Okay, wonderful. So I think we're going to get started then. So Dr. Mock is here with us. I think the idea of these webinars that we've had, this would maybe the fourth or fifth webinar, is that we can kind of introduce all the pillars of lifestyle psychiatry and lifestyle medicine to the group so that we'll have some foundational knowledge and information. And then from there, we will start getting more nuanced into the different aspects. I know we had a very robust discussion with the nutrition one, and people have different points of view, but at least we had one point of view, and we'll continue to develop those themes further along. Dr. Andrew Mock is a board certified in family and preventative and lifestyle medicine. He's faculty at Loma Linda University School of Medicine, and he serves as the preventive medicine and population health clerkship director and director of lifestyle medicine residency curriculum. His clinical practice is adult primary care with a major emphasis on integrated lifestyle and obesity medicine in an academic setting. Dr. Mock is a professional middleweight strongman holding the title of California's strongest man and owns his own strongman and powerlifting gym in Redlands, California. His life goal is to use his personal athletic experience and clinical expertise to improve lifestyle medicine education and to ensure clinicians are appropriately trained to assess activity habits and equip their patients with resources to reduce physical inactivity and promote exercise across the lifespan. And I think for those of you who came in late, he's also the new of the fitness member interest group in the American College of Lifestyle Medicine. So he's taken on this great leadership role. Very excited to hear what Dr. Mock has to say. Thank you so much for joining us. So wonderful. Gia, thank you so much for that introduction. Yeah, I feel like I live a pretty simple life. It could be summed up in these three pictures here, right? My clinical practice and teaching that I do for Loma Linda, my gym, that's my small business that I run outside of work, and then my own athletic career competing as a strongman and how all of those come together to be the same thing in my life, right? They're all for this common shared purpose of being able to share my love and joy, which is exercise and the benefits specifically with resistance training. So as far as our conversation today, here is where we're headed. We're going to talk about the physical activity guidelines for Americans, as well as just how prevalent something like inactivity is in our population, and start to get an idea of the impact of physical activity on overall health, as well as to discuss some specific mental health evidence that we know as far as how that can be impacted with physical activity. And then we'll actually think about how we can start to write an exercise prescription. What are the components we will need to write that prescription? And then use a model I assume many of you are probably familiar with called the SBIRT model, where we'll screen what they're currently doing, provide some sort of brief intervention, and then referral to treatment if needed. And so we'll work on developing these strategies for these very important partners that we need in the community to actually implement all of these things, because I think it's no surprise to any of us that we do not have the time, capability, resources, right, to be doing all of these components ourselves as our patients' physicians. So what are the current recommendations, right? So these are two of the three parts of the exercise guidelines. I left off my very important and symbol here. So many people will be able to tell you that there is a recommendation to do at least 150 minutes of moderate intensity cardiovascular activity. You can do a little bit less if you work a little bit harder, to where that you can also do a combination of the two to get about 500 met minutes per week of that work. Certainly there's more benefit with doing more. But there's this very important and, and that and is certainly my life mission. It's that in two days per week of muscle strengthening for all major muscle groups at moderate or greater intensity. So while that's one sentence, there is just so much packed into that one sentence, and hopefully I'll be able to convey a little bit about that today. And then the third part that I neglected to list here is in general, right, we should just focus on moving more, right, and reducing inactivity. So that's the third part of this. So I call the resistance training piece, the forgot and guideline. So excuse my pun there, but yeah, the data supports that. So this is all self-reported data. So there's limitations with that. But from the 2020 CDC data, about half of Americans say that they were meeting physical activity guidelines for aerobic conditioning. And then only about a quarter were doing both aerobic and muscle strengthening with about a third doing only the muscle strengthening piece. And this is just to kind of highlight that there are unique differences to both and that the best exercise is going to have a combination of both. So it's less about a conversation of which one is better. It's, we should all be doing both when we can, because there's additional mortality benefit from doing both. And so there are, there is a lot of evidence for exercise providing benefit across all ages, right? So even kids, we can see improvement in cognitive function, test scores, bone health, reducing their risk of developing what is contributing to the top 10 causes of death, right? All of our lifestyle associated chronic disease. And, you know, exercise can look very different as a kid, right? So often we're just starting out, moving our bodies, learning how to use them and doing it for fun. So here's my daughter, Thea, right? Making exercise fun in a way that makes sense to her. So she's, They say, but not just children, also those that make children. So there are exercise recommendations for pregnant persons as well. And we see significant benefits in a lot of conditions. So this is one of my good friends and gym members at 39 weeks doing her last squats before she went in for induction. So this is Jen. She has since delivered and her claim to fame for being a lifter is it took her three and a half pushes to deliver her baby. And I was really worried because she is thin and has very narrow hips, but she did great and handled labor like a pro. And her lifting likely helped her with that quite a bit. But lots of other benefits that we see across all ages. I'm going to highlight some of the more mental health pieces. So a lot of the cognitive benefits in terms of reducing risk of dementia, especially as we think about metabolic disease, as well as some sleep related issues and mood symptoms. And then for adults with preexisting conditions, again, kind of highlighting the major benefits, especially in terms of chronic disease with metabolic components. But interestingly, right, the cancer piece because of the immune effects of the muscle cells themselves, right, drastically altering the course for cancer mortality when we are exercising routinely. So there is a lot of information about the benefits of exercise and tons of proposed mechanisms for why it works on different neurotransmitters and things like endocannabinoids and things like that, as far as why they help with chronic pain and other pieces. So this is a great article looking at the effects of acute exercise on different things like mood, cognition, neurophysiology, and neurochemical pathways. So I would reference you to that one. So we can spend more time talking today about something that you can actually do with your patients. So in terms of mental health benefits, I think these numbers speak quite loudly for themselves. So if we're looking at the number needed to treat for depression, some evidence will say TCAs are around 6 to 16, median around 9, with SSRIs being somewhere around 8, and then things like psychotherapy being around somewhere between 2.5 to 3.5, depending on the risk of bias for the study. But this is the one that blows my mind. Exercise is 2, right? And so if we look at the low-risk studies only, it's about 2.8%. If we get very strict with our major depressive disorder diagnosis, it comes down to 1.9. And then fascinating to me, if we make that supervised exercise, so not self-directed, but somebody's actually watching them and making sure they're doing the correct dose, even less, right? So now down to 1.6. So we're all nerds in our own way in medicine. You're allowed to have a favorite graph. This is actually my second favorite graph. My favorite graph is from the state of US Health, looking at the lifestyle factors as far as all-cause mortality that now shows nutrition as past tobacco products for all-cause mortality in terms of risk factors. But this is my second favorite graph. And I think it kind of tells an interesting story, right? Most of the benefit that we get comes in that first little bit. So yes, we can get more benefit by doing more, but it's probably that first 3,000 to 6,000 steps, right, that are making the biggest difference. Just like with pharmacotherapy, certainly we can drive medications up to the maximum dose, but probably most of that benefit is occurring in that first little bit of the dose. So there's even this concept of vigorous intermittent lifestyle physical activity, where you, for very short bouts, maybe 30, 45, 60 seconds, are just exercising as hard as you can. And you spread that out multiple times per day. And this one study actually showed that there was decreased cancer mortality risk when someone accumulated at least three to four minutes of that, right? All right, so some people think about this as exercise snacks and just trying to break up that inactivity that's occurring throughout the day. But I found this study quite fascinating. So an inpatient study looking at these acute bouts of exercise for improving mood, rumination, social interactions in the inpatient setting with mental health disorders. So significant benefits, and then very cool, further improvements were observed if patients participated in physical activity a second time, right? So that one bout made a difference, and then the second time continued to make a difference. So we at Loma Linda have what we call an intensive therapeutic lifestyle change program. It is an eight-week program focused on behavior change, including nutrition, exercise, mental health, sleep, and the other pillars of lifestyle medicine. And I write the exercise programming for that. For every Zoom meeting that we do, we do some sort of exercise together. And I had one patient in our first round of the ITLC. He said, I was just struggling with the exercise until this video. So I think there's power in music. I think there's power in dance. And Chuck actually told me that after he danced with everybody in the group to this video for one minute, he then started doing that every single day in the mirror as part of his wake-up routine. So I am going to set a timer for one minute, and then Pharrell is going to make sure that we're happy, and we are going to dance as hard as we can for one minute. If it makes you feel more comfortable, you're welcome to turn your camera off during the time, but hopefully the video will play for us here. OK, guys. Everybody get up. Let's dance. I just put my table up. Let's get going. I make people do squats. I like this method. This is going to be fun. We might just clap together. I'm not going to torture everyone with my singing voice. But yeah, so now we don't have music as motivation. So yeah, move in a way that makes sense to you. I'm going to start the timer now. So I'm just going to jog in place this whole time, and then maybe I'll even try to keep talking while we're doing this. So hopefully you can actually hear how my voice and breathing changes as we start to run in place more and more. So when we talk about exercise or any intervention, there are benefits, right? But there are also risks. And I think the risk of exercise are often overstated. So I like to be quite explicit about the risk that we're aware of. So straight from the physical activity guidelines for Americans, be confident that physical activity is safe for almost everyone. All right, 20 more seconds for those that are participating. So I will hear people all the time, hey, don't do that. That's dangerous. And then my response is, well, compared to what? Eight more seconds to go on our running in place. All right. And then 5, 4, 3, 2, 1. All right. So for those of you that participated, I want you to take note of your breathing rate. Are you breathing faster? Do you feel like you could speak in full sentences but not sing? So if so, then you've hit moderate intensity, which we'll explain in just a little bit. All right. So that's dangerous compared to what? Here are the risks that we know. This slide is very dense, mostly just so you have the data to come back to. We do know that the risk is higher in those with certain health conditions. So cardiac conditions, renal conditions, and metabolic disease that contributes to both of those things. And so people get concerned, right? That we do have this increased risk of having a sudden cardiac event when we are participating in exercise. But the reality is that most cardiac events occur at rest and in those that are not exercising. But we should acknowledge that the most risky time is when someone is first initiating a program. In addition to that cardiac risk, there is the musculoskeletal risk, which is primarily the risk of an acute musculoskeletal injury or exacerbation of chronic pain. So that's dangerous, but compared to what? Here's life, right? Walking to your mailbox, running, gardening, gym training. And this is in terms of injury risk per 1,000 participation hours, right? So you can see sports that people play for their entire life, like soccer and tennis, is higher risk than gym training. And running is similar risk to gym training. What about actual lifting sports? So bodybuilding, right? Arnold Schwarzenegger's of the world, right? Trying to look as big and pretty as possible. Those guys are pretty low risk. And then we have power lifters trying to do one repetition maximum, most weight they can lift for three lifts, squat, bench, and deadlift. Those guys are on the order of running. And then there's my sport, which adds in some variability and some unstable components, but still we're only the second most dangerous strength sport, which is strongman. So I just pick up rocks and then other odd objects and put them back down, sometimes in a different place than when I picked them up. But let's compare that to college sports, right? You can see much higher risk for team sports. So things like soccer and basketball. So if there's anything that I would hope you take home from today is not lifting weights is dangerous. We know that there is increased risk of chronic disease. If your child is playing another sport where they are likely to come in contact with another individual at some sort of force, right? One of the best things that you can do to reduce their risk of fracturing their growth plate from a helmet hitting their arm is make sure that they lift weights. And there is a dose dependent response for that. So here's the introduction to the SBIRT model for exercise interventions. So this information is coming from the Exercises Medicine Initiative and the American College of Sports Medicine. So we start with screening using things like our physical activity vital signs, our stage of change, and then an additional risk assessment tool will provide some sort of brief intervention based off the individual that is in front of us, and then we will provide a referral to treatment if needed, whether that's going to be some sort of program, an exercise professional, a specific place, or a self-directed exercise program. So these are the two physical activity vital sign questions. These have now been moved to be a quality metric that we will begin tracking all across the country. So EPIC has integrated them into their EMR as part of their social determinants of health wheel. So on average, how many days per week do you engage in moderate to strenuous exercise like brisk walking? And on average, how many minutes do you engage in exercise at this level? And then there's the proposed third question to start to capture that strength training piece for how many days per week do you perform muscle strengthening exercises such as body weight exercise or resistance training? So my job in the world is to convince you that these are not enough. But I am also a realist and say that these are very appropriate to begin collecting this information, especially in the primary care setting. I think when I try to explain to medical students what I do in lifestyle medicine, sure, there's like the facts about, you know, the different nutrition components and exercise components. But at the crux of it all, it's motivational interviewing, right, and behavior change. So these are some different motivational interviewing questions that I think about when I'm seeing patients for exercise. So I tell my students, right, one of the most important things is assess where they are currently. So not just assessing the current behaviors they're doing, but assessing their perception about those current behaviors and what they know about those behaviors and the benefits they provide, right. And then think about those past successes, what resources they have to change any barriers they have to change, and then where they are in that stage of change. So number one tool that I use, as far as effectiveness, I think is that one to 10 scale, right on a scale of one to 10. How important, confident or ready are you to make this specific change, try to make sure that we have some sort of component of self monitoring in there, and then seeing when we can bring in a support system. Right, so what we do will depend on our stage of change. If you want the bigger version of this, the exercises medicine playbook for clinicians has all of these documents in a much larger font. So once we understand where that stage of changes, we can individualize our prescription. But we should also make sure that it is okay for a person to begin an exercise program. So this is the clinician version of the ACSM pre participation guidelines, where we stratify someone based off of, are they currently active? Do they have a known disease that puts them at higher risk? So cardiovascular, metabolic, renal disease? Or do they have signs and symptoms of those diseases? And if they answer yes to those riskier situations, right, then the ACSM conservative recommendation is that they should talk to their doctor first, before beginning an exercise program. And then you and your patient are allowed to determine what that workout looks like, right, it could just be the history, you might add some physical exam components in there. And then plus or minus laboratory testing or additional diagnostic testing. And then there's the fitness professional version of that called the PARQ. So similar questions, but just in a yes or no format. And then if you answer the wrong way, the default conservative recommendation is follow up with your your doctor to talk about if this plan is safe for you. I will put a small bug in your ear to say that even if there's someone right who has known disease, and may or may not be having symptoms of disease, instead of telling them to do nothing, which we know will make things worse, my own approach is, is there something we can do without making things worse at this time? Because we know the effects of inactivity are that metabolic disease will get a lot worse. And your angina is not going to get better, right? If you just stay in your house, right, and don't move. And, you know, the dietary habits are also the same. So the sub symptoms threshold exercise is actually coming from the post concussion and TBI data. So I really like the term. So just kind of thinking about, is there something this person can be doing without making things worse? And, you know, the common example I use is if I walk out of the clinic right now, and cross the street to go to my car, and God forbid, my femur gets broken, being hit by a car. Well, that was only one leg. I have three other extremities that are okay, and should be exercising, right? They will actually help that affected leg heal quicker if I'm able to exercise. So that kind of covers our screening piece of things. In order to actually get into the intervention, we need to understand the components of an exercise prescription. So frequency, intensity, time, type, volume, and progression. And so we'll talk a little bit more about each one of these. Frequency is how often someone is doing the exercise. For aerobic exercise, it can be whatever you want. So there's a very cool study called the weekend warrior study, where they only exercised on the weekends doing those leisure activities. And they had just as good mortality benefit as those that were exercising routinely throughout the week, right? So probably some additional benefit because, you know, those are often tasks done with loved ones out in nature rather than in a gym, on a time crunch, right? On a treadmill, standing in front of a mirror, or watching TV while you're doing it. So maybe something different about the weekend warrior activity. And then for resistance training, the minimum recommendation is twice per week per muscle group. So if you're training the whole body, that's going to be at least two sessions per week. But if you're dividing it up into muscle groups, which is commonly done, you might have more days than that just kind of split and you're only training a certain muscle group per day. Intensity or how hard, I would say that this is the most important component of the exercise prescription. If it is not hard enough, we will not receive benefit. If it is too hard, risk goes up and we may run into problems. So many people will be familiar with ways that we kind of talk about external intensity or the measure of the work being done. So that is the weight on the bar or the difficulty setting on the machine, the speed of the treadmill, the slope of the bike. And then there's the very formalized science version of that, the metabolic equivalence task. And then there's internal intensity. So now we're talking about the subjective, which can include things like the toxin test, which actually has a physiologic component behind it, right? So as lactate starts to build up and I hit that first lactic threshold, I can talk, but I can't sing. As lactate builds up more and more and more, right? And I get to that point where I can't talk or sing, I've now hit that second lactate threshold as I'm starting to move into anaerobic exercise. But for internal intensity, the most common tool that I use is something called the rating of perceived exertion. It's a form of auto-regulation. So how hard does it feel? And regardless of the technique we're using, our goal here again is moderate or greater. So there's the classic Borg scale, which was originally developed to be a six to 20 scale, not very intuitive, but when you multiply that number times 10, it gave you the person's heart rate. So that's how it initially started. But now we use the one to 10 scale, which I like quite a lot because it gives us a different proxy. So on a scale of one to 10, 10 being maximum effort, how hard are you working? And if we kind of line that up with our toxin tests, that moderate range is somewhere between three and seven. So you'll see a lot of variation in the moderate intensity for the conditioning pieces. And it tends to be less concrete across resources. But in general, we kind of agree that eight plus on that one to 10 scale is considered vigorous. But then there's this concept of reps and reserve that works quite well for resistance training. So if you're going right and you're doing bench press and you're going and it starts to slow down and then you stop and you said, well, I only had about one rep left in the tank or one rep left in reserve that would correspond to an RPE of nine. So I would be in that vigorous range because it's somewhere north of eight. But I think that concept of how many left in the tank is probably one of the more helpful things that I teach my patients. So they know that, Hey, when you're going and it starts to slow down, right? The velocity decreases. We're getting closer to those, that first lactic threshold, and we've started to hit right. That moderate intensity. So, you know, that is hard enough to be getting benefit. People will say, well, how do you divide it up from, you know, doing most of your work, which is somewhat hard. And then a little bit of work doing very hard. And it's a little bit arbitrary as far as this breakdown, but the Pareto principle or the 80 20 rule is how I use it. Because I teach that multiple times in my course. So most of your work should be moderate and then a smaller portion of that should be vigorous. Here's my big nasty table for how all of those principles line up. If you ever want to compare it to classic things like the percentage of your one rep or five rep max, or use other principles that are using conditioning training, like a maximum heart rate percentage and heart rate reserve percent percentage. So how long should we exercise? We mentioned the minimum dose. We would like to get at least 150 minutes of that moderate intensity, cardiovascular exercise, a lot of different ways that you can break this up. A common example is walking 30 days on at least five days of the week. But if you are working harder, right, doing that vigorous activity, then you could do a shorter bout of time for the same number of days. Resistance training, there's actually not a recommendation for how long that should take, but I use time to start to think about different things like how long I should rest between sessions about two days and how long I should rest between sets. So if you are working hard enough, it should be somewhere around three minutes per set. If you rest less than that, you might be getting additional cardiovascular benefit, but you may be making some trade-offs in terms of the strength side of things. And then I also use time to think about how fast we're moving. In general, if you want to recruit the most muscle mass, then you will focus on moving fast, right? So if you just tell yourself, I'm going to move this fast, right? That will turn on more muscle fibers and, yep, increase your power. And then I also think about the opposite side of things. So a lot of times, tendons will not tolerate a very heavy weight when they're going through a recovery process. You can increase their stress by slowing down the movement and increasing that time they're under load. So that's me forcing everything into the FitVB model with the time piece. The type with aerobic, it's quite simple. You can do whatever you want. I will tell this to this group. When I was in, on my family medicine rotation in my hometown in Southwest Georgia, I had a young black female attending that I was working with, and she was seeing her young black female patient that had challenges with weight. And she said, girl, you go home, you have your man lay down and you get on top of him and you You go home, you have your man lay down and you get on top of him and you set a timer and you go to work. And you are just going to focus on getting your heart rate up while enjoying that time with your loved one. So right. A third year medical student, me is like beat red during that conversation, but certainly any activity that you enjoy and that you can do in that rhythmic motion can be considered aerobic exercise. For resistance training. This is where I start to talk about different tools. Each of them has their pros and cons, but we can use things like body weight exercises, bands, machines, and free weights. Not one of these has been shown to be safer than the others, but they do have different benefits in terms of availability, access, equipment requirements, and scalability. And then I think about using multiple joints at the same time versus a single joint using both sides of the same, both sides of the body versus one side of the body. But if you want my opinion, right. To get the biggest bang for your buck, focus on compound movements. We're using multiple joints with free weights because these are quite efficient for stimulating multiple muscle groups. They're kind of intuitive because it's general movements that we do. They are infinitely scalable and there's probably some additional balance benefit if you're doing them freestanding with free weights. So how much work should we be doing? It really depends on where someone is. So we can calculate this work on the aerobic side with the frequency times time. And then we probably should be adding in that component of intensity to really understand what the current dose is. I'm just going to check real quick. Okay. On the resistance training side, right. It's similar formulas for what that looked like. But the minimum goal would be at least one set at that appropriate difficulty in this rep range that actually drives strength adaptations for each muscle group twice per week. Additional benefit comes with more. So at least the sweet spot that I like to get people up to is at least three to four sets per session. So around eight sets per week. But the beautiful part about being human is our bodies adapt to stress that we show to it. So if we always show the same stress, and then we go to this recovery process, at some point we stop building additional adaptations. So we actually need to change the fit V components over time to technically increase the internal stress to keep that internal, sorry, increase the external stress and keep that internal stress high enough that it's going to lead to these adaptations. So, um, some strategies for doing that, keep it simple. Um, a nice rule of thumb is don't increase the volume of work that you're doing by more than 10% per week, right? So if I currently walk one mile per week, I will not increase it more than by 0.1 mile in the next week. Um, that is an example of a linear progression where you just add a set unit each week. So you can also do that by adding a set amount of weight each week. But if instead of saying a set number of pounds, if you said one to 2% of the weight on the bar that you use from the prior week, that would be a reasonable progression that most people can continue for quite a long time when they're first starting out. So, um, here I will make my argument for why I think some sort of internal measure of intensity is the way to go. So if I teach someone how hard it should feel, right? When I run, I want to be at least to that point where I can talk, but not sing. When I lift weights, I want to be at least to that point where I only have somewhere between two to five reps in the tank. As I get stronger, if I know how hard it's supposed to feel, I automatically have to adjust the weight on the bar. So the external intensity is going to have to change to keep that internal dose the same. And like all of us, and especially when I think about my learners and residents, 24-hour calls still exist, right? Bad days in clinic still exist. So, right? I slept bad and this bar feels glued to the floor, right? So if I know how hard it's supposed to feel, right? I can adjust for those not so good days, but I can actually adjust for the good days and say like, hey, I'm feeling great. We're going to add a little bit more weight to keep it the right internal intensity. So my silly statement is that using audit regulation allows you to adjust the weight on the bar for the weight of life. And then from a self-efficacy standpoint, such a powerful tool because I never have to tell the patient what weight to use if they understand that concept. So like I mentioned, a lot of things wrapped up into that muscle strengthening recommendation. So train all major muscle groups. Here is what ACSM lists as the major muscle groups. I take extreme offense to this because after 20 plus years of being very consistent with this, I don't feel like my calves have grown very much. But so thank genetics for that one, but here we are. I would like to make this a lot simpler. So this is another part of that active piece. So once we get to the gifts, you can move along with us. But we kind of just do six things when we move in life. We push things overhead with a vertical push. We pull things from overhead with a vertical pull. We push things out in front of us with a horizontal push. And then we pull things from out in front of us with a horizontal pull. And then we bend at the waist, like when we bend down to tie our shoes or pick something up off the ground. And then the single most important exercise, because a third of the world still does it to poop, the squat. So you cannot walk if you cannot squat. But the squat is probably the single most prescribed exercise in my office. So if I ever see someone using significant hand assistance to stand up from chair, I already know what something I want to work on to decrease their mortality. But here's some examples of a vertical push. You can see using a band, a barbell, and even just holding any item. So in the wonderful state of California, we pay $0.10 for our grocery bags, but that makes them a little bit thicker. And they're great because they have handles and they create a nice scalability. So you can take that grocery bag and you can start with one can of beans. And then next week, you can add another can of beans. And then the next week, keep going until you actually end up having to go purchase some weights. The vertical pull, like the pull-up, is one of the ones that's hardest to do without some sort of tool. So I will leave this one off if someone doesn't have access to some sort of equipment. The horizontal push, right? So my girlfriend is an orthopedic surgeon, so I get to make all the ortho bro jokes. So they say International Bench Press Day is every Monday, but true lifters, we actually squat on Monday because we need to get it out of the way. But here you can see me in the middle doing a scaling wall push-up. So I will use this to teach my patients how to make it more difficult to find that right dose by walking their feet further away from the wall. And here is that example of that horizontal row using the back and biceps. The body weight version of the hip hinge, which is often where I will start for my patients coming in with acute low back pain. And then different variations of that squat movement. So all of that's great. That's the information you need to understand to get someone started. But we have to find a place to start, right? So we need to do this in a way that is non-threatening to them. So identify that appropriately dose movement in that non-threatening context. And then we're going to select exercises based off the individual that is in front of us, their desires, their interests, their abilities, their resources, and their goals, right? So those that's where all of those motivational interviewing questions come back, right? Thinking about past successes and things like that. And when I initiate exercise, my goal is to not make things worse, especially in that 24 to 48 hour period and beyond. So if you've ever went back to exercising for the first time, right? And then had to pray to God to help you get off the toilet because your legs were so sore, then you understand delayed onset muscle soreness, right? So that's not what we're talking about here, but in general, I don't like that to go on more than a couple of days. Anyway, it should get better over time. And if it's persisting for too long, it's a dose concern. So things do happen, right? Providing that statement and setting some expectations can help providing education that when things happen, find a way that we can move that's non-threatening without making things worse. And I discuss constantly the natural course of a musculoskeletal condition that it'll get better on its own, unless we do something to make it worse. So how do we modify that activity? We find a place to start. And I will adjust the load to begin with. So can you move through a full range of motion with any weight? Okay. Then let's see what happens when we gradually add some more weight. And then I increase that dose until we find the point where it's like, nope, symptoms are starting to creep up. Okay, we might need to back down and then see how close we can bump up against that threshold. And so people frequently ask about proper technique. So I'm in the pro-movement category of this discussion. So there's a lot of interesting occupational medicine data that shows that we cannot actually lower someone's risk by telling them to lift a certain way. And the reality is most people just need to lift to reduce their risk. So this is a simple model put out by the barbell medicine guys who are an excellent resource. So they say, focus on doing something in that repeatable fashion in an efficient way that you will self-organize in. So not having those extra planes of movement that you don't want. And then we make up some arbitrary points of performance based off those goals and any other criteria that are needed. So here is a simple example of an aerobic exercise prescription. So I will walk 10 minutes at a pace where I can talk, but not sing on five days of the week. I will add one minute each day, every week until I'm doing at least 150 minutes per week. So that includes all of those components for frequency, intensity, time, type, volume, and progression. And you can see here one that I actually wrote last week with a patient trying to think about tying multiple systems together for her mood. So every morning, when the sun comes up, trying to get that morning light exposure, I will walk to the mailbox, which is a hundred feet away and back. I will rest at the halfway point for five times the amount of time it takes me to walk each half. So this was an individual that was severely deconditioned. Her BMI, I think was 71. And so she's experiencing a lot of joint pain. And I didn't want her to get to that point of no return, right? I wanted her to work up to it a little bit hard, but not so hard that she's done for the rest of the day. So she will actually auto-regulate and stop for the day when she's having trouble catching her breath with that same rest interval. And then the goal will be to increase by a little bit more each week. For time's sake, this bottom one is actually one of my favorite ones to tell. So I love to attach a behavior that someone wants to change to something that they're already doing really well. So this patient is really good at taking care of his tropical fish. He has these massive, massive a hundred something gallon tanks that he will change over the entire water volume every day when the fish are sick. So every day after changing the water in my fish tanks, I will refill the five gallon buckets and perform three sets of 12 for each movement. Sumo squats and side handle deadlifts, right? Cause he really wanted to focus on getting his legs stronger and reducing his risk of falling. The most fun part about that story is like, well, yeah, the buckets actually have become too light and I had to go purchase some weights. So I will take that victory. These are just some templates that I frequently use in clinic. So identify which versions of each one of those six compound movements someone can do. I start them out at a set amount of work, and then I gradually increase that volume of work in the initial period. And then once they get up to around that three to four sets per movement on two days per week, then I start to change and add in some variation because that additional variation will create additional adaptations. So, but that intensity is internal and is constant. So I guarantee you that when someone is in week one of the prescription, the weight is going to be lighter compared to week one of the refill. So they've made all those neuromuscular adaptations during that initial period and learned how to use their current muscle and nerve mass better. And the extra coordination means that almost always that weight on the bar will have to be higher. So that external load goes up to keep the internal load the same. And then here's how I kind of structure my advanced prescription. So for some of the athletes that I coach it's relatively straightforward. So for strength purposes, which is a lot of the people that I see and where the mortality benefit is, I pick a main movement based off, right, their goals, desires, and abilities. And then I pick a secondary movement that looks a little bit similar to that, but it's different enough that it's a different adaptation. And then I have tertiary movements, which are often those isolation or single joint exercises that we'll add in there. So I tend to train the primary movement very heavy, the secondary movement at lighter loads, and then the tertiary movements at even lighter loads and higher rep ranges, all to try to get as many adaptations as I can as possible. Well, how can we improve our success? So having individualized prescription is the most important thing. It's also the thing that makes this the hardest to do. Frequent follow-up has been shown to be quite helpful in behavior change, setting small goals, right, and building on that success, improving that self-efficacy. So asking my patients, how will you know that you're successful between now and the next time I see you? So trying to get at that, some sort of system of self-monitoring, certainly doing things with friends and family or a community is why things like CrossFit are incredibly successful, right? It's almost a cult at that point. And then adding in variety to reduce burnout and get additional adaptations. And then coming up with a plan B. So something happens, what are we going to do when something happens with that contingency management? And absolutely, right, we don't need to use only one tool in the toolbox, right? We should use every tool we have in the toolbox if needed to build our house. So adding in those therapy treatments that are going to complement those exercise efforts. Unfortunately, this is where everything falls apart in our current healthcare system, right? So that's the information that you need to understand to do this. The hard part is getting people connected with professionals that can do this more. So this is an area that our medical fitness interest group is hoping to, you know, drastically improve. So the people that came before me have done so much work to make things better. And I would just tell you that my best advice is go find out about your local system. So who are the people in the area that are working on these things that you know and trust? And you need to honestly, personally vet them, right? There are databases, but it's hard to identify somebody just purely based off academic credentials, right? Seeing, hey, do you understand how to work with this population and how to increase the dose as people get better is an important concept. So here's the actual physical therapy referral that we developed with our own physical therapy department, really just trying to address that inactivity. So I would love feedback if anybody ever tries this in their own system to see what happens. But exercise physiologists, we need to start using them more. They are pretty rare in our system and insurance currently doesn't pay for them very much. The big game changers that are going to bridge this gap is going to be the medical fitness professional. So think about your personal trainer that has additional training to work with special populations. Personal trainers, they're a very mixed group, right? So we could all right now go online and take a personal training certificate and we would pass because they ask questions like what is the powerhouse of the cell, right? For their biology questions. So you all have adequate training right now with a few additional readings on programming specific training to go be a personal trainer. But there are very important community resources and I would say these are the three biggest that I use the most. So if you're not aware, all your patients on Medicare can get access to free gym memberships through the silver sneaker program. So just go to the website, type in your zip code, and they can even have multiple memberships. So great resource. The YMCA is another good example. They have a lot of classes and then your local council on aging might also have some classes. The next parts, right, we can skip for time's sake, but that's most of it. I would just say this is the referral system I'm trying to build where we will actually assess someone's exercise level by doing a neuromuscular assessment for some metrics that have big data behind them. Doing a submaximal talk test, which is kind of like your VO2 max, but not as intense that we can track over time and also teach patients how hard they need to work to exercise. And then actually having them work with a personal trainer to find out what their current strength level is for those six movements. It also gives them the opportunity to be taught during that time. So I mentioned that I thought those three questions were inadequate. Unfortunately, I don't think a questionnaire currently exists in the research world to answer the question, is this person currently meeting physical activity guidelines? So this is what I've been working on over the past several months, trying to think about all those validated questions that I would want to ask in my most ideal clinic with a nice IT solution to have these questionnaires come to the patients in Epic, where they could fill in and we could start collecting all this big data and utilize tools like Epic Cosmos to make some conclusions. So here's the questions for move more and sit less throughout the day. There's the cardiovascular questions, but we probably want to add in some stratification for those, how much is the dose at higher intensities? And the resistance training piece is quite complicated, right? So I divide it up as far as the type of activity you're doing, making sure they're at least working hard enough, and then either having a muscle group assessment or a movement pattern assessment. And then these two questions get at, are they at least meeting the minimum dose? And are they training in a range that is going to be promoting strength versus hypertrophy versus muscle endurance? So here's some recommended strategies for vetting local professionals. Feel free to email me and ask me what I think about that professional and their current habits. So if there's one statement that I would say is the most important thing to take away from this, if anything happens from this, you know, and someone walks away and they improve their exercise habits, I will feel incredibly successful because for you as clinicians, if you can exercise consistently, you are more likely to assess and counsel your patients on exercise. And at the very least, your health is going to be better with all the things that we face in healthcare. So we do need a system to support all this. So I encourage you to be the change that you want to see, and I'll keep doing the best I can on my side. Here are some of my favorite resources. Barbell Medicine, if you want plenty of evidence-based articles that talk about this. So Austin Baraki and Jordan Feigenbaum, they're both physicians, and they're some of the best in the business in terms of health education. The Medical Fitness Institute is actually put out by Jeff Young, who is the founder of the medicine and fitness MIG for American College of Lifestyle Medicine. So him and John Bonnet wrote the Medical Fitness Bible. That is an excellent resource if you want to read more about everything that was just in this lecture. And then three other websites that I use quite a lot in my own practice. So this is how to get in touch with me. I don't think a lecture would be complete without an obligatory dog photo. So this is Sarah, short for Triceratops, because she only has three legs, but that is my little monster there. How to get in touch with me, that is my professional email. If you try to message me on Instagram, this picture is a warning, right? That is my strength athlete and gym page. So you will see gym photos for me promoting myself as a strength athlete. If you want a nice handout that includes some of my templates, as well as a summary of everything we just talked about, and even some of my dot phrases that I use in clinic, please scan this QR code. It'll take you to the Dropbox file. And I can certainly share that if anybody doesn't have the opportunity to scan it here. But that's my whirlwind for exercise as an introduction to health interventions. So any questions about anything? Oh, thank you so much. This has been amazing, amazing. I wanted to start with the questions and if anybody else has any, you can put them in the chat or raise your hand. Oh, Viz, you're here. Do you want to start with the question first? Oh, okay. You can, yeah, I'll come and talk to you. Okay, so let me, so maybe you can stop sharing for a second so we can kind of see each other, Andrew, is that okay? Absolutely. Yeah, so I talk a lot on this topic because it's one of my favorite topics. I talk a lot on a lot of topics, but I generally approach physical activity within five realms. And I modeled that after the physical activity guidelines, second edition. So I talk about the aerobic, cardiovascular and the strength, obviously. And then I also add the flexibility, endurance and balance. So I kind of say that there are five buckets and we are incomplete unless we justify buckets. Could you speak to that a little bit and how you incorporate all five elements into- Yeah, absolutely. So, yeah, and I should have included the American College of Lifestyle Medicine physical activity pyramid, which will have the kind of sit less, move more, the leisure activity, right, as the base, right? And then the next level up is going to be the two guidelines where we have the most evidence, right? The conditioning and the muscle strengthening. And then if needed, right, individuals can work on the flexibility and the balance components. The reason that I spend less time talking about that is our evidence is weaker on those pieces as far as spending more time on those pieces, providing significant health benefits. And I would just say there's a massive asterisk on this one because exercise and any complex psychosocial behavior science is hard. So that's one of my big reasons behind designing those questions is like it's hard to compare study to study because I can't tell if someone's even doing the right dose. So of course I'm going to have heterogeneity in the data to say that like there's not a significant benefit. To come back to the flexibility and balance component, one of the beauties of doing resistance training through a full range of motion is that it provides both that balance and flexibility benefit. So resistance training through a full range of motion increases range of motion just as good with providing additional benefits as static stretching. So my warmup for the day is do whatever I'm going to do, but at a lighter intensity. So if I'm going to squat 315, I will start with just the bar and I will work through that full range of motion, right? And then I will gradually add more weight and it becomes even easier to move through a larger range of motion. So outside of right true pathology, I can't say that there is going to be significant benefit for somebody to spend a lot of time gaining additional range of motion if they currently have the range of motion that they need to accomplish the task they want to. So I guess the caveat would be the geriatric population I think that we really need to have the balance and the flexibility built in. Absolutely. But that's the nice part about the free weights, right? Is they provide that component and they provide that component in a very good dose that produces very good results. So I love right fall drills, right? So if somebody pushes you from behind your ability to not fall is actually a power piece. So that strength that you display over time. So how fast can you put that foot out in front of you and catch yourself, right? Which is a power or strength training over time. So, yeah. Beautiful. So it's funny because I just wanted to share that I actually, I have an internet personal trainer 7 a.m. in the morning and his claim to fame and his bias is strength training which is I'm fine. So we do strength trainings five days a week, 7 a.m. We do different muscle groups and then at least I get it done and the rest of the stuff I have to do on my own. But at least I get that done with somebody every morning. So that's what I do. And he's internet, he's very cost-effective but it's an appointment. And so that gets me up and that gets me started in the morning. Financial commitments are a great way to increase our behavior patterns. Yeah. So Archana, she had a comment, a question. Yeah. That was a great, great talk. So I incorporate exercise with a lot of my patients. I do functional medicine and most of them are in this spectrum of not doing very much exercise, no exercise to moderate exercise. There's the occasional patient who is over exercising and they don't believe that that is the cause of some of the issues that they're seeing before which would be fatigue, brain fog or joint pain. And it tends to be those people who are in CrossFit or running marathons, ultra marathons. They're not feeding themselves enough food or to provide the fuel. So getting them to see that part of the reason that they are experiencing the symptoms that they're experiencing because of the overtraining. I'm curious if you have any tips about how to get them to see some of the damage that they're causing themselves by overtraining. Yeah. It's that motivational interviewing process for sure. Right. I do a lot of obesity medicine as well. And it's very straightforward when someone comes in and their BMI is 40, 45. But I will see weight loss patients and their BMI might be 23.5. And then my reflex response is not to say like, hey, you don't actually need to worry about your weight. It's to explore the thoughts and feelings for why they feel that way. So I start with assessment always. Hey, what's your understanding of the types of things that make these symptoms worse? And see what have you tried in the past to help with those symptoms? Because yeah, it can be tough. And oh man, I just remember inpatient peds so vividly, it would break my heart to see the excessive exercising teens. And I'm like, this positive health behavior is the downfall of this individual. I want 95% of the population to do what they're doing, but they're the ones that's for some reason taking it too far. And so, yeah, it's tough. I do okay, I think on the exercise piece and exploring that myself just because of my own interests. I need a lot of help on the nutrition side of that. And right, trying to decide like, hey, what kind of tracking am I okay with you doing versus one tool I will use a lot is changing the goalpost, right? So weight loss is a common example, but I guess you could use like my one repetition max. So if you shift from a goal oriented outcome, right? Saying like, I wanna hit this number on the scale or this number on the bar more towards a process oriented outcome saying, hey, I know that if I just consistently go to the gym and do the work that's programmed as it's programmed, my max is going to just climb, right? That's how it works. And if I consistently eat my vegetables and fruits day in and day out, I'm extremely likely to lose the weight. So I would say shifting from that goal oriented outcome to process oriented outcome is one of the big things that I find helpful. Right, right, great, yeah. Thank you. Sometimes you have to put people on a hard cap, right? And just say you are not allowed to increase by this much more than this much each week, especially if they're like the recurrent back injury person and they're like, oh, I feel great and I'm gonna send it, right? Oh, I know, that's exactly right. The recurrent injury. I'm gonna send it again, right? And then I'm back in the same pattern, so. Right, yeah, it's also listening to their bodies and fueling their body, I think is what they're not paying attention to. They just push, push, push, push and go over the edge sometimes. It's hard to get them to pull back some. Yeah, so the data says, right, nutrition is number one for all-cause mortality in terms of risk factors. I will slightly disagree with that and say that sleep is number one because when sleep is a problem, it is a problem much faster than anything else, right? We can all die, right, if we just stop sleeping and someone keeps us awake through a lot of complicated things that only Russians understand. But then, right, it's nutrition, then the exercise piece and then sleep again. So, but yeah, if someone is having trouble with the sleep and nutrition part, certainly a place to talk about why they're not recovering. And also maybe even change the expectation, like you're on your surgery rotation, like it's okay to not be progressing at this time. Maintenance is a lot easier than making progress. Mm-hmm, absolutely. Yeah, it's learning how to train, yeah. Thank you. You're welcome. Thank you for the wonderful talk. And I'm glad that you focused on weight training, because many people know the importance of aerobic, but many people, including many physicians, don't realize the importance of strength training. And with, in fact, with my elderly patients, I tell them once you lose the ability to get up from the chair, everybody goes downhill. And so I have two questions related to that. And I often tell my patients to stand up from the chair without holding onto anything in the beginning, before they move on to squats and all. But the question is, it's kind of similar to squats in that moment, but the question is, is it better not to let you, when you sit down, not to let your body touch the seat or is it better to let up, sit down and then get up and sit down and get up? Yeah, so just think about them as different variations with different doses. So that person who's struggling to stand up from the very deep chair, if we throw multiple books in that chair, they might be able to stand up because we've shortened that range of motion and made it easier for them to stand up, right? And now as I take the books away, as they get stronger, they can go through that fuller range of motion. But especially if I'm concerned about them falling, right? I will use that touch point to kind of cue and make sure that they are able to sit down. And then in some ways, I think it sometimes feels less like exercise and more like a normal movement that they're used to. And so they're more comfortable in that way. But yeah, just think about them as two different options. When possible, not having the chair there will allow them to go through a larger range of motion and provide additional benefit. Yeah, yeah. The second question is to me, the hip hinge looks similar to, in terms of the muscle groups involved, similar to squats and then with squats, you get more bang for the buck. So why do, if you're limited in terms of the time, why, what's the importance of doing a hip hinge? Yeah, great question. It's just a different way of sending a signal. So yeah, there is a ton of overlap, right? Both of them are gonna be using hamstrings, quadriceps, calves, gluteal muscles, truncal stabilizers in a very similar way. The additional benefit is, right, it's the hit and get it in a different way that provides it a different adaptation. And so, yeah, those are the largest muscle groups in your body. So maybe giving them a little bit extra work in that case. Thank you. Great. Thank you. Anyone else? Dr. Beck, I see you there. Do you have any thoughts, questions? I'm honestly, I'm looking at my grand rounds for tomorrow. I know. So I'm giving a grand rounds tomorrow at Jefferson on applying lifestyle psychiatry to child and adolescents because I'm a CAP fellow. And I'm just thinking, you know, it's funny because I just also did this today. I just saw a patient at four o'clock. I was looking at your one slide, like where you were talking about how you prescribe, prescribe exercise. And I just did this at four o'clock. We set a goal that my patient is going to go to a spinning class on Tuesdays at six o'clock. And her mom's, this is a, we're working on independence really, but the mother is going to walk on the treadmill while she goes to the spinning class. So she can be, feel independent like a young adult, but also get exercise and do these things. So I really appreciate it. Yeah, thank you. Yeah. Andrew, the QR code's not working for anybody. Didn't work for me. Oh yeah, I'll send that attachment to you, Gia. Yeah, can you just send us maybe the PowerPoint so that they can share it with everybody with the update? So I'll have to delete the GIFs that are in it that show me moving with the different movements because they are massive in terms of the size. And then, but I, yes, absolutely. Anything that you ever see come from me, please use it in however you want, right? I don't need anything from this. I have all that I ever need in life. My statement with residency is like, what am I going to do with like even the measly preventive medicine salary? Like am I going to buy more squat racks? And that's actually my financial strategy with the gym is I reduce my taxable income by buying more squat racks. Gym, squat racks. Yeah, no, and that's what I was telling Joanna earlier. Like I shared my PowerPoints with her so she could do grand rounds. Why not? We're educators, we're there to educate. Please take my material and run with it, you know? And that's, it's just, yes, thank you. Thank you, because we really need to keep disseminating this information. And that's part of it. Anybody else have any questions, thoughts that you want to bring up? I just want to make sure we have the, thank you so much. Yeah, I have a question, actually quite important, yeah. Tell us about protein, you know, like you read that if you take a protein within 30 minutes of a strength training exercise, that's better? Yeah, so yeah, the whole concept of chrononutrition or nutrient timing, in general, we think it matters a whole lot less than total daily protein dose, right? And we used to think that it needs to occur every three to six hours to stimulate muscle protein synthesis. So Alan Aragon is kind of one of the big researchers in this area, if you want to go read more about it yourself. The recommended daily allowance for protein is 0.82 grams of protein per kilogram of body weight. But that is not the optimal amount for muscle protein synthesis and muscle performance. So somewhere around 1.2 to 1.6 grams of protein per kilogram of body weight is what I would recommend. So most people around 1.6. If somebody is very sick, dealing with multiple chronic diseases, older, or they're at a very large calorie deficit, you might want to increase that dose to send a stronger signal. The nice thing about 1.6 is it doesn't matter where that protein is coming from, right? Whether it's animal that may be more bioavailable or the plant proteins, which can be more challenging to get all the protein out of that digestion. So it need not be divided throughout the day? Not necessarily, right? So I would base that off of individual preference. So intermittent fasting is a totally viable option. So yeah, exactly, that's the reason I'm asking. On purpose, right? Not what we do in medicine, where we will work through lunch and accidentally skip our lunch, right? That's what I don't like to see. Whatever you do, do it with intent. Thank you. So there was a question about, will they be able to see this video again? I just posted in the chat, and it's also in our discussion forum within our landing page that all the videos of all the webinars we've had to date are in our YouTube channel and are available for everyone to see because there are at least 20, 30 people every week that tell me they want it to 10, but they can't because of timing. So there are people that are watching those videos. So we want to continue to build our group of lifestyle psychiatrists and that understand and propagate this lifestyle medicine. Okay, I think that's it then. Thank you so much, Dr. Mock, for joining us today. We really appreciate you and I hope you're feeling better. Thank you for hanging in there with us. We really appreciate you. All right. Absolutely. Thank you. Oh, thank you so much.

lifestyle psychiatry

health management

exercise benefits

resistance training

mental health

exercise prescription

SBIRT model

muscle strengthening

aerobic training

cognitive benefits

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