Rania Habib, MD, DDS (Host): The World Health Organization reports that physical inactivity is one of the leading risk factors for non-communicable disease mortality. We know that regular exercise can help us maintain a healthy weight, but did you know that exercise can improve our cardiovascular, cognitive, bone, and mental health too?

This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Rania Habib. Joining me today is Kiley Owen, a Physician Assistant in hospital medicine. Her main clinical interest is in long-term healthy habit development, and she's here to discuss the benefits of exercise for our overall health.

Welcome Kiley, and thank you for joining me today.

Kiley Owen, PA: Thank you, it's nice to be here.

Host: This is a very timely topic that we're very excited to delve into. We know that exercise has many benefits, so let's break down the benefits of each area of our health. Let's begin with our brain. Kiley, could you describe the cognitive and mental benefits of exercise?

Kiley Owen, PA: Absolutely. This is actually a really fun area to talk about, I think, because it's one we don't always think of. Often when we're talking about exercise, we're talking about the body, but the exercise has such a profound impact on cognitive function and on mental well being. So let's just start by looking at the cognitive side.

 For one thing, exercise increases blood flow to the brain, so that's going to improve overall brain function. But it also stimulates the production of growth factors, which help new blood vessels to grow in the brain, and that helps with new brain cells so that they can survive and thrive.

Exercise also promotes neuroplasticity, which is the brain's ability to form new neural connections, and this helps with cognitive flexibility and with learning. And then, also, exercise is really important in boosting memory and in reducing the risk of cognitive decline; in part because it generates brain derived neurotrophic factor, BDNF, and this improves the health and function of the hippocampus, which is a part of the brain that plays an essential role in memory.

Now, when we look at the mental health side, I think this area is especially fun because the effects here can be really immediate. So we're not looking at effects that are taking place 10 years from now. We're looking at things that we can enjoy today when we take on more physical activity. So some of the benefits are that exercise is a great stress reliever. It also decreases anxiety and it's been shown to alleviate symptoms of depression, in part because it releases endorphins, which are natural mood lifters. Some other things is that it can really improve our mood by stimulating the production of serotonin and dopamine, which enhance our mood and our overall sense of wellbeing.

Exercise improves our sleep. So that also helps our mental health. And then a couple other ones that I think are really important to keep in mind is just that it gives us a sense of accomplishment, and it boosts our self esteem, and who doesn't want more confidence and self esteem, right?

Host: Absolutely. I can definitely say as a surgeon, one of my favorite things after a long day in the operating room is to come home and work out because of exactly what you said, that immediate endorphin rush. So I'm very excited to see that it's also going to help with my long term cognitive ability.

Kiley Owen, PA: Yes, absolutely.

Host: Now, Kiley, how does exercise improve our cardiovascular health? We all know that it's heart healthy, but let's delve into a more on why.

Kiley Owen, PA: Yes exactly. This is one we do commonly think of when we think about the benefits of exercise, and there are really many mechanisms here. For one thing, it strengthens the heart muscle. It improves circulation by increasing the capacity of our blood vessels to deliver oxygen and nutrients to the tissues.

It also lowers our blood pressure and it improves our cholesterol levels. It also reduces inflammation, and that's a big contributor when we're looking at acute cardiovascular events. Exercise will help us with weight management, so that puts less strain on the heart. It also, in helping to control our blood sugar levels, which decreases the risk of diabetes, you know, we know diabetes is a major risk factor for cardiovascular disease.

So that's another mechanism that it really helps our cardiovascular health. And then, it's important to remember that it both lowers the risk of cardiovascular disease, that's in people who are trying for prevention reasons to prevent that, but it also lowers mortality in people who have existing cardiovascular disease.

Host: So basically for our heart healthy patients, there's no reason not to exercise.

Kiley Owen, PA: Exactly. And for our heart patients, I mean, obviously, you want to do this under the guidance of your doctor, but that's why we have programs like cardiac rehab, for example.

Host: That is fantastic. I really love that Carle Clinic is putting that forward to help patients understand and emphasize their health. And now we've learned about cognitive benefits, mental benefits, cardiovascular health. So let's move on to bone health. The CDC estimates that 10 million Americans have osteoporosis and we know that exercise can help improve bone health.

So how specifically, Kiley, does exercise influence bone health?

Kiley Owen, PA: Yeah, with bone health, a lot of times we think about our diet, right? We think about calcium and vitamin D, and maybe we're thinking about medications that might help with osteoporosis, but it's so important to think about exercise and the positive impact it has on bone health. In particular, weight bearing exercises, so that's going to be exercises like walking, and running, and resistance training, or those strength training exercises, as opposed to something like swimming. Swimming is great for you from a cardiovascular standpoint, but you're not working with gravity in quite the same way, so it doesn't have quite the same effect on our bones. So that's where the weight bearing exercise is important, because it increases bone density, by stimulating bone formulation and also slowing the rate of bone loss. It actually helps with the shape and structure of bones too, by enhancing their ability to bear weight and resist fractures. Exercise helps with calcium absorption. The increased blood flow of exercise is helpful for getting more nutrients to our bones.

And then also a little bit more indirectly, when we are strengthening the muscles around our bones, this is going to reduce the load on those bones and decrease some bone injuries that could happen if we don't have sufficient musculature. Also through reduced inflammation, that inflammation can weaken the skeleton over time.

So the way that exercise reduces inflammation is helpful. And then a huge one here is how exercise can improve balance and coordination and reduce our risk of falls and injury.

Host: Now, for the patients who are trying to improve that bone health, is there a minimum time amount that they need to be doing these weight bearing exercises in order to see those benefits?

Kiley Owen, PA: Well, really any exercise, is better than no exercise. So if you're doing nothing now and you're making even a small step of doing something more, that is a step in the right direction.

Host: Absolutely. Well, Kiley now that we have explored the positive benefits of exercise, what are some specific exercise recommendations that you can share with our audience?

Kiley Owen, PA: The first one is regarding aerobic activity. And this is going to be the activity that it's designated physical activity that gets our heart rate and our breathing up. And the big number we want to remember here is 150 minutes a week. So that would be the equivalent, for me it's kind of hard to think about what 150 in a week looks like to me.

It's easier to think like, well, that's about 30 minutes, five days a week, but it doesn't have to be broken up like that. You can spread that 150 minutes out, however you want to do it. Now that is for moderate aerobic activity. If we are looking at vigorous aerobic activity, then because that's harder and the minimum requirement for that is a little bit less, then we're looking at, at least 75 minutes a week, or it could be some combination of those two. Let me explain a little bit more about what that looks like. So moderate, probably the easiest way to understand this is that if you're looking at a scale from 0 to 10, moderate is going to be about a 5 or 6 on that scale. So you're kind of in the middle. You're not just like killing yourself out there, but it's, harder than just walking around the house.

Whereas vigorous, you're going to start getting on the end of that scale, about 7, 8 and beyond on that scale. But when talking with our patients, I think the easiest way to help them understand this, is to describe what's called the talk test. So with moderate activity, that means while doing the activity, you can talk while doing it, but you wouldn't be able to sing while doing the activity.

Whereas with vigorous, you're working pretty hard, so it's hard to say more than a few words without stopping to take a breath.

I think that's the easiest way to describe it. So for a lot of people, a brisk walk is going to be wonderful, moderate activity. Whereas as you start to get into running, and certainly something like a HIIT workout, a high intensity workout, you're definitely going to get into more vigorous activity.

Keep in mind that those numbers I gave you, the 150 minutes a week for moderate and the 75 for vigorous, those should be treated as absolute minimums, okay? The research is clear that the more we do, the better the effects. So please don't think that's a cutoff in any way, and please strive to get as much activity as you can during the week. So the second type to keep in mind, so that's the aerobic activity. On top of that, we want to think about just sitting less and moving more. So this is not necessarily designated exercise time, but it's just being more active in our everyday life. It's really important to think of sitting as a separate risk factor.

Even if you are meeting and exceeding the guidelines for aerobic activity, for example, someone who is an endurance athlete, for example, even those people are at risk for some of the negative side effects that happen when we sit too much. Because if you think about it, let's take an athlete who is working out, let's say three hours of their day.

Well, what are they doing the other 21 hours of the day? Are they sitting behind a desk all day at work? Are they sitting on the couch at home? This is what we actually call being an active couch potato. You're meeting the aerobic guidelines, but the rest of the day is very sedentary. So it's really, really important that we think about that too, because sedentary behavior increases all cause mortality as well as increasing things like cardiovascular disease, Type 2 diabetes, certain cancers, things like that. And so that's why it's been said that sitting is the new smoking. So just another aspect of physical activity to think about.

Host: And absolutely, you don't even really think about that. That example was very telling. So I've never thought about the athlete who works out three hours and then just sits around. So it's a good reminder to utilize those walking pads or to choose a standing desk at work instead of a regular desk.

Kiley Owen, PA: Absolutely. And that's why our watches, if you have a fitness watch, that's why it will be like, get up, move. That's that aspect of physical activity it's talking about. You're sitting for too long. That's a separate risk factor. So the third area that's really important to keep in mind is, resistance training. So this is like your strength training. Muscle strengthening activities are really important. And the recommendation is that we are getting all major muscle groups at least two days a week. So by all major muscle groups, I'm talking about legs, hips, back, abdomen, chest, shoulders, and arms.

So that can look different for different people. That might be a full body workout that you do two days a week. That may be you're doing upper body one day, lower body the next, upper body one day, lower body the next. Sometimes people do what's called a push pull legs routine.

 So that can look different and get more sophisticated depending on what a person's goals are. But as a minimum, what we're trying to do is get some muscle strengthening activity, of all the major muscle groups at least twice a week.

Host: Okay. That's amazing. So you've now reviewed three really important elements of our exercise regimen, but we also know that consistency is key to optimizing our workout routines. Kiley, could you share some tips for staying consistent with exercise?

Kiley Owen, PA: Sure. I'd actually like to share just a short little story and this is about me in college. So I was in college and I was very inactive and I was eating all kinds of junk food. So surprise, surprise, I put on some weight and I was feeling lousy. And so I would every now and then get this motivation, like, I need to get in shape.

And so, what I would decide to do to get in shape to exercise is I would decide that I needed to go out and run for 30 minutes. There's two big problems with this. One was that I hated running. Two was that I didn't have the fitness for that. It was like trying to go from couch to 5k in a day. Like I was not physically in shape. So for me to do that, was like torture.

 So what would happen is I would do this for two, maybe three days, and then I would give up, and then I would not do anything. I'd go back to being inactive for weeks at a time, until I felt bad enough again, and then I would try to exercise again and run into the same vicious cycle.

So let that be a lesson of what not to do. Don't do what I did. And understand that with long term consistency there are actually some important things that are helpful to understand. One thing that I think is really, really important to understand is that our brain naturally likes to seek pleasure, avoid pain, and conserve energy.

And there's actually a survival advantage to this, especially in environments of scarcity, because this keeps us safe and alive and reproducing and all those kinds of things. But most of us in the modern world are not in an environment of scarcity. We're in an environment of abundance. So, these protective mechanisms of our brain actually get us into trouble in this kind of an environment. That's why it's so easy to form the quote, bad habits like eating ice cream while you're sitting on the couch and binging Netflix. it's very pleasurable. It requires minimal effort. And so the brain sees this as something nice and safe and pleasurable to do and the brain wants more and more of that. So you can see how this is problematic with physical activity. Physical activity doesn't exactly coincide with the conserve energy part and often with the seeking pleasure and avoiding pain part too.

So the question is, what can we do about this? Well, if we look at how habits work, there are four parts of a habit loop. It starts with the trigger, also called the prompt, and that's that thing that triggers us to do it. But the next step is what's called a craving. It needs to be something we want to do for some reason. And then we move into the third step of the habit loop, which is the behavior itself, the habit itself. And then the fourth part of a habit loop is the reward. Now keep in mind, this should be an immediate reward. So this isn't like a long term reward. That's more of an incentive. It needs to be an immediate reward.

So the parts I want to draw your attention to are parts two and four of the habit loop in particular. These show us that habits are about getting our wants and needs met and that habits are about rewards. So this is where so many people get it wrong. Instead of making the baseline habit easier and enjoyable, keeping in mind that you can always do more if you're feeling extra motivated, instead, they're trying to create a baseline habit that is just way too difficult, way too enjoyable, which is exactly what I did back in college, right?

At that point, it becomes a willpower struggle. And we can do things through sheer willpower, but our chances of long term success are much, much lower. So that's why when I'm working with clients on building healthier habits, I tell them that enjoyment, it's not a nice to have sort of thing. It's their job to make this as enjoyable as possible because it's very smart and strategic.

It's also very, very smart and strategic to ask yourself, if this were easy, what would it look like? How can I lower the barrier to entry for that activity, so that I can get that consistency that's going to be needed for long term habits. The other thing that's really, really important is to have positive emotions associated with the activity because that's going to be what keeps us coming back for more.

Host: Absolutely. Now, for the person who wants to start this exercise routine, so now they're finally motivated, they're like, I've got this, but maybe they're nervous or even potentially overwhelmed, what are your suggestions, Kiley?

Kiley Owen, PA: My biggest suggestion is to start small. Start with where you are. A lot of times that can be a simple walk. Think back to my example in college. I did much better when I decided not to go out and run, when I decided, well, maybe I can walk instead. And I realized that, oh, that's actually pretty enjoyable.

So start with something small that you can do. Try new things. Figure out what works and what doesn't for you. This is going to be, in large part, personal preferences. You can always refine as you go. You can always get fancier as you continue to do it, continue to learn new things. It really, really is about consistency over intensity.

And, consistency often leads to more intensity because you will incrementally challenge yourself a little more and a little more.

Host: That makes a lot of sense because you're right, when people start into an intense program right away, that might make them stand back and say, I can't keep doing this. So I love that as just start small and build upon that foundation.

Kiley Owen, PA: Yes, absolutely.

Host: How does Carle Foundation support patients in this regard? I'd love for you to give us a little talk about maybe how they do the therapy or the rehab programs, you know, for patients who are injured or want to start a weight loss routine.

Kiley Owen, PA: Carle has so many therapy folks and I want to give a huge shout out to these folks. Areas like physical therapy, occupational therapy, rehab programs. We depend on these guys so much. In healthcare, we're dealing with populations of people who have serious barriers and need extra help. These are people who often can't just go to the Y and join a fitness program. So our professionals in this area are so incredibly valuable to our patients quality of life and helping them to get onto the road of more activity.

Rania Habib, MD, DDS (Host): Kiley, you have given us so much knowledge today. We explored the health benefits of exercise, how to start a routine, and how to stay consistent. Kiley, what are your main take home points about exercise that you would like to leave with our audience today?

Kiley Owen, PA: The thing about exercise is that it has such a profound impact on our quality of life. So often in medicine, we're focused on prolonging life, and that's great, but we also need to look at quality of life, and that's where exercise is so important because it directly affects the ability and the stamina we have for life's activities.

Exercise is what keeps us young. A quote that I love is, "We don't stop exercising because we get old. We get old because we stop exercising." Exercise is really a way that we can turn back the hands of time. We can't change our chronological age, but we can work on our functional age and through more physical activity. This is how people can reach the age of 80, for example, and function more like someone in their sixties. To me, this is such a hopeful message that we can give to our patients.

Another quote that I love is that "exercise is a celebration of what your body can do. It's not punishment for what you ate." It is so important that we not treat exercise as a punishment and that we find ways to enjoy it and appreciate it and have positive emotions surrounding it. Because as I mentioned before, that's going to be what keeps us coming back for more. That's that craving and immediate reward part of the habit loop.

And then finally, the last thing I want to say is just that the benefits of exercise begin with any amount that you can do and just go up from there. So keep that in mind. Anything is better than nothing. So start somewhere and it's never too late to begin.

Host: Ah, I love that. Those quotes will actually sit with me and I will definitely share them with my patients as well. Thank you for joining me today.

Kiley Owen, PA: You are very welcome.

Host: Once again, that was Kiley Owen, a Physician Assistant in Hospital Medicine at the Carle Foundation Hospital. For more information and to get connected with one of our providers, please visit carle.org. Or for a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at carleconnect.com. I'm your host, Dr. Rania Habib, wishing you well. That wraps up this episode of Expert Insights with the Carle Foundation Hospital.