Dr John: If you had someone who was come to you, had a diagnosis and they weren't, they were already active or they became active and they had prostate cancer, they reduce their risk of dying from all cause by 30%.
Dr Rupy: 30%.
Dr John: And then for breast cancer it was 40% and colorectal cancer 50%.
Dr Rupy: Wow. Welcome to the Doctor's Kitchen podcast with me Dr Rupy where we're going to be discussing the most important topics and concepts in the medicinal qualities of food and lifestyle. When you optimise your food and your lifestyle, you can improve your health and wellbeing and that is my underlying belief. And today we're going to be focusing on exercise. I'm talking to Dr John, AKA Health and Fitness Doctor on social media. He's the director of the British Society of Lifestyle Medicine. He's also a qualified GP with a strong interest in sports medicine. He regularly lectures at Bristol Medical School and he's the reason why I've been dragged down there so many times this year and last year to talk to the medical students. He's such a passionate educator and he's very, very well researched, particularly within the field of exercise as medicine. If you're interested in why exercise can improve your health, what physiological benefits this has and how to get active to lead to ultimate health benefits, you're going to absolutely love this podcast episode. Let's kick off with the podcast.
John, thank you so much for coming down, mate.
Dr John: Oh, thanks for having me.
Dr Rupy: So you've come down from Bristol today.
Dr John: Bath.
Dr Rupy: Bath. I get confused because you always drag me to Bristol, but you're actually based in Bath now.
Dr John: That is true. And I grew up in Bristol, so I'm kind of Bristol really.
Dr Rupy: Yeah, yeah. And you're preparing for your big leave, aren't you?
Dr John: I am, yeah. So I'm off to Australia for about 18 months working as a GP out there in Sydney, which I'm very much looking forward to both the lifestyle aspect of that and just seeing kind of a different world of GP really. So yeah.
Dr Rupy: Yeah, so you're going out there as a general practitioner, right?
Dr John: Yeah.
Dr Rupy: The NHS beat it out of you and you're going out for some rest and relaxation.
Dr John: To a certain extent you could say that, but I think it's also just to kind of learn from a different system and to kind of develop new ideas about how we can, you know, use our NHS to really help people and especially in this kind of lifestyle medicine area, which as you said is kind of my passion, especially around the physical activity stuff. So, yeah, it'll be interesting to see what I learn about it out there.
Dr Rupy: Yeah, because we were talking the other day when we were both lecturing at the Bristol Medical School prevent day about just how tough it is to try and introduce these sorts of conversations into your clinical consultation with the time constraints, with the number of patients that you see in a typical NHS GP clinic, right?
Dr John: Yeah, it's really tricky. And most patients don't even have one problems, they have two or three. And to actually try and talk about lifestyle within that as well is really tricky. And I know when I first qualified, I was very keen to try and do this and I was constantly running late and I often found that I was probably picking the wrong battles. And so it's about finding the right times and the right situations to talk about this and maybe using bite-sized chunks, bits of information around lifestyle and hoping that's going to have some impact and then catching up on that later in further follow-ups. But I'd love it if we were in a situation in the NHS where we were really jumping on this idea more, having more follow-up clinics with clinicians, doctors, nurses, healthcare practitioners in order to really kind of help people make lifestyle changes in set lifestyle clinics because actually having the time dedicated to this in terms of the long term and even the short term will make a massive difference, especially to the big conditions that we worry about, you know, the non-communicable diseases which we know are actually overtaken the infectious diseases now. You know, your diabetes, your heart disease, strokes, and even things like cancer, you know, they are, you know, really quite big now and we need to be making a real change in the way we manage them.
Dr Rupy: Yeah, and I think that's one of the reasons why you're going to Australia as well, right? To actually investigate and see and test if this can actually work in the NHS, like testing environments where you can bring patients back with a mini MDT almost of different specialists that can give some lifestyle changes.
Dr John: Yeah, exactly. We'd love to set up a clinic while we're out there. Now, not knowing the full ins and outs of the system before I get out there, we'll see what happens when I do get out there. But that's the plan and I'd love to bring something like that back into the NHS in some form. So yeah, fingers crossed, we'll see what happens.
Dr Rupy: Yeah, and I love the bite-sized sort of information that you give on social media as well. You've got some really cool graphics and if you haven't seen it on Health and Fitness Doctor on Instagram and Twitter, there are nice little graphics that just give people a little snippet of information. Doesn't go too deep into the science unnecessarily, but it gives people enough in the way of motivational support to try something quite gentle in a lot of cases, right?
Dr John: Yeah, definitely. And I think in terms of our consults, that can be really key. Where there's often some teaching that I do again to the medical students and to GPs around trying to just make these kind of little comments or little habits that you do in front of patients which make a difference. Just to mention a few, there would be one where I'd always try and get my patient from the waiting room. And every single patient after that would say, oh gosh, doctor, is the, is the tannoy system not working? And every time I'm like, no, it is working. I just, you know, I like to get my steps in. And I always get the comment, oh, I need to do a bit more exercise. And then immediately you can say, oh, is that, is that something you've thought about? Is that something you'd like to do? And it means that you're not nagging them. You're just kind of, you know, jumping on a comment that they have made. And other things like having your cycle helmet in the corner. I know one of our good friends, Dr Zoe Williams does this quite a lot. And just doing little simple habits like that can actually introduce the conversation, which can make a really, really big difference.
Dr Rupy: Yeah, I love the work that both you and Dr Zoe Williams do actually. She's the champion of physical activity for the RCGP and I think it's those little snippets of sort of talking points that you have in your, in your waiting room. And a good friend of ours, Professor Trevor Thompson.
Dr John: Yeah, Prof now.
Dr Rupy: Yeah, Prof. He has a jar of healthy items in a cupboard, doesn't he? That he brings out and, you know, whenever he talks about healthy eating, he'll open this cupboard and it will be full of things like nuts, seeds, legumes, beans. And it's like, you know, these are the things that you just need to put in your diet. You know, it's a Mediterranean style diet. It doesn't have to be too overwhelming. You don't even have to cook sometimes. You just need to eat the stuff.
Dr John: Yeah. Yeah. No, it's just those little points and just making those little lifestyle changes can make a massive difference. And especially in the kind of physical activity realm and that's why I'm so kind of passionate about it really. Yeah.
Dr Rupy: Yeah. So what got you interested in physical activity in particular and lifestyle medicine yourself? Was there a story behind it? Was it something personal?
Dr John: Yeah, to a certain extent. Yeah. So I, I wanted to become a doctor because when I was younger, I had a knee condition which I was told would stop me playing sport. And I saw a sports specialist and they said, no, you can keep playing sport, but we need to adjust what you do. Stop playing a couple of sports, but you can keep playing. And you know, the initial diagnosis that I was told that I wouldn't be able to play sport for two years was just devastating. You know, I was playing sport like kind of three, four hours a day. I couldn't imagine not playing sport. So I really wanted to get into sports medicine. And when I started to attending conferences, seminars, lectures, sports medicine is linked with exercise medicine, which is kind of big in other countries. It's kind of getting there here, but it's not quite as big. And every time I was going to these lectures, I was amazed by the evidence for the benefit for physical activity in terms of treating disease, managing conditions, reducing disease, and in fact, in some cases, even reversing conditions. And it just meant me, well, I became a complete evangelist for it really. And I just couldn't stop telling people. Me being someone who does enjoy being physically active themselves. And I just saw it as a real way of helping patients and kind of preventing the onset of other things going wrong and disease happening.
Dr Rupy: And did you have to take off two years for your?
Dr John: Well, I didn't in the end. So I went to the sports specialist and they got me on a kind of special regime. They got me stretching, they used some ultrasound, which I'm not sure looking back at the evidence of the how much benefit that had, but you know, I was able to keep playing. And in fact, within a week of being told that I couldn't play for two years, I was back playing competitive football. And after that, you know, I had to reduce what I did, but and there were times when it was, it was hard, but I was still able to play. And I don't want to make a big deal of it because it wasn't like a big terrible like, you know, career ending injury, but it was an injury that had a massive impact on my life. And in terms of my wellbeing and, you know, things that I did as a kid, I wasn't really good at paying attention to studies. For me, exercise was my thing.
Dr Rupy: I would actually argue that's quite a big change for you. Someone who does sports three to four hours a day and being told, you know what, you can't do that nowhere near as much as you do at the moment. There's a lot of personal identification involved in your daily activity. And something that you're clearly passionate about, especially something like sport as well, where there's that competitive edge, the team edge, the social bonding element of it as well. It's it's quite a big change.
Dr John: Yeah, it would have been. And I I was really fearing that to be honest. And it was the thing I was passionate about. You know, I wasn't passionate about my studies at the time. I certainly wasn't the best academically, but I really did find my place in team sports. And it didn't matter what it was. It was anything. And I just loved it. That interaction with people, getting outside, that kind of buzz off being active. Yeah, I just just absolutely loved it. And I still do.
Dr Rupy: And you still do. Yeah. And you still you do like your studies. I know that.
Dr John: I do. Yeah. That kind of developed later. I was a late bloomer for that. Got there in the end.
Dr Rupy: You got through your exams. Yeah. So when it comes to exercise outside of your personal story, you've seen obviously a lot of evidence, but a lot of your own anecdotal experiences with patients, right? With improving the outcomes.
Dr John: Yeah, big time. And I think the the biggest area where I see that is in mental health. Now, that's interesting because a lot of people don't associate kind of being active with mental health. And when I say mental health in this situation, I'm talking about depression and anxiety, which is something that I see a huge amount of in the NHS. And it's something that I'm again, quite passionate about because it I just find it so sad seeing so many people who are feeling so low, feeling so anxious about their day-to-day stuff. And they don't have an outlet. And the patients who I see who I try to in a obviously a very sensitive way, talk about the idea of becoming more active, even if it's something small, going for a walk, getting a bit more daylight involved as well, trying to do a bit more activity. I've I've found some actually who will just go nuts for it, who will go from being very low, tell me that they're not that keen on the tablet, which I'm I'm more than happy to to go down that line. And then say actually they just want to do a bit more activity. And those are the ones, if I'm honest, that often come back and say, you know what, I feel so much better having been more active and incorporating that into my lifestyle. And it's great to see. And I can almost tell sometimes when I see patients and they're kind of using motivational interviewing techniques, their confidence and their motivation to exercise when they have got a low mood, how well they're going to do. And often those who've got a good motivation to be more active will do pretty well. And we're seeing loads of evidence for this, you know, across the board. And the thing for me is that it doesn't just affect mental health. You know, the benefits for so many different conditions are massive. Just to throw out a few kind of stats, because I love a few stats. But you know, we reduce our risk of diabetes by 50% if we are hitting the guidelines for activity. We reduce our risk of heart disease by about 35%, osteoarthritis by 60 to 85%, depression and anxiety by 30%. And then even cancers like colorectal cancer, we reduce our risk by 50%. 20% reduced risk in breast cancer. And then if we're thinking about other conditions like dementia, we reduce our risk of 30%.
Dr Rupy: These are huge, huge numbers because when we just to give you a little bit of context, when we read journals and papers on pharmaceutical interventions, which are sometimes absolutely fantastic and they're very, very necessary in our daily work, they're nowhere near the numbers. Those are like block blockbuster drugs, which we're talking about the numbers. So and there's a quote that you always like to use.
Dr John: Yeah, so Robert Butler has a great quote, which is if exercise could be packed into a pill, it would be the single most widely prescribed and beneficial medicine in the nation. And I really do believe that's true. And I've heard lots of different variations of that quote, but I really do think it is true. If we could package up exercise or physical activity into a pill, not only would we give it to every patient, every patient would want to take it because they'd see those benefits.
Dr Rupy: Yeah. And you mentioned like the general guidelines and how that has the impact of 30% reduction of dementia, 50% on colorectal cancer. What are the general guidelines and how do we actually, how do we interpret those?
Dr John: Yeah. So essentially the guidelines are to do 150 minutes of moderate intensity activity a week, as well as two muscle strengthening activities a week as well. And that's for 18 to, you know, above 65 year olds. So essentially the moderate intensity activity is variable for different people. I often say the best way of testing it is the the talk test. So when you are doing moderate intensity activity, you could you're a bit sweaty, you're a bit hot under the collar, you maybe feel your heart rating a little bit faster, and you're able to talk to the person next to you doing that activity, but you can't sing. So you can talk but can't sing. And then when you're talking about vigorous activity, which is actually, if you did vigorous activity during the week, you can do half the amount. But then in that situation, you're not able to talk to the person next to you. You're so out of breath, you have to take a pause in between. So that's a good test. I must say it hasn't always worked for when I've tried it myself. But it's a rough way of working out those levels. And moderate, you know, intensity activity can be anything from running, cycling, walking at a fast pace. I think that's something that we really underestimate as a form of activity. And then muscle strengthening can be anything again, you know, we don't have to be going to the gym to lift heavy weights and all that kind of stuff. Actually, just body weight exercises, you know, just doing something fun, even games of tag running around, that kind of stuff, that will have benefit to our body.
Dr Rupy: Yeah, and I I like the talk test. The reason why is because it doesn't really put a specific number on what a specific activity, doesn't assign it to a specific activity because I know a lot of patients would get completely out of breath by going at half the speed that I'd be able to do on a treadmill, for example, or even just brisk walking down their road. And that talk test just gives an idea of their cardiorespiratory fitness and how it's a lot more personalized to them.
Dr John: Yeah, definitely. And patients can kind of associate with that a little bit better because I think the word moderate is so so broad. Yeah. And I think what I often say is I don't even often use that language. I just say as long as you just feel like you're, you know, you're putting in the work, you're feeling a little bit like this a little bit hard, then that is moderate activity. If you feel like it's really hard, and you'll know when it's really hard, then that's vigorous. And we've talked about the benefits for so many conditions. I think it's worth bearing in mind that for some patients with heart failure, for COPD, walking 100 yards is going to be really hard.
Dr Rupy: That's super difficult.
Dr John: Really hard. And that would be classified as vigorous for them.
Dr Rupy: COPD is a chronic obstructive pulmonary disease and that's something that we see with tends to be smokers where they have a restrictive lung disease and and heart failure is where you you have an inefficiently pumping heart. So these patients are there's different classifications of the degree of severity, but generally they have very poor exercise tolerance. They can't in some cases walk more than a few yards, let alone 100 yards.
Dr John: Yeah, can be really tricky. And telling them to exercise can be a really hard, hard thing to do.
Dr Rupy: And traditionally, actually, we've been telling patients to rest, right? After cardiac, myocardial infarction, so you have a heart attack. It was it was standard practice to tell them to rest for a few weeks.
Dr John: Bed rest used to be part of the management plan.
Dr Rupy: Yeah. And now it's the opposite.
Dr John: The exact opposite. Yeah. Yeah. So the risks of not doing exercise, which a lot of us, I mean, I feel like we should be standing whilst we're doing this podcast.
Dr John: Yeah, I was thinking that.
Dr Rupy: My producer's probably going to have a go at us. We're going to mess up the sound or something. So we won't stand, but the intention was there.
Dr John: Yeah, we tried.
Dr Rupy: But the risk of being sedentary are pretty scary, right?
Dr John: Yeah, they're massive. And I think it's amazing looking at the stats for sedentary behaviour and how sedentary we are as a nation. I think it's really important here to clarify what we mean by sedentary. So if I was working an office job and I worked eight till till 5 o'clock and then I did an hour of gym in the evening, then you could probably say that I was active for that day because I've done my activity for the day. But if I'm sat down for that whole period in the morning and in the afternoon, then I'm actually sedentary for a long period of that day. And although I'm active during that day, I am sedentary. And the problem is with being sedentary is we know that confers risks in itself. There are also some scary stats around the UK and how sedentary we are. So we know around 78 days of the year we are spent sitting. About 64 days a year we're watching TV. And it just really make you realize how much sitting we do. It's nuts. And when you see the risk and, you know, when you look at the studies, I suppose the thing that scares me is you're looking at the kind of markers that we look for in disease. So high cholesterol levels, high triglyceride, which is another type of fat in the blood that we worry about, lower levels of HDL, which is the good level of fat. So those things are all detrimentally associated with sitting more, you know, across the board. And then when we look at kind of um other studies which look specifically at heart disease and death rates, we know there's an 84% increased risk of dying if you spend from heart problems, if you spend greater than 10 hours in a car during a week compared to less than four hours. Wow. Which is massive. And then when we look at kind of overall sedentary behaviour, if you spend greater than 23 hours of your week being sedentary, you have a 64% increased risk of dying from a heart problem compared to if someone had sedentary behaviour of less than 10 hours a week. Yeah. You know, again, massive numbers, massive increased risk from being sedentary. It really makes you worried about us sitting down right now.
Dr Rupy: It does. Yeah, it does actually. And they're quite scary. I think like one of the things I I started doing a couple of months ago is just monitoring my activity levels using a tracking device. And I actually really I I I regard myself as someone who's quite active, keeps in shape. But for someone, if if I was the kind of person that wouldn't force myself to do some exercise, and I enjoy exercise actually, so it's not really a an activity I have to force myself to do. But had I not been doing that, I looking at my activity levels, they're very, very like very inactive during the day if I'm at home working from home. If I'm in A&E or working in general practice, I do the same thing as you. I always go get up and I go and get the person from the the waiting room. But a lot of people just don't have that opportunity. And that's why I think there's quite a few hacks that you can you can do to improve your activity levels, right?
Dr John: Yeah. You sound like you've got some yourself.
Dr Rupy: I do. Yeah.
Dr John: You go first. You go first.
Dr Rupy: Standing desks. I mean, I'm a really big fan of standing desks. It's actually helped my posture. It gets me active, it gets me walking around. It means that I'm not just it actually helps me think, I find. When I was writing the second book, Eat to Beat Illness, I got a standing desk. It was something I just put on my regular table. I think it's about 20 quid or something from Amazon. But I'm sure there's other places you can get it. And I just put that up there and I I just I felt a lot more active and I could certainly tell looking at my tracking device that actually helps.
Dr John: I got I actually got the same desk after seeing yours. And I use it quite a lot. And in fact, it's interesting you say that about the stimulation of the brain because we know that actually being active, which does include kind of just standing and even just, you know, going side stepping from side to side, that will actually stimulate the hippocampus area of the brain. And that's involved in learning and memory. And I actually, you know, believe that so passionately that now whenever I do a teaching session, regardless of what it on, what it is on, but it normally is on physical activity. I will get people to do a squat challenge or I'll get people to even just get up from their seat and just do some movement around the room because it makes such a difference. Even if it just gets people chatting and laughing a little bit, then actually they're more stimulated to then learn again.
Dr Rupy: I can personally vouch for that because a couple of weeks ago we were in Bristol Medical School, he got the entire year group of about 300 students all doing squats in this massive hall. And it definitely got people chatting and definitely got people laughing, which has lots of other benefits as well. So
Dr John: Certainly does. Certainly does. Yeah. I mean, I suppose one thing that I'd like to come back to is kind of talking about the kind of physical activity levels because we talked about sedentary behaviour and there's no doubt that although we've got a problem with sitting, we've got a problem with physical activity as well. So we know that as a nation, about 19% of men and 26% of women are defined as being physically inactive. Now, terrifyingly, that means that they do less than 30 minutes of activity a week, not a day, a week, which is quite profoundly low when we think of what just activity that could involve. We know that kind of 33% of men and 45% of women are not active enough for good health. And this is the stat that I really don't like and it's the one about children. So we know that actually 79% of boys and 84% of girls age 5 to 15 are not hitting the physical activity guidelines. Wow. And that makes you terrified when you look at the future and you know, the guidelines are slightly higher for children, but they should still be hitting them and they should still be getting a lot of play during their day and that doesn't seem to be happening. And you know, when we think of the ramifications of this, it's massive. The cost of the NHS is about 74, sorry, 7.4 billion, but that's still big. And some estimates are as high as 20 billion a year.
Dr Rupy: 20 billion.
Dr John: 20 billion a year.
Dr Rupy: Wow. In the context of the entire budget, that's um
Dr John: It's massive.
Dr Rupy: 20%.
Dr John: It is, yeah. So and and we've just got so much evidence leading to physical activity contributing to increased risk of death. And there was one big study that was done in 2009, well the the data was analyzed in 2011 and a more recent one in 2018. But the the 2009 one looked at 55,000 people over a 15 year period. And what they did is they looked at contributing factors to death. And they looked at obesity, diabetes, hypertension. These are things that we all look for all the time in general practice and really kind of make an effort to manage. But what they found was the biggest contributing factor to death in that population was low cardiorespiratory fitness, which they actually measured on a treadmill test. Which is massive. I don't know the fitness levels of any of my patients. And you can guestimate and you can work it out using screening tools, but it's still an estimate. Yet other things like hypertension, diabetes, so hypertension, high blood pressure, we we really screen for and check for and manage. Yet fitness levels, we we don't pay any attention to. Yeah. And the more recent study that has been done in 2018, which is just as impressive, in this study, they looked at 120,000 people over a 25 year period. And what they did is they put people into different kind of fitness levels. So they had elite, high, moderate and low. And they found that the elite level actually had an 80% reduced risk of death during that period, which is similar to not smoking, so smoking compared to non-smoking, similar to being diabetic or not diabetic. That's massive when we think of how much of a risk those two things are to our general health. Absolutely, yeah. So those studies for me really kind of show you how important it is to be fit. And maybe the question I ask is, should we be as a an NHS, as a group, be actually screening for that more?
Dr Rupy: Absolutely, yeah. Yeah. And there are there are easier ways of I suppose I think the easiest explanation as to why we're screening for certain things other than others is because of the ease and the fact that it's always been in clinical practice. Whereas cardiorespiratory fitness, is it harder to screen? Is it quite a bit more intensive?
Dr John: It would be harder to screen. It would be harder to screen, but I think the thing that frustrates me is the screening tools that we've currently got available in general practice for me aren't fit for purpose. And there are other screening tools that could be used and could actually um benefit us in terms of helping people. And I think off the back of that, I think we need to be having more kind of incentives for practices who are encouraging activity. So there's the initiative with the RCGP, which is the Royal College of General Practitioners to incorporate a partnership with Parkrun, which is brilliant. And I really want to see that keep happening really. And there's walk for health as well.
Dr Rupy: Do you want to just explain what Parkrun is actually?
Dr John: Yeah, so Parkrun is um normally at the weekend a 5 kilometre run, but it can be a walk, it can be a jog, it can be whatever you want it to be. But it's a fantastic community, a volunteer led organization, which essentially encourages people to be more active. Now, when we think of lifestyle medicine, obviously there are lots of elements and the two that really Parkrun hits for me is community as well as activity. And you're outside as well, so sunlight as well. So we'll go for three. But I'd say that, you know, the the community side of it is massive.
Dr Rupy: I think that's huge. Yeah.
Dr John: It makes a big difference. And there are some fantastic stories about partners, GP practices that have linked up with Parkrun and have got patients who have completely changed their life from being depressed on blood pressure medications, on cholesterol medications, coming to their GP every month, not for really much of a reason, as opposed to they just feel a little bit down. And they go to Parkrun, they, you know, it's not the easiest thing, but they they walk bits of it, they run bits of it. Some of the GPs get involved and help them go around. And you know, some of the stories of people ending up, you know, running half marathons, blogging about it, changing their lives, genuinely changing their lives through this intervention of just simply a GP asking someone to go on a Parkrun with them.
Dr Rupy: It's amazing that.
Dr John: It's incredible.
Dr Rupy: And I think, you know, there's a lot to be said for the community aspects of a lot of these things. In lots of cases, especially as a general practitioner, I'm witnessing loneliness and record levels of social isolation. And I think it in part is fueled paradoxically by social media and the the need or the want to act and look like someone, but also the fact that we've we're doing less of community-based activities like running together, like cooking together. Families are becoming a little bit more separated and we're becoming a lot more dependent on other forms of activity that don't involve people collaborating in groups.
Dr John: Yeah, I completely agree. And I think that loneliness thing that you touched on there is is so key. You know, loneliness is massive. And as a GP, I see it all the time. And it doesn't matter what age group it is. Like whether it's the elderly, the middle-aged, or even your kind of teenagers who I've been amazed in my last two years of clinical practice, how many patients I've seen with low mood who are under the age of 18. And I, yeah, if I'm honest, I feel social media can contribute to that a big amount. It's something that's here and it's here to stay if we're honest. But so we can't tackle that, but I do think tackling initiatives to try and reduce loneliness is a priority for our NHS. And I feel incorporating things like, you know, Parkrun, but cooking as a group, there are, you know, some fantastic initiatives in Bristol around cooking with associated with GP practices. You know, your culinary medicine movement, which is actually, I hope, going to start getting more cooking within GP practices and and helping patients to cook because I think that's key. But again, that's touching on the community aspect of of of that. And and that's a huge part of people's health.
Dr Rupy: Yeah, huge. We've talked a lot about death and how what happens when we don't move and all that and the guidelines. Let's actually talk about what happens when you exercise at a biochemical level, why is this actually leading to benefits and how can these be attributed to all the different conditions that it can help with? Because it seems like a panacea, right? It seems like, you know, it can just be good for everything. But there are actually some core clinical reasons as to why this is the case.
Dr John: Yeah, big time. And I kind of easiest to split this up really into the kind of cellular benefits and then the benefits to each condition. And I think that's the easiest way to explain it. So from a cellular point of view, there are kind of four main benefits that I've done looking into the research and two are anti-inflammatory and two are anti-ageing. So the first one in anti-inflammatory is visceral fat. So when we are inactive, we will accumulate visceral fat. And visceral fat is the fat that lies in and around our organs. And we know that actually this is an inflammatory agent. It will actually produce cytokines, which are kind of inflammatory proteins, which are in our body and they signal around the body and they can either be promoting inflammation or reducing inflammation. Now, when we've got visceral fat present in the body, that will actually increase the inflammation. And that will be due to two specific cytokines, which is interleukin 6 and TNF alpha. Now, when these two are actually together, we know that that's potent for inflammation. We actually see it in sepsis, which is a really horrible type of infection and an overwhelming infection that happens, which there's a lot more awareness about these days. But those are the two main cytokines which are involved in that process. And it's the same two cytokines that we see when we've got large amounts of visceral fat. However, when we're active, we actually reduce the amount of visceral fat that we've got. It's the first fat that is kind of got rid of by our body, mainly, I think, because our body knows how damaging it is. And actually, that means we don't get that pro-inflammatory effect and we don't get that low-grade inflammation.
Dr Rupy: Yeah. Now that's really important because the low-grade inflammation contributes significantly to a number of different conditions.
Dr John: Yeah, inflammation has become almost like this unifying theory of why we see different types of chronic lifestyle-related disease, right? It's the signaling process that is very necessary in short, it's a short adaptive response to stresses from your environment and we've adapted over our evolution to produce inflammation for benefits for the body. But it's this chronic low-grade inflammation that we deem meta-inflammation in the studies that is responsible for some of the things that we're seeing like diabetes, high blood pressure, cardiovascular problems, dementia even.
Dr Rupy: Yeah, exactly. And in fact, we've got good evidence showing links between heart disease, you said diabetes there, that's thought to be due to the inflammation contributing to insulin resistance. And it really is quite clear from a lot of studies that there is an obvious process going on there due to this low level of inflammation. Interestingly, that takes me nicely onto my second point, which is when we actually exercise, we stimulate muscle myokines. Now, muscle myokines, confusingly in a way, is a similar group, but they work in a different way. So when you stimulate your muscle, you actually produce anti-inflammatory interleukin 6. Now, interleukin 6 is actually increased by about 100-fold when we're active. So it's the acute response to being active. And that will in turn mean that you don't, for some reason, in exercise, get the production of TNF alpha. Now, as I said, TNF alpha in conjunction with interleukin 6 is the one we worry about. When interleukin 6 is on its own, it's anti-inflammatory. And when we don't get the TNF alpha though, we actually get increase in other kind of cytokines like interleukin 1RA, interleukin 19 and STNF-R. And this generally works to reduce inflammation in the body. So again, it touches on this whole idea of reducing inflammation, reducing all these kind of processes which could lead to all those diseases we've just discussed. And there's really good association studies which show in multiple groups of patients, we're talking elderly, those with um kind of metabolic diseases and those that are just healthy, that the general inflammation in the body is increased when we are inactive as a group. It's a blood test that we can sometimes do in general practice called a CRP or C-reactive protein. And lots of studies have shown clear association with being more active and a reduced level of this as high as kind of 40% in some studies. And in some studies, we're looking at kind of patients with metabolic disease. So metabolic disease typically you have a higher CRP anyway. So a reduction of 40% is not to be laughed at.
Dr Rupy: Yeah, absolutely.
Dr John: And that will definitely be contributing to, you know, them feeling better, them potentially not progressing their disease. I'd love to think it would be contributing slightly to them reversing their disease and having huge impact on their health. So that's the two anti-inflammatory ones. And then we've got two anti-ageing ones. So the first anti-ageing one is to do with the mitochondria. So mitochondria are the batteries of all the cells in our body. Now, we need healthy mitochondria in order to have a healthy cell. And if we don't, then sadly, the cell won't work as well. The cell will age worse. In the worst case scenario, cells will even die. So the mitochondria has many processes that go on in it, but as we all remember from our biochemistry days, the Krebs cycle, which goes on in the inner mitochondrial membrane, and that produces energy, but what it also does is produce reactive oxygen species. Now, there are many forms of reactive oxygen species, and essentially, it's a reactive form of oxygen. So it can
Dr Rupy: Which is a normal product of metabolism.
Dr John: Exactly. And in a normal situation, that's fine, and our body can deal with it. It can actually use antioxidants to get rid of them, but it can deal with it. However, if we are not doing anything for a period of time, this charge builds up. And these reactive oxygen species can actually be really damaging to the cell, but really importantly, the mitochondria. These reactive oxygen species actually target the mitochondrial DNA, causing direct damage to this. This disrupts the function of the mitochondria, stops the proper ageing processes of the cell. And as I said, in the worst situation, leads to death of that cell. And again, that can even contribute to the inflammatory process even further through these reactive oxygen species or through these cells just dying off and then we've got these waste products which haven't been cleared properly by the kind of cell processes like autophagy. So that's really key not having that mitochondria health. However, again, when we're active, what we do is we release that charge that's generated in the mitochondria. We don't get that build up of reactive oxygen species. And what we find is actually we get a healthy mitochondria, we get better energy levels, and we get the normal ageing processes going on in the cell.
Dr Rupy: And this can explain in a lot of cases why when people become more active, they actually report these subjective measurements of, you know what, I feel like I've got more energy even though I'm moving more. Or, you know, I feel clearer in my head. And there are lots of processes going on, but this is just one that can explain that phenomena.
Dr John: Yeah, definitely. And, you know, just touching on the mitochondria a bit more, we know that activity, especially for things like diabetes, actually contributes to an increase in number and size of the mitochondria directly. And we've seen this in studies. So it does have a big impact on the mitochondria. And as I said, if that's the battery of the cell, we need to be looking after that.
Dr Rupy: Exactly. And this mitochondrial biogenesis, this is something that a lot of people are getting more interested in, particularly in the hit training world, because there are some studies where I think they looked at muscle biopsies with post-hit training, they found that after certain sessions, it was more in terms of the number and the function of mitochondria versus just simple endurance training. Not to say one is better than the other, but purely looking at that one microscopic test of looking at the mitochondria, it showed some some pretty significant benefits.
Dr John: Great. I didn't know about that. That sounds great.
Dr Rupy: I'll put them in the show notes for sure. It's super interesting. But I I think there's definitely like a a focus on certain types of exercise these days, particularly in London. And I think variety, as we'll I'm sure we're going to cover a little bit later, variety of exercise is definitely your best friend. You want to do, yes, some hit training, but also not negate the endurance training as well as yoga, flow, mobility that is going to keep your joints supple and actually reduce the incidence of you getting injured from your other activities.
Dr John: Yeah, definitely. I suppose I'll just touch on the last benefit, which is the telomeres. It would be really interesting to chat about hit in a second though, because I've got some interesting studies in that area. But the the telomeres, which is the last kind of cellular benefit, and that's an anti-ageing process as well. So telomeres are the caps on the end of chromosomes. And we know that when telomeres divide, so every cell divides and will replicate, or most cells will. And when that happens, the telomere needs to divide as well and protect that chromosome that's dividing. So in order for that to happen, we need an enzyme called telomerases. If that enzyme is not present or not around enough, that length of the telomere will shorten. And we know quite clearly from the studies that cardiovascular disease, diabetes and other kind of inflammatory diseases are associated with a shorter telomere length. And that's almost a sign of chronological age. But we know that when we're active, actually what we do is we produce more of this enzyme. We actually get more replication of the telomeres because of that increased telomerase activity and production. And actually we don't get the ageing process happening in the same way. So, yeah, those are the kind of four main benefits. And I suppose touching on what you said about the hit training, I think my evidence of the research shows that there isn't a huge amount of difference between steady state cardio and high intensity interval training in terms of weight loss. If you're overweight, then there is a little bit of evidence to show that it might be slightly beneficial. And in fact, we see the most benefits for patients who are obese or overweight for high intensity interval training. If you're a normal weight, in that normal BMI, although that's not the best figure sometimes, but in that rough category, then actually the best benefit you get from hit is an increased fitness level. Now, we've already just talked about studies looking at the benefit of fitness. So actually, there's no doubt there is a benefit and that's really important. But I think sometimes the the benefit of hit is exaggerated. And I think that's important, not because I want to discourage people doing it, but some people find it quite hard work in terms of and that's obvious. But I say I look at my day sometimes, when I've had a 12-hour day in GP, the last thing I want to do is a hit training. You know, I couldn't even imagine doing that. However, on a day off, which doesn't happen too often, but on a day off, actually, I'd love to do that. I'd be buzzing for that. So I think catering what exercise people can fit in, what's suiting them is really important. I mean, especially when we think about hit, hit does increase that kind of acute stress response on the body. And that's okay. But if we're already in like stress mode, we don't want to give ourselves more stress. We don't need our body having more insults. Actually, maybe a yoga session or a stretch session or something just, you know, you can go and do. I know some of even my sessions just generally are quite relaxing. I find going for a steady long run, even if it's quite a long one, really, really relaxing.
Dr Rupy: Absolutely. It's something that I've tried to filter into my regime now because I used to do a lot of hit training, I think whilst I was in Australia, purely for time perspective. And I think certainly from a convenience point of view, hit training is really, really convenient. You get your heart rate up, you can, you know, reach your cardio respiratory peak and you can keep yourself fit on a time budget. But certainly now I've become a lot more intuitive about when it's appropriate to do hit and when it's actually appropriate to take a little bit of a step back and go into a lower gear and do yoga, flow, mobility. And it sounds very sort of middle classy, but actually, I talk about yoga to patients quite a bit these days. There's so many free things that you can get on the internet, but also going to the old class every now and then will give you a few tips and pointers that you wouldn't get from, you know, other forms of exercise. And I think it's it's super interesting.
Dr John: And I think the takeaway point from that really is finding something you enjoy and finding something that fits your schedule because ultimately, if you say, right, I'm I'm going to do CrossFit and I'm going to just do these sessions. And CrossFit's great fun and I've done it recently and I've enjoyed it. I'm terrible at it because my flexibility is terrible. But I do enjoy it. And but there are days when I just don't feel like I can handle that. So there are other days when I'd like going for a long run or like doing something else or even a walk. Like all these forms of activity are beneficial. And it's so important that we just make sure we are doing something rather than nothing because actually it has such an impact for our health.
Dr Rupy: Absolutely. And I love the way you've broken it down into the two cellular reasons as to why exercise is beneficial and the two anti-ageing benefits as well. How do we apply that through the perspective of different disease? So I was thinking maybe we should start off with a somber topic, cancer, but we've had Dr Elsa who's an oncologist on the pod before and she's a very, very big advocate of exercise both as an in a preventative manner, but also during cancer treatment as well and the benefits of it.
Dr John: So this is kind of a subject which I just think is amazing. A subject which I when I first heard the evidence, I I genuinely couldn't believe it because it's just so incredible the numbers that we see associated with this. One systematic review which really blew me away showed that if you've got patients who get diagnosed with cancer and they're either already active or they become active, they reduce their risk of dying considerably. And the numbers for the different types of cancer were massive. So if you had someone who was come to you, had a diagnosis and they weren't, they were already active or they became active and they had prostate cancer, they reduce their risk of dying from all cause by 30%. And then for breast cancer, it was 40% and colorectal cancer 50%. Wow. And it's amazing. It makes you think when as practitioners, we have a diagnosis that we have to give and I suppose the old way of thinking, similar to what you said earlier about the cardiovascular disease, is we used to say, oh, you know, this diagnosis is is hard, which it is. I'm not I'm not downplaying that at all. But maybe get someone to help you with the shopping, maybe get someone to to do that job for you. Maybe you shouldn't do that. When actually, without being silly about it, we should be encouraging activity for a number of reasons. And in fact, there are um kind of care homes which um uh kind of the hospices near near where I live, even in kind of palliative care that are doing lots of exercise classes. They've got their own gym now because they see the benefit in functionality, in mood and in so many aspects of their health through this.
Dr Rupy: Absolutely. I actually had an opportunity to visit the Penny Brohn Centre in Bristol and they have their own gym as well as relaxation centre and a great garden where people take walks and stuff like that for both patients who are terminal and going through treatment. And I think it's just incredible that now we've got to that stage where in certainly in some parts of our profession, we're actually encouraging people to move with reason. Obviously, it's a very emotive disease. There's lots of other factors that we have to take into account whenever advising anything for for patients. But but certainly exercise is sounds incredible.
Dr John: Yeah. And I think when we when I used to think about it, I used to think, okay, well, it improves their functionality. That's really important. And we want to make sure people are kind of having quality years as opposed to just longer years and, you know, not enjoying life. But when we see the reduction in mortality, so reduction in death statistics for being active, I think it's just an absolute no-brainer. Now, the interesting thing is we're we're doing a lot of research in terms of working out why those benefits are. And we're we're not 100% sure. They're thought that there is some link between estrogen and progesterone levels, which we know are higher in inactive people. And we know that will feed certain cancers like ovarian cancer or breast cancer and thought to be linked with other cancers as well. There is definitely a link with this chronic inflammation thing that we talked about earlier. So we know that those who are inactive will have this lower level of chronic inflammation and that is shown to be associated in many studies with increased risks of cancer. And another really interesting theory that is around this is around natural killer cells. So natural killer cells are the scavenger cells in our body, in our immune system, which target cells which shouldn't be there. So if they see cells that are growing that shouldn't be there, they'll get them. However, when we're inactive, we actually don't stimulate our natural killer cells and they don't proliferate as much. When we are active, we actively mean to proliferate those natural killer cells. We get more of them, they're more active and they will search and destroy those cells that shouldn't be there. Which is again a massive element of the etiology of cancers.
Dr Rupy: Yeah, absolutely. There's a lot of people talking about the immune system, which is essentially our our system by which we keep homeostasis of our cells. So we actually keep check of the inevitable mutations and the inevitable growths that happen every single day and keep everything in balance. And I think the impact of exercise on your immunity is another interesting subject and I'm going to be speaking to Dr. Jenner about that in a bit more detail. But that stimulating natural killer cells, which is a natural part of your immune system and how that impacts on cancer recurrence as well as prevention is is really is enough for me to just talk quite openly about exercise in a medicinal manner.
Dr John: Yeah, definitely.
Dr Rupy: We touched on it briefly, mental health. There's loads of evidence now, I think, about exercise and anxiety, low mood. What's the basis of that from a cellular point of view? I know we've talked about inflammation and I think there's a lot of information now about how inflammation is involved in the mental health process.
Dr John: Yeah, and some of it isn't specific in terms of knowing exactly why it's contributing to depression and anxiety, which are the two big things that I see. We do know that there are a couple of processes that are involved. One of them is that there are brain-derived neurotrophic factors produced when we are active. And it's known that these actually work as an antidepressant. And there's also the effect of endorphins. So everyone's heard of that runner's high when you get and you don't just get it with running, do you? You get it with any times of activity really.
Dr Rupy: I get it with hit training.
Dr John: Yeah, definitely. I get it with anything. Like I think it's fantastic. And when people, you know, I come back from like a really long run and they're like, oh, you must be dead. I'm like, no, I'm buzzing. You are mental. But yeah, they the the benefit in terms of those endorphins in acting as an antidepressant are quite massive. And in fact, there are some studies which show that medication compared to an activity intervention, the activity intervention will be basically the same. In some cases even better. And the benefit of that is we know there are so many other benefits that they get. They don't just get a tablet getting one element of benefit. They get all the other benefits they see with physical activity. The benefit in terms of other aspects of kind of mental health when we look at kind of Alzheimer's and and dementia, it is really important. Again, those brain-derived neurotrophic factors are produced a lot more when we are active. And that's involved in kind of keeping neurons still connected. It's involved in making new neuron connections. And it also has that antidepressant effect. But because we know those processes are keeping those connections in place, keeping them going, keeping them stimulated, it does reduce our risk of things like dementia by about 30% again. So again, huge numbers.
Dr Rupy: Huge numbers. I mean, anything that you're looking at, even if it's 10%, you think, wow, that's a huge amount. So in the context of that, 30% is massive.
Dr John: Yeah. And again, the the studies do reflect this. The Hunt cohort study showed that they did a one-hour exercise intervention in a week. So it's not that much. One hour in a week is is doable. And in a big population of about 250,000 people, they had a reduction of about, I think it was 12% in incidence of depression. Again, massive, massive numbers for an intervention which is quite minimal if we're being honest. Like 60 minutes in a week is very doable. And when as I said, mental health is such a big issue in our country, it's something we really need to be pushing.
Dr Rupy: Absolutely. I have a few sort of anecdotes that I use whenever I try and get people to move a bit more, but I know people listening to this will be listening to the numbers, listening to just how much an impact sedentary behaviour has in a negative perspective. How do you like to get people moving a lot more at a practical level? If you've never really done exercise fitness class, you don't even know what CrossFit is, or, you know, yoga just scares you. And to be honest, it scared me the first time I did it. But yeah, what what kind of practical tips that you do you talk about?
Dr John: So, I think to really touch on it with patients or with anybody, it's about understanding a little bit about their lifestyle because actually lifestyle can give you a great insight into what things can fit their daily life and actually mean that putting in some activity isn't hard. You know, people are going to find it hard to find two hours every day to be active and go to the gym. That's fine. That's not what's needed. Actually, finding out their their story a little bit. So I often say, what does your day look like? So if they say, oh, I tend to commute to work, and that doesn't matter what time of commuting it is, that's a first immediate buy-in. And then if they say, well, what do you do during the day? Well, I work at a desk and I kind of, you know, sit at my desk most of the day. That is like pretty standard example that I get. I've also worked in an area where there are lots of lorry drivers and there are similar kind of little bits of evidence that I can give. So what I often say is, right, how can you make your commute a little bit more active? Can you get off the the the metro stop kind of two stops earlier? Can you park further away? Could you get the bus in and maybe walk half the way? Are there other ways in which you could get to work which actually increase your activity levels? And people often when you think active commute think, oh, I need to cycle in and get all the gear and I'm going to get soaked going in. No, it just needs to be something small. And that's the starting point from whatever they're doing. That is the starting point and then try and do a little bit more, build it up gradually. I always say to people, try and aim for the 150 minutes, but ultimately, any little bit will make a big difference. And we actually know the biggest benefit in terms of overall is you're going to get from activity. So say someone's doing a moderate amount, they go to high amount, there's a bit of benefit there. If you go from high to elite, there's a small benefit. But if someone goes from being sedentary and not doing anything at all and completely inactive to doing something, they will have the biggest benefits. So those are the target population that we need to reach and just encouraging them to do a little bit more, even if it's just a walk around the block, 10-minute brisk walk, and there are some great apps for tracking that. Then actually that will make a huge difference to their health. And we've got lots of research to back that up.
Dr Rupy: That's brilliant. The one thing that I like to do is teach people the one-minute workout. So, yeah. So even before you go and have your shower, you do 60 seconds of a workout in your home, whether it's your bedroom, you're just before you go to the bathroom, whatever. But it's 10 seconds of jumping jacks, 10 seconds of high knees, 10 seconds of running on the spot, anything like that for 60 seconds. You will feel sweaty and you go at your own pace, but as hard as you can. And you do a little stretch before, a little stretch after, and then you go have your shower. And honestly, I there's a number of people whose mindset that has changed has been phenomenal. And then they might take up like going for a run or maybe going for a longer run. And there's some really good apps and podcasts like the NHS Couch to 5K. I think are really motivational. And like you said, there's a there's a couple more that I'll put in the show notes as well.
Dr John: But I think the interesting thing you've noted there, Rupy, is the fact that you've got buy-in there. They've seen the benefit from just doing one minute. And if they think, oh, this feels all right, actually. Yeah. I can do two. I can do three. And it's getting over that first hurdle. That's the biggest step for a lot of people. And it won't be that you're going to turn people from being sedentary into marathon runners. That's not the point. Getting people from going from sedentary to doing walks every day, walks every other day, that is a massive benefit to their health and something we really need to keep pushing for.
