Karen Basen-Engquist, Ph.D. Hi, I'm Dr. Karen Basen-Engquist, a researcher in our department of Health Disparities Research at MD Anderson Cancer Center with a focus on physical activity and weight management for cancer survivors and high-risk individuals. And I'm here today with another researcher from the Health Disparities department, Dr. Scher Mama. So, welcome, Scher. And this is the Cancerwise podcast. So glad that you have agreed to have another one of these conversations, Scher. This is a lot of fun. And we're here today to talk about exercise snacks. So, can you tell me a little bit about, what are exercise snacks? When I have mentioned this to other people, they say, "Are those the snacks we eat when we exercise?" Because there are, you know, everybody was always very excited about eating more.  

Scherezade Mama, Dr.P.H. Yeah, everybody's always excited about snacks, right? Well, thanks for having me, first of all. This is a really great topic. So, I'm really excited to be here. And contrary to popular belief, exercise snacks are not actually snacks you eat while exercising, before exercising or after exercising. An exercise snack is a structured bout of exercise that can be dispersed throughout your day. It's supposed to be easy and digestible, right? So, they can be as short as 15 seconds. They can be as long as ten minutes. They usually don't exceed like that length of time, because we want it to be something you can incorporate rather easily into your day. So, the term "snacks" means it's more approachable, right? You don't necessarily have to set aside a long period of time to go to the gym, have a ton of equipment with you, or have a special outfit or go somewhere special. It's sort of this idea of, can I do something small throughout the day? And that can build up toward maybe doing more exercise later. So, kind of like a "gateway drug" to doing more exercise, if we could call it that. And I think exercise snacks, the beauty of them is that can target multiple components of fitness, right? So, it doesn't have to be one thing or the other. It could be aerobic, it could be muscle strengthening, it could focus on flexibility, it could focus on balance. So, targeting multiple components of fitness and multiple intensities. They could be light intensity, it could be moderate intensity, it could be vigorous. So, really, like, there's any combination. It's kind of like the wild wild west of exercise right now. We're still kind of working on it, but just little things that you can do. A good example would be something like, let's say you want to work on your aerobic fitness, maybe doing some jumping jacks during commercial breaks, right? And maybe not every commercial break because I feel like they're getting longer and longer. But maybe, you know, pick two commercial breaks during a 60-minute show to do some jumping jacks, or one that I heard recently was somebody who said she does 5 to 10 pushups every time she uses the restroom. And I was like, well, every time I get up to go to the bathroom, I will be Diesel at that point. But, you know, that's another good example of a of a short bout of exercise that you can do. And it can target lots of things to different types of fitness, different lengths of time, different intensities. Really, you know, the world is your oyster. 

Karen Basen-Engquist, Ph.D. And I love that. And I think an exercise snack sounds like a lot more fun than a long, grueling workout. So, I can see where it's more approachable, especially for people who are just getting started. And those are some great examples. I also think about, like getting up and dancing to a song a few minutes, right? Just getting your body moving, I think is a great way, you know, to do something fun, and get some fitness out of it, for sure. 

Scherezade Mama, Dr.P.H. Yeah, totally. 

Karen Basen-Engquist, Ph.D. I guess one question that comes up is, like, do exercise snacks really work? 

Scherezade Mama, Dr.P.H. So, that's like kind of like a loaded question, right? Overall evidence shows that they are safe. They are feasible, meaning people are willing to do them. That's the important part right. Any exercise, like, what's good exercise for you? Anything you're willing to do, right, to move your body. And then, safe I think I said, but also, like, you're willing to adhere to it, so it can build up to good exercise habits long-term, or maintaining exercise habits over the long run. And then, that cumulative effect of doing exercise more regularly throughout your day, or throughout the week, or throughout a month can lead to some pretty significant health improvements, right? Lowering your risk of cardiovascular disease, or lowering your risk of cancer, or risk of morbidity, developing other complications or health conditions. And then, ultimately, you know, the goal is to reduce your risk of premature death. So, there is evidence supporting that exercise snacks can really make a difference. Again, this is kind of a new area, right, which is kind of why we're talking about it. But, so it's limited. But, it's suggestive that these could be a really good way particularly for inactive people who are just figuring out a way to start, like, how do I get started, you know? And thinking of doing 150 minutes of moderate intensity physical activity, which is what our physical activity recommendations say, or 75 minutes of vigorous intensity activity. That seems a little daunting sometimes, right? So, how can I break it up into a small, digestible piece that I could do more regularly, and maybe build up to the health benefits of regular physical activity that we know from the vast majority of the research? 

Karen Basen-Engquist, Ph.D. I was just going to add, I think it's, the benefit for people who maybe are just getting started is really obvious, right, because it's much more approachable. But, it seems like with what we're starting to learn about the dangers of too much sitting, too much sedentary behavior throughout the day. Seems like it also would be good for people who maintain a regular exercise routine. So, even if you are getting up and working out for 30, 45 minutes every day, but then sitting all day long, that can have its own risks. But, you know, to your musculoskeletal system and just in terms of like the mental fatigue of sitting still all day, it seems like exercise snacks would be a good solution for people who, even people who are exercisers. 

Scherezade Mama, Dr.P.H. I think that is where the vast majority of the evidence lies too, right, in inactive adults, older, younger, you know, doesn't matter. And I think there's a lot actually in workplace settings, right, where you are trying to break up prolonged bouts of sedentary behavior, sitting. And then, you know, I know I do it, right? And your Fitbit watch or your Apple Watch and you know, all tell you to do these things too, right? You know, "You have 250 more steps this hour to call it an active hour." That's an exercise snack, right? Two hundred fifty steps is a snack. So yeah, it definitely could help break up sitting time. And we know, you know sitting is the new smoking. And so this could definitely help with that. 

Karen Basen-Engquist, Ph.D. Certainly there are a lot of tools on our wearables and phones and so forth to help us integrate exercise snacks. So, are there some examples of studies where they've actually looked at benefits of exercise snacks or short, really short bouts of activity? 

Scherezade Mama, Dr.P.H. I think the research in this space is relatively new, but also like, quite compelling, right? People use very different definitions of what an exercise snack is, right? Sometimes the snack includes only your body weight. Sometimes the snack includes a resistance band. Sometimes it's walking, sometimes it's climbing stairs. You know, something along those lines. So, that kind of varies. And then the intensity of the snack can vary over time, right? Is it light? Is it moderate? Is it vigorous? There's actually more data on, like, vigorous, high-intensity exercise snacks, right? So, like a "snack sprint" or something along those lines. But it could be as little as, you know, again, 15-second snack or a ten-minute snack. It just really depends. So, lots of different definitions. And I think then it's also been done in lots of different populations. So, we talked about some older adults, adults who are physically inactive and are building up maybe to regular activity, adults with diabetes or prediabetic adults, older cancer survivors. But, I think regardless of what the exercise snack is or who the population it's targeting, overall, the studies are showing that these are safe, they're feasible and people are willing to do them. And actually, like, you and I have been doing exercise interventions for quite some time. And one of the biggest barriers we have is adherence, right, and getting people to adhere to an exercise protocol is quite challenging. I mean, you can just think of it from, I know from my own perspective, right? Like, I have a hard time sticking to an exercise routine. And so, but these exercise snack studies are showing adherence rates of like 80%, 90%, 96%. I'm like, maybe I need to do, yeah, exactly. Maybe I need to do one of these. So, I looked at one study that I was really interested in, and it was exercise snacks that included body weight exercises plus tai chi exercises, which tend to be a little light intensity. So, not too rigorous, you know, didn't require any equipment, and it was done among physically inactive older adults. And they found some really compelling results. So, their exercise snacks were ten minutes long. They were instructed to do it twice a day for one month. You needed to do this exercise snack. And during this ten-minute period, one minute on and one minute off. So, one minute you're doing body weight exercises, repeating as many times as possible, and then one minute of rest, and then one minute of maybe tai chi exercises, and then one minute of rest, and so on for ten minutes. And they found really compelling evidence for improving physical function, muscle strength and balance, also led to increases in physical activity, reductions in sitting time, which was really important, and then, overall improvements in cognition in older adults. So, I thought, you know, sold. We should be doing this, right? But I think that there's mixed research out there because there's so many definitions and so many different populations, it's really hard to replicate these findings. And so, I think just more work is needed in this space. 

Karen Basen-Engquist, Ph.D. Sure, sure. It does sound like a really promising area for research. Just to sort of clarify, for people who might not be familiar with the term body weight exercise, so that refers to something like, any kind of exercise that uses your own body weight to give some resistance. So, like a squat, or a sit-to-stand, you know, sitting down in a chair, standing up, sitting down repeatedly is a body weight exercise, or a wall pushup or something like that. So yeah, I think body weight exercises are kind of great exercise snacks because they don't require any equipment, right? 

Scherezade Mama, Dr.P.H. Yeah, exactly. And I think it's something like you can relatively easy to maintain over time. And I think the number one barrier for people to being physically active is time, right? So, these are meant to be like woven into your day, easy to maintain a routine. You know, I know you do a lot of work in this space. So, what are your thoughts on how people can like start or maintain a routine over time? 

Karen Basen-Engquist, Ph.D. Sure. Well, you know, I think the same kinds of behavioral skill tools that we use in helping people develop a regular exercise routine can be helpful for developing an exercise snack routine too. You know, using skills like like goal setting. So, in our Active Living after Cancer program that we offer, we work on both exercise snacks and regular physical activity. But one of the main behavioral skills that we teach is goal setting, right? So, creating some really, well, both short- and long-term goals. But with the short-term goals, we particularly focus on having them be SMART goals. So, goals that are specific, measurable, achievable, relevant and time-bound, right? So, for example, if you have a goal of, you know, on five days this week I'll walk outside for five minutes, three times a day, you know, once in the morning, once at lunch, once after lunch, once after dinner or something like that. So, it's a SMART goal because it's specific. We talk about walking is the activity. It's measurable. You can you know yeah put a checkmark on the calendar or something like that if you did it. It's achievable. I mean, at least for me. I know that's something I could walk for five minutes. It's something that I could fit into my day. It's relevant. You know, walking outdoors is great. It can be, it's a moderate physical activity. It's a good mood lifter, you know? Yeah, especially beautiful weather like we're having right now. And it's time-bound. You know, I've said specifically I'm going to do it three times a day, five days this week. So, making goals like that to help you achieve, you know, to really develop that exercise routine, especially if you haven't done it before, you know, develop the exercise snack routine, I should say, can be really helpful. And, you know, another key part of goal setting is self-monitoring. So, keeping track of whether you met the goal or not. And you might even decide you're going to give yourself a little reward if you do meet that goal. So, incorporating some behavior change techniques like that can be helpful in developing a routine a real habit around exercise. 

Scherezade Mama, Dr.P.H. Last time we were talking about adopting a new like a walking routine. You know, we talked about how you could use your trackers or a wearable device or something to help also keep you accountable. So, that's great. I've heard about people talking about habit stacking. What is habit stacking, and how can it maybe help you maintain your routine, or maintain an exercise snack routine or something along those lines? 

Karen Basen-Engquist, Ph.D. I'm so glad you asked about that, because I think habit stacking is really ideal for encouraging people to do the exercise snacks, right? In fact, you even mentioned an example of it earlier with the woman you met who says she does pushups every time she goes to the bathroom. So, habit stacking is basically taking something that you do habitually already, something you do daily or whatever frequency is appropriate for the exercise snack, and saying, "I'm going to do an exercise snack in conjunction with that." So yes, you know, pushups every time you go to the bathroom would be an example. 

Scherezade Mama, Dr.P.H. Good habit stacking. There could be bad ones, too, right? 

Karen Basen-Engquist, Ph.D. Well, yeah. You know, like eating, a snack and actually, you know, sugary snack every time you go to the bathroom. That would be a bad, you don't want to do that. I try doing squats while I floss my teeth, so. 

Scherezade Mama, Dr.P.H.  That's a good one. 

Karen Basen-Engquist, Ph.D. Yeah, it takes some concentration. 

Scherezade Mama, Dr.P.H. My hand-eye coordination probably wouldn't be up to that challenge. 

Karen Basen-Engquist, Ph.D. And I think it also kind of points out, that example kind of highlights that if you are doing some body weight exercise or any, even if you're picking up hand weights or something, if you're doing some kind of resistance exercise or strength exercise, you do even though it's a snack, you want to make sure you're using good form because you don't want to injure yourself doing an exercise snack. You're going to feel silly going to your doctor and saying, well, I hurt myself doing an exercise snack. But at any rate, you don't want to hurt yourself. And so, take a look, there are some videos online at MDAnderson.org that show proper form of some body weight exercises, for example. 

Scherezade Mama, Dr.P.H. Like squats, or pushups or something. 

Karen Basen-Engquist, Ph.D. Exactly. So, it's kind of important to pay attention to that, even though you're just, you think, I'm just doing this for a few minutes. 

Scherezade Mama, Dr.P.H. I think that's great. Like pointing people to resources as well, or form and making sure we don't, you know, avoid injury and things like that because I feel like that's common. The other one, pushup seems really daunting. I think when the woman told me she does pushups before she goes to the restroom, I'm like, she told me she did 20. And I was like, I cannot do 20 pushups. So also, you know, maybe looking up the MD Anderson resources to see modifications because there's lots of different ways to use your upper body or increase your upper body strength that doesn't require you, you know, always being on your hands in your toes. Right?  

Karen Basen-Engquist, Ph.D. Yeah. It's very important to tailor those kinds of exercises to your fitness level. I cannot do 20 pushups. I would not recommend that for most people who are just getting started. But, you know, sometimes we tell people to do wall pushups, you know, to sort of, stand a few feet away from the wall and do your pushups against the wall. And it's a good modification for, you know, people who don't have as much upper body strength. And most of us do not have the body, at least most women do not have the body strength to to do 20 pushups every time they go to the bathroom.  So, that's a good thing. 

Scherezade Mama, Dr.P.H. The timing of that is important too, right? Maybe do after you use the restroom not before. 

Karen Basen-Engquist, Ph.D. That's true. Yeah. Think about modifications to the exercise to make it realistic for you. You want it to be challenging but not unmanageable. And you definitely don't want to find that you're, you know, sore for days and days afterwards because this is something you want to repeat frequently. The sort of incorporating activity into daily life is something we talk a lot about in Active Living after Cancer. So, our Active Living after Cancer program is a 12-session program for cancer survivors to help them basically incorporate physical activity into their daily life. When we teach behavioral skills like goal setting and so forth, to help them do that. And I know you also have been studying an approach to sort of, incorporating short bouts of light activity called Harmony and Health. Do you want to tell us a little bit more? 

Scherezade Mama, Dr.P.H. Yeah. Our Harmony and Health program is specifically designed for adults who are physically inactive. And so, for the folks who are, you know, think 150 minutes, that's crazy. I can't reach that goal. I'm doing zero minutes of physical activity per day. And so, the idea behind Harmony and Health is, well, can we at least just get you to sit a little bit less and move your body more, whatever that looks like, right? So, it could be light intensity. It could be moderate. It could be whatever you want it to be. And the idea is to kind of work up into it. And we do teach strategies. I never actually thought about it as exercise snacks, but we do teach strategies in that program about how to break up your sitting time, which could definitely be an exercise snack, right? Standing, sitting during a commercial break or something along those lines, right? Or if you're in a lecture, or you're sitting through your workday getting up and taking a lap around your office or something along those lines. And so, yeah, Harmony and Health focuses on that. We also incorporate breathing, stretching and guided relaxation to kind of also touch on mental health and stress management and how important that is for, you know, increasing your exercise over time. Exercise can help with that. But if that's your barrier to being physically active, then that's also something we want to make sure we address as part of the program. 

Karen Basen-Engquist, Ph.D. That's right. We could all use more stress management, to be sure. For sure. As we talked to people, cancer survivors and others who are trying to be more physically active and are interested in exercise, we do sometimes hear about some interesting, well, fads or trends in exercise. Everybody's kind of looking for the new thing, the new type of exercise they should be doing. So, two of the things I've been hearing a lot about from people are weighted vests for walking and also these lymphatic vibration plates. So, what do you know about those? Are those effective or are they helpful to people? 

Scherezade Mama, Dr.P.H. Yeah, that's a really great question. I mean, they're all over social media, right? So, social media will lead you to believe that there's substantial evidence, but there's really not a lot of studies. So, weighted vests, for example, they'll help you burn calories, right? I think there's been some research in like bone strengthening or bone density. But other benefits, like if you're trying to lose weight or, you know, burn calories or, you know, musculoskeletal benefits, I think the findings are mixed, right? And I think it just depends your goal, right? We talked about exercise snacks could be used for multiple components of fitness. If this matches your goal, by all means do it. I think we've had this conversation before, right? Weighted vests are one example. Ankle weights are another example. Or weighted belts when you're walking. And at the end of the day, if you're willing to be like active, if this is going to help you to be active or motivate you to get out and go for a walk. By all means, put on that vest. Put on those weights. Go do it. But if it starts becoming a deterrent to being physically active, maybe it makes your ankle sore, your wrists sore, or something else, right? Maybe you don't have your vest. So, you're like, I don't have my vest, so I'm not going to go for a walk. I'm sometimes guilty of this, you know, with my Fitbit. I'm not wearing my Fitbit today. I forgot to wear my Fitbit today, so I'm not going to do activity. It doesn't count. If it does any of that, don't do that. Right? 

Karen Basen-Engquist, Ph.D. Right. Yeah. If it discourages you from being active in any way, I could see where, you know, if it provides you with that extra challenge. You know, sometimes people say, like walking just doesn't feel physically challenging enough to them. So, I think it can be helpful. But for some people, walking is plenty challenging, especially if you're living in a place with a lot of hills. We happen to live in a very flat place, so sometimes people might need that extra challenge. But if it starts to feel too challenging and like you said, makes it less pleasant and enjoyable so that you're less likely to do it or you just won't do it if you don't have your best with you, then maybe it's not such a good thing. 

Scherezade Mama, Dr.P.H. Right. Don't let it be a barrier. I think the lymphatic vibration plates are another interesting one, right? There really isn't a lot of evidence on them. But you know, I know people are using them again for different reasons. 

Karen Basen-Engquist, Ph.D. So, this is just a plate that vibrates that you stand on? 

Scherezade Mama, Dr.P.H. Yeah. It's just a vibrating plate. It's like a board, a flat board, and you stand on it, and it goes, and shakes everything in your body, right? And I think, you know, that's great and maybe good for some things, right? They might just be relatively fun. I bet it has something to do with like improving balance, right, you have to stay on this shaking board. So, I think that there could be benefits to it. But I think at the end of the day, it's not a good substitute for physical activity. You still need to be physically active to really achieve, you know, optimum health benefits, right? And so, I think no matter what people try to decide to do, you know, again avoiding injury, make sure that it's motivating you and isn't creating a barrier, and then, you know, you can do all of these things, but you also need to be physically active, regularly incorporate that. And I do think exercise snacks can help with that, right? Just helping you to build up to that regular physical activity that we want people to achieve for good health. 

Karen Basen-Engquist, Ph.D. Well, this has been a great discussion today. Thank you so much for engaging on this topic and and sharing it with everybody. And thank you so much for tuning in. If you enjoyed this episode, be sure to follow or subscribe on Apple Podcasts, Spotify, YouTube or wherever you get your podcasts. And don't forget to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org. Thanks for listening to the Cancerwise podcast from MD Anderson Cancer Center.