No more excuses EXERCISE WORKS!

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No more excuses EXERCISE WORKS!

Virginia
McMillan
Rocket
Reducing your inactivity is good, doing anything is better than doing nothing, and more is better

Everyone accepts that being physically active is important, but a large number of us don’t exercise enough to get any health benefits. Virginia McMillan talks to the experts about what we have to gain from upping our activity – and what we have to lose if we don’t

Human beings were meant to run and walk. We are the running apes.

Ministry of Health chief science advisor John Potter says he borrowed that phrase, but he likes it.

“We have gluteal muscles that allow us to run; gorillas and chimpanzees don’t,” Dr Potter says.

“We are built to run and walk, we are good at it, and we forget. We don’t build it into our lives, and this is what we’ve got to do.”

THEY ARE hospitalised many times a year

THEY ARE hospitalised many times a year. Chest pain and shortness of breath bother them with every exertion. On their first go on a stationary bike, they barely manage a minute.

Something is better than nothing...The alternative is putting on one or two kilos a year and that, if it carries on, will lead to diabetes and other metabolic disorders

Exercise gives hope to these sufferers of chronic obstructive pulmo­nary disease, referred to clinical exercise programmes in the U-Kinetics clinic at UCOL tertiary education institute in Palmerston North.

Even such unwell patients can build up to 20 minutes at a time, achieve moderate fitness, and experience better health and wellbeing, UCOL associate professor of exercise science Lukas Dreyer says.

Each patient is guided to incrementally increase the intensity and duration of their activity. Workouts in­clude very brief, high-energy effort, interspersed with low exertion – a now well-established approach known as high-intensity interval training (HIIT).

Latest exercise advice from the ministry gives a nod to the importance of intensity, noting the extra benefit from vigorous activity, and recommending some moderate activity be exchanged for higher-intensity sessions.

What’s happening to the body as a result of vigorous movement, that starts to make a difference with even small amounts of activity?

Among other things, endorphins are released; the body heats up, prompting a relaxation response; and the men­tal focus on exercise helps control anxious thoughts, Dr Dreyer says.

More oxygen is reaching the cells’ mitochondria, stim­ulating increased numbers of capillaries.

This means better oxygen delivery to the working mu­cles, so the muscles’ ability to produce energy improves. “Over time, you can do more work at a lower heart rate and with less perceived exertion.”

Patients with severe depression may still be highly de­pressed but report (via the standard SF-36 questionnaire) they are feeling and functioning better.

The COPD patients’ lung damage remains, but exercise seems to slow down disease progression and reduce flare-ups, Dr Dreyer says.

Particularly when combined with removing sugar and refined carbohydrates from the diet, exercise has also helped many diabetic patients at U-Kinetics to reduce their requirement for insulin.

Take the 100kg-plus patient who made dietary changes and pursued a three-month exercise programme. The diabetes nurses were able to phase out his insulin completely, from an initial 90 units daily. He also lost 15kg.

“The moment you start exercising, your body starts using glucose...your ability to control glucose, and not have it fluctuate, improves significantly with exercise,” Dr Dreyer says.

“WESTIE” William Ferguson surfs every chance he gets

“WESTIE” William Ferguson surfs every chance he gets. It’s not often enough, perhaps once a week, because his GP day usually ends after 9pm, says Dr Ferguson, of Kumeu Village Surgery west of Auckland.

If anything like this was a drug you could put people on, everybody would be on it, and it would be the first thing they were told about

“I do keep a reasonable level of fitness [by] surfing, because you’re going hard-out like your life might depend on it.”

His other main form of exercise is a bit of a short cut, using the stationary cycle. And, keen researcher that he is, he won’t do just any old cycling.

He uses a form of HIIT developed by Australian pre­ventive medicine and metabolism researcher Stephen Boutcher, associate professor in the School of Medical Studies at the University of New South Wales. The method involves eight seconds of maximum exertion, followed by 12 seconds of recovery, alternating for 20 minutes.

It is good exercise, Dr Ferguson says: “You certainly feel as if you have achieved something.”

He finds many patients are pressed for time, but most can find 20 minutes.

Then there are the patients who have made him “sit up and take notice” by tackling their osteoarthritis with exercise.

“Non-weight-bearing exercise turns back the clock on osteoporotic knees and probably hips as well,” he says.

For these patients, he advises “water-walking” and ex­ercycling, saying “the worst thing is weights and squats”. One patient who went on a regime of non-weight-bearing and quad-strengthening exercises no longer needed the knee replacement surgery she was booked for.

Dr Ferguson says exercise influences the way hundreds of genes are expressed – and its influence is generally preventive and protective.

Genes appear to affect tumour development in breast cancer. “There are hundreds of genes you don’t want be­coming over-expressed, and those are often cancer-related, for example, inflammation and insulin-signalling – which is rocket fuel for cancer.” Exercise has been shown to reduce inflammatory gene expression.

In some people, the genes that regulate key antioxidant enzymes over-express, meaning a low ability to deal with oxidative stress. Running long distances is damaging for these individuals, while resistance training can reduce expression of the genes, Dr Ferguson says.

He orders gene analysis for some patients, looking for information that will inform management of chronic con­ditions. “Diet and exercise are two of the most available and potent tools for changing hundreds of genes,” he says.

He wants to be able to give patients cutting-edge ge­netic information, and he expects this kind of precision medicine will soon be affordable.

“To what extent are we winning with our ‘imprecision medicine’ right now?” he asks. “Our modus operandi [with many drugs] is that you have to treat 20 people to help one patient.

“We are...sending people out the door feeling comforta­ble in our sense that this is evidence-based medicine, and we are at the top of our game and carrying out best practice.

“We’re feeling jolly good about it, but are we delivering for that person?”

Tamoxifen offers “nothing like” the effectiveness of exercise on breast cancer mortality and survival, he says.

“If anything like this was a drug you could put people on, everybody would be on it, and it would be the first thing they were told about.”

Stuart Armstrong, a marathon-running sports physi­cian from Hamilton

Stuart Armstrong, a marathon-running sports physi­cian from Hamilton, agrees exercise has a massive and profound impact, unmatched by medication, surgery or other interventions.

The most exciting fact is that physical activity reduces a person’s risk of heart attack and stroke whether they weigh 120kg or 60kg, Dr Armstrong says.

Most of his patients are ordinary people finding it hard to get active. Sounding them out, and helping them de­cide and follow through on lifestyle changes, takes time. “Encouraging them is a very powerful thing,” he says.

Many New Zealanders just aren’t active. Last year’s Annual update of key results 2015/16: New Zealand Health Survey found 48 per cent of adults were physically active, down from 52 per cent in 2006/07, and 15 per cent were physically inactive, up from 10 per cent in 2006/07.

“If everybody did more,” Dr Armstrong says, “I would expect to see less obesity and overweight.”

As someone who cycles to work, runs 80 to 90 kilometres a week, while making sure he puts in at least 10,000 steps a day, he says most people can definitely make the time for exercise. “It comes down to motivation...how much you want to prioritise it.”

Ximena Hunefeldt says she has reversed her diagnosed osteoporosis by exercising

Ximena Hunefeldt says she has reversed her diagnosed osteoporosis by exercising. The body’s ability to rebuild bone with muscle-strengthening exercise is acknowledged by the International Osteoporosis Foundation.

When Dr Hunefeldt, a GP at Carterton Medical Centre, learned her bone density was back to normal, “that was amazing”, she says.

“It was a breakthrough for me.”

Taking prednisone for an autoimmune disorder in­creased her risk of osteoporosis. It also deepened her commitment to exercise and healthy eating (organic foods whenever possible).

“We were born to be active,” she says. “I hate running, but I do it for my bones.”

The local community offers many opportunities for physical activity, often for a few dollars a session. Dr Hunefeldt encourages patients to find the right exercise for them.

“I emphasise the importance of it again and again and again. Even if only five per cent do what I recommend, that is success...

“It is trial and error to find what works and what you enjoy, then you will keep it up.

“I am really passionate about lifestyle changes, and my emphasis is on prevention. I don’t just tell people, I live it,” she says.

Dr Hunefeldt can often be found digging in her garden, where she spends at least an hour a day. On some days, she adds a couple of gym classes and some resistance training as well. “Exercise makes me happy,” she says.

EXERCISE GIVES many people a buzz

EXERCISE GIVES many people a buzz; so much so, they’re motivated to get back into it if they miss a few days. You have to reach a decent level to get the exercise “bug”, Auckland GP Stephanie Taylor says.

Dr Taylor graduated in physical education before stud­ying medicine, so she’s highly educated about exercise and fitness. But it’s no easy task, even for this St Heli­ers Medical GP, to steer her patients in the direction of physical activity.

Half an hour a day is her rule of thumb for most patients. It’s not going to make a couch potato fit, but it will gener­ally improve their lipids, liver function and psychological wellbeing, she says.

Half an hour is not the ultimate goal but a good starting point, Dr Taylor say “I get asked this every day, and the first port of call is to get mobile and, if you can do 30 minutes a day, that’s great.

“If you’re aiming for a half marathon, I will recommend that.”

Exercise and the motivation to pursue it are very indi­vidual, depending on comorbidities, age and background, she says.

To go beyond walking usually requires spending money, and many people can’t afford the gym fee or equipment.

“Unfortunately, it is very hard to get people who are used to a sedentary life, and who don’t have the time and, sometimes, the means, to start [getting regular exercise].”

One patient is a zero-to-hero character. Told by Dr Taylor his blood lipids were far too high, and warned he was heading into heart attack territory, he began, off his own bat, to train for the Coast to Coast.

In eight months, his cholesterol and lipids were normal.

“That’s a one-off case,” Dr Taylor says.

She is constantly suggesting to patients that they make the effort to find a mode of exercise that suits them, that they can enjoy and sustain.

“It is so individual. It is difficult to make a blanket state­ment that, if you do ‘x, y and z’, you will improve this much.

“But something is better than nothing...The alternative is putting on one or two kilos a year and that, if it carries on, will lead to diabetes and other metabolic disorders.”

As it follows in the US’ footsteps, New Zealand has already normalised obesity, Dr Taylor says.

Kids can easily avoid sports at school, she has noticed. “You have to start them young, so it’s a natural thing to do every day of their life.”

Janet Turnbull looks at the wave of obesity and diabetes in younger age groups

Janet Turnbull looks at the wave of obesity and diabetes in younger age groups and hopes there will be good man­agement for these people, to reduce their risk of disability in older age.

“If we could have people manage their lifestyles better, we would have fit and healthy old people,” says Dr Turnbull, a Wellington consultant geriatrician.

She sees many old people with disabilities, pain and low fitness.

Doing outpatient and community consultations, she is wary of multipharmacy and the problems inherent in each of the pain-relieving medications available.

Dr Turnbull talks patients through a plan to gradually walk more. For some, it might be around the mall or along the street. “Set the goals low, and then increase,” she says.

She cannot recommend strongly enough, “exercise, exercise, exercise, in the 60s and 70s, for prevention”.

It is part of keeping older people involved in community interaction. “It works for everything; the brain, the ticker, the joints. If you remain active, and support people to re­main active, then most things are improved or maintained.”

ACC, the Ministry of Health and the Health Quality & Safety Commission have just put money into this concept.

Their Live Stronger for Longer programme acknowl­edges the poor outcomes of people who have falls in their 70s and 80s.

ACC corporate medical adviser Geraint Emrys says a first fall affects independence, and the older person rarely recovers completely from their second fall injury.

This age group has the highest number of serious falls, fractures and head injuries, Dr Emrys says. Helping the older person get fitter and stronger should “push out the negative outcomes from falls even further”, he says.

Muscle mass is important in earlier age groups, but the fact it declines in the later years makes strength training integral to the programme.

ACC’s first venture of this type and scale, it is aimed at ensuring over-65s’ strength and balance training classes, meeting specific criteria, reach most parts of New Zealand.

THE HEALTH ministry’s Dr Potter says children are active by nature, and “we should hang on to that ability as we age”.

Instead, most adults spend hours at desks and com­puters, as physically demanding jobs continue to decline.

Exercise is not a medicine, it is part of being human, he says.

“It is not that exercise adds something; it is that losing exercise subtracts something.”

Look for practical stuff to build into the day, walk or run at lunchtime, get off the bus and walk the last block to work, join a yoga group, cycle, play bowls.

Dr Potter has a solid international background in ep­idemiology, disease aetiology, diet, genetics and cancer. He says: “We know physical activity is beneficial. That is an empirical fact.” He also trusts experience. “We know it – deep in our hearts, we know it...

“Anything that improves people’s movement and phys­ical activity in an increasingly inert and obese society is a good thing,” he says.

Where the evidence is pointing

Findings from latest research include:

Reducing BP in hypertension

Short bursts of exercise at a high intensity (more than 70 per cent of the individual’s aerobic capacity or VO2 max) appear more effective at lowering blood pressure than exercise at a steady pace. (J Hum Hypertens 2017;31:157–64)

Risks of sedentary life

Study of almost 10,000 patients suggests inactivity greatly increases risk of all-cause mortality. Spending more than 12.5 hours a day sedentary, and for more than 10-minute periods at a time, produced the greatest risk of death. (Ann Intern Med 2017;167(7):465–75)

Adding life expectancy in CHD

In the STABILITY study, 15,486 patients with stable coronary heart disease reported their exercise. After three-and-a-half years, all-cause mortality was 18 per cent lower in the top exercisers. Those at higher heart risk got the greatest benefit from exercising. (J Am Coll Cardiol 2017;70(14):1689–1700)

Helpful in breast cancer

Mounting evidence of benefit of exercise for breast cancer prevention and treatment. (Transl J Am Coll Sports Med 2017;2(15):92–96)

Confusion about dementia?

Following more than 10,000 people over 27 years led researchers to conclude exercise did not provide a protective effect. However, the difference in global cognitive score between people following and not following recommendations on moderate to vigorous physical activity was four times as large at age 80 as at 50. (BMJ 2017;357:j2709)

Reduced mortality

The seven-year, 17-nation PURE study of physical activity looked at 130,843 people without cardiovascular disease. Compared with low levels of activity (<600 MET minutes), moderate and high activity levels were associated with a graded reduction in mortality. (The Lancet, online 21 September 2017)

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