biceps. And then of course our legs and you know, we need to make sure that they have a good appropriate warm up. This doesn't have to be anything fancy. Um they don't have to balance on balls and risk falling down. Like some of the trainers do out there, but they just need to do very basic fundamental stuff and somebody needs to teach them some of these terms like repetitions that will shorten two reps the number of movements in a set. They need to learn what a set is. It's the group of the consecutive repetitions. Maybe other little details, like there's something called time under tension, that's how much time the actual muscle is moving in a certain repetition. Maybe teach them what s centric versus concentric movements are that. But you know, you can really get into the weeds with this stuff but teach them the very basic things And training volume. So especially for resistance training, this is where patients really maybe have the most lack of knowledge and so where you can really help them learn what things to do at home or at a gym or using bands or equipment. Um 2-6 days a week. It depends on upon preference. I suspect that Alex and I prefer to wait train like six days per week. Other people might only want to do it two or three days a week and you can split it up between all those different muscle groups that we talked about, but you do need to take some time off between those muscle groups to allow them to recover, grow etcetera intensity. You know, pick a weight that they can perform safely and think about how many reps they can do it safely and slowly. We want to increase it. We can even do things like drop sets where you start with a heavier weight and drop it down so you continue can you can do more repetitions and the overall volume sets reps go into failure. Um More is really better if we can get it there. Uh you do have to take some time to rest in between sets specifically. But this isn't power lifting. You know, they don't need to pick a weight that they can only do twice and then rest four minutes. That's not gonna be metabolically healthy. And so this is actually a little graphic from a guru who's, who publishes a lot on muscle hypertrophy, growing big muscles and he talks about the volume to maximize muscle hypertrophy. But actually think some of those same concepts really are applicable for cardio metabolic health and so more reps more weight, less rest, higher volume overall is good for patients. And so this just goes back to some of the basic starting points. Um This exercise in the top right as an heir Dine type mission bike where you get your upper body and lower body involved. I think that's great. Um Talk to patients about if they want to work out at home or at a gym. I personally prefer going to a gym because it makes me do it. But there are all sorts of different ways to help patients get involved with some sort of resistance training for their health circuit training. Combination training. Think about doing push ups and and using dumbbells or kettlebells at home, going to a gym where you have a machine like this where you can do pushing one set and then pulling the next set and maybe some active rest in between while you rest. But but then go back and forth. I guarantee no matter what weight they use, it will be very hard and good for the cardio respiratory fitness. And then of course if they're using free weights, make sure that they know to do it safely. Yes, that was great. So we have gotten so many questions for you. So let me just throw out a few of them. Um In terms of exercise, can you go a little bit more into how exercise causes waking? Like just exercise leading to weight gain? Well, so again, it depends on the individual. I think going back to that waterfall plot is what the question is probably asking about um What it turns out is that there that our energy balance system, the archaic nucleus, the hypothalamic control of appetite metabolism can overcompensate. So when people increase their their exercise volume and intensity, if there's no other intervention, if they don't pay attention to their diet, they may overcompensate their energy intake. So that's one aspect to it. Certainly if they do that and they gain muscle. Now, that's that's a good thing. That again, why the weight per se on the scale doesn't always matter because they might get healthier even with some weight gain, but they do need to be aware they some people gain some some adipose tissue and that's just kind of different across the board and while some people have under compensation and they lose a ton of weight as you saw in that waterfall plot. True. Okay, great. Um There were some questions also about how you can get insurance involved in coverage for exercise, whether it's personal training or equipment. Do you have any experience in that? I not exactly. Um However, I have certainly engage with patients who have limitations and and used our physical rehabilitation services within my system and those can get covered sometimes and those are good resources to help patients figure out what injuries, what barriers they have. And they can help us design an exercise program for patients and that usually gets covered if they have, you know, you know, good reason. But that's that's a tricky one. That's great. Um Do you actually recommend writing a form? You mentioned a prescription for exercise but you actually write something down with a prescription? Yeah, I I do. Um every single patient and it depends on how much time I have and what our focus really is. But I always again, going back to if they don't do anything. I always talk about something the daily habit and then and then we can go from there and frequent follow up is important. I also think, you know, I would love my dietician since they are generally covered to gain some expertise in some exercise prescription so they can help follow up with patients and and continue in the exercise prescription with me.