COMMENTARY

Walking the Path to Health: Small Steps Can Yield Big Dividends

Henry R. Black, MD; Paul D. Thompson, MD

Disclosures

September 20, 2016

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Patient-Tailored Recommendations

Henry R. Black, MD: Hi. I'm Dr Henry Black, adjunct professor of medicine at the Langone New York University School of Medicine. I'm here today with my friend and colleague, Dr Paul Thompson. Paul, welcome.

Paul D. Thompson, MD: Henry, thanks for having me. I'm chief of cardiology at Hartford Hospital in Hartford, Connecticut.

Dr Black: You're my go-to guy about exercise. You're an Olympic-level runner, which we can get into at a future date. What do you advise your patients, and the rest of us, about the best kind of exercise to do: How much, how often, and so on?

Dr Thompson: Let me stick with patients. I think there are a couple of things that are important. The first is to ask patients what they do already. There are some people who think that an exercise history should be part of your vital signs, because exercise capacity is one of the most important indicators of someone's overall health.

As a clinician, you should first ask what patients do for activity, so that they know you think that it's important; and second, you should recommend that patients exercise. Specifically, the recommendation is for 150 minutes per week of moderately vigorous exercise, such as walking briskly, or half of that—75 minutes per week—if you want to do vigorous exercise like jogging or running.

The key point is that doing anything is better than doing nothing. Even simply being in the upright posture—standing rather than sitting, which we may not think about as exercise—reduces the risk for cardiovascular disease. So ask patients about it, and then recommend.

I personally recommend that patients walk briskly for 30 minutes every single day. Why every single day? Because if you recommend every single day, you're lucky if they get 5 or 6 days per week. Patients will say to me all the time, "What if it's raining?" I tell them to get an umbrella, because the point of the matter is, you want to do something every single day.

Dr Black: Does it matter what kind of exercise? Do you need to work up a sweat or get your heart rate to a certain level?

Dr Thompson: It depends on what you're trying to do. Vigorous walking is probably the best general recommendation for clinicians to give all patients. Why is that? It's because most people can walk, and walking and locomotion help to reduce body weight. If somebody's overweight, one of the most efficient things they can do is to move that extra weight. A heavy person walking a mile has more caloric consumption than a light person walking a mile. So my standard recommendation is that everybody who can should walk. That's probably the best for cardiovascular health.

If they're time-limited, then something like jogging gives you the same amount of benefit in a shorter period of time. What we know is that you get the biggest bang for your buck going from zero exercise to something.

The goals are what really matter. If your goal is to lose weight, then you have to walk a lot of miles to burn up those calories. If your goal is to get in somewhat better cardiovascular shape, then walking works quite well. If you're going to run races or marathons, or really want to improve your aerobic capacity, then something like jogging or running is more important.

For patients, it's best for them to check with somebody who knows a lot about exercise to get specific advice for their situation. For clinicians, the overall recommendation is simply to ask their patients about it, then tell them to do something about it.

Different Strategies, Identical Goal

Dr Black: Does it matter if you use a stationary bike, treadmill, or some other machine, for example, if you can't go outside?

Dr Thompson: No, it doesn't. Doing something is better than doing nothing.

Now if you're going to try to lose weight, riding a stationary cycle is not as good as walking, because on the stationary cycle your body weight is supported. I always tell overweight people that walking is a way to make lemonade out of their lemon, because when you walk you burn more calories if you're heavy. Although a stationary bike is a great form of exercise, for it to be effective you've got to really push it, either by turning up the resistance or the revolutions per minute.

The elliptical is also great exercise. Given its very low impact on the joints, it's frequently recommended for people with arthritic complaints, especially in the knees and hips. Overall, though, if you don't have an orthopedic problem, walking is about the best exercise you can recommend.

Dr Black: When it comes to walking, does it make a difference if it's outside or on a treadmill with an elevation?

Dr Thompson: It does make a little bit of a difference. We recommend that when somebody's walking outside, that they simply walk. But when you're walking inside on a treadmill, we recommend a 1% or 2% grade. This is because when you walk outside, believe it or not, there's a little bit of air resistance that slows you down a bit, even though it's imperceptible to you. When you walk on a treadmill, the same speed doesn't burn the same number of calories, so you'll want to put a 1% or 2% grade to mimic air resistance and help with the caloric burn.

Dr Black: There are weight-loss programs and other things that modern machines include. Do you have a recommendation as to how many calories you should burn, say, in a 45-minute session on a treadmill?

Dr Thompson: There's an important point to understand in this area. Unless you're running something like 10 miles a day and getting in shape for a marathon, it's very hard to lose weight with exercise alone. It's clearly a contributor to weight loss. But without some caloric restriction, a person rarely loses weight with exercise alone. You can lose weight if you walk for several hours every day, but most of us don't have the time.

My overall recommendation for weight loss is for everybody to "walk their butt off," so to speak. Then specific advice in terms of how fast your heart rate should be and other activities to pursue is that it is best to check with a physician who knows something about this, or an exercise specialist. Groups like the American College of Sports Medicine have certified exercise trainers and specialists. They're very useful people to check in with about your specific recommendations.

Dr Black: What do you recommend, for example, to someone like a 60-year-old who's fairly healthy, has no risk factors, and just wants to maintain his or her weight?

Dr Thompson: It's the same recommendation: a minimum of 30 minutes every day with something like walking to have some caloric burn. If they want to do something more vigorous, I often suggest that they start by jogging the length of one telephone pole, walking three telephone poles, then as they get in better shape, jogging two telephone poles, walking four.

Recommendations for Cardiovascular Health

Dr Thompson: The question that is frequently asked is whether all of these people need exercise stress tests and that sort of thing. The current recommendation from the American Heart Association is that if somebody's going to engage in a vigorous exercise program, they should see a physician for something like an exercise stress test. I usually don't recommend it. Instead, what I recommend is that people start an exercise program and pay attention to themselves. If they have new symptoms that come on during exercise, then they ought to discuss those with a physician. I'm afraid that if we required everybody to undergo an extensive evaluation before they start an exercise program, it would prevent a lot of people from starting an exercise program.

All the way back in the [1700s], when William Heberden first described angina, he said he didn't know how to cure it, but he did have one patient who sawed wood for 30 minutes every day and was nearly cured. Of course, we would recommend walking over sawing wood at the present time! But the fact of the matter is that an exercise program is beneficial for you even if you have occult heart disease.

Dr Black: Do you have other recommendations for what a good cardiologist would say about improving cardiovascular health, or does it all pretty much follow common sense?

I make sure that the clinicians I work with weigh their patients every single time. This is because it's easier to lose 1 pound 50 times than 50 pounds once.

Dr Thompson: With respect to exercise, most things are common sense. Don't ask too much of your body too soon. You'll be amazed at how plastic and adaptable the human organism is to muscle and exercise overload, but go gradually. The take-home message is basically that you've got to do something to get something.

As for other recommendations, I make sure that the clinicians I work with weigh their patients every single time. This is because it's easier to lose 1 pound 50 times than 50 pounds once. If you see a patient who's going up by a pound a year, it's important to get on them about that before they're up 20, 30, or 40 pounds, which is much harder to lose.

An exercise program is very important. Taking and watching people's body weight is also a very important thing for clinicians to do.

As for other activities, such as the use of baby aspirin, I must admit that the guidelines go back and forth on this. However, I've been a real fan of low-dose aspirin use in people at 7.5% or 10% risk for cardiovascular disease, as long as they don't have a contraindication.

The most important thing, though, which I think we all know, is to pick the right parents. Genes have a lot to do with this.

Simple Exercise Routines

Dr Black: What about weightlifting or moderate weightlifting? Does that help in any way, or does that just increase muscle mass and make you seen fatter?

Dr Thompson: We're big fans of weightlifting. In our current environment, people are living so long that they can outlive their muscle strength. I routinely recommend that patients have a light weightlifting regimen, doing such things as biceps curls, bent-over rowing, bent-knee sit-up and push-up exercises. Those sorts of things are probably best described to you by a personal trainer or the fitness specialists certified by the American College of Sports Medicine, which I spoke about earlier.

I generally recommend that patients do simple shoulder shrugs. Also, that they lean over and do bent-over rowing, that they do biceps curls, and that they do triceps extensions. They can lie with their back on the floor with their knees bent, and simply lift their head and shoulders off the mat. Doing that allows you to feel all the muscles in your stomach tighten. Simple exercises like that can be taught very quickly by a clinician or by an exercise expert, and can really help people maintain their muscle mass.

Now, are there cardiovascular benefits from weightlifting? It's been harder to prove that compared with aerobic exercise. Yet the purpose of weightlifting is not only to help with cardiovascular health but, more importantly, to maintain your skeletal muscle health. We don't think about this a lot as cardiologists, but the skeletal muscle is actually an endocrine organ. The skeletal muscle secretes all sorts of myokines, which are cytokines that come out of the muscle and signal the liver and other parts of the body. So it's important to stress the skeletal muscle system a little bit every single day.

Dr Black: I recently got a trainer, as I think you've recommended, and he wants me to do planks. What are planks? What do they do for you? And are they something I should be including every day?

Dr Thompson: Most times, a plank is simply done by leaning on your elbows, with your toes on the floor and your body supported off the floor. It's like the push-up position, but you're on your elbows. Planks are excellent exercises for strengthening all of those core abdominal muscles that support your spine. I think they're a fine exercise to do. A lot of us were doing planks for years when we were doing push-ups; we just didn't call them planks—we called them push-ups. But a plank is kind of a stable push-up that strengthens those central muscles, which are very important for people. So, yes, I think that's a good idea.

I think that the idea of getting someone to advise you on an exercise program, if you can afford it, makes a lot of sense. But there are inexpensive ways to do it as well. Senior citizens often have access to exercise programs at places like the YMCA. I think getting somebody who's an expert to help you is very useful.

Dr Black: How long should you do a plank? As long as you can handle it, or is there a limit to how many minutes or seconds you ought to be doing it?

Dr Thompson: I don't know of a limit to something like that. If you're in good shape and are used to doing things like push-ups, then you can go for a very long time. I think 30 seconds or so would be fine.

Sneaking in Workouts

Dr Black: Any other general recommendations for cardiovascular health? As you say, we're living longer and ought to be in good shape as we do.

Dr Thompson: The most important recommendation for cardiovascular health is to keep moving and doing stuff. Be physically active, whether that be gardening or stair climbing. Look to incorporate exercise habits into your life.

I work on the seventh floor here and will routinely take the seven flights of stairs rather than the elevator. So there are ways to work exercise into your life even if you're very busy—walking to work and things like that.

Dr Black: I remember my boss said that what we really want to do is be like batteries that run at full speed and then stop. It would be good if we can all do that.

Paul, I want to thank you so much for your time and always-great advice. I appreciate it. Thank you very much.

Dr Thompson: Thank you for having me, Henry. It's a pleasure to see you again.

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