STRONG HEART, SHARP MIND

Chapter 5: Functional Fitness for Heart-Brain Health to STRONG HEART, SHARP MIND: The 6-Step Brain-Body Balance Program that Reverses Heart Disease and Helps Prevent Alzheimer’s by Joseph C. Piscatella and Marwan Noel Sabbagh, M.D., with a Foreword by Michael F. Roizen, M.D. In this chapter we discuss the importance of physical for heart health (something many people are aware of); its value in brain health (a fact that many may not realize); and—using new prescriptive material, including a regimen of neuro-cardio exercises that even many fitness professionals are not yet incorporating—its significance in promoting the nexus that this book examines, heart and brain health. ***** In 2008, the federal government issued the first national guidelines for physical activity. Some might joke that they were only 12,000 years late. Humans have been physically active since our species first worked up an appetite. The hunter-gatherers we are descended from were engineered for movement. In a fascinating 2012 paper, neuroscientist Mark P. Mattson listed the many ways that this is so, including our long, elastic leg tendons, our sweat glands and sparse body hair, our swivel hips. And—of particular relevance to this book—our advanced cognitive capabilities, which suggest a brain-heart connection that helped distinguish humans from other species—and which we contend in this book is now being recognized as a critical nexus of human health. All of these factors helped make us, quite literally, born to run—or at least walk briskly—over long distances. And because we were able to do that, starting about two million years ago and continuing through the end of the hunter-gatherer period, it could be argued that we were eventually able to create civilization. Early humans didn't need to be told to keep track of their distance in miles, minutes or steps. And their sojourns weren't just in the pursuit of game. Researchers have speculated that a natural cycle of regular activity, intense and moderate, was likely the norm for most of human existence: one or two days of vigorous and strenuous exertion in the hunt for food. punctuated by one or two days of less intense activity, which might have included long walks to nearby villages or to trade with other clans and communities. This activity pattern—episodes of vigorous and moderate exertion, accumulated throughout the day—is not dissimilar to the recommendations made in the modern guidelines. And that's the important point here: The onus on physical activity and exercise, the contemporary fitness culture of marathon running, CrossFit gyms or Peloton bikes, may seem like a fad, but it's essentially a return to the kind of natural activity that our mind and bodies have been developed for— something that, like language and emotions, is a critical part of what it is to be human. The Centers for Disease Control and Prevention said as much, in a white paper on physical activity in 1999. "Viewed through the perspective of evolutionary time, sedentary existence, possible for great numbers of people only during the last century, represents a transient, unnatural aberration." In other words, we need to stop thinking about physical activity as something strange, new and uncomfortable—some kind of castor oil we are being forced to take by people in white lab coats. Rather, we should view it as something that is an inherent part of who we are, a skill or talent you never realized you had. And regardless of how fast or slow your ability to walk, you do have this ability. We all do. We've just made it easy for ourselves to forget that by relying on machines to do what our legs or lungs used to accomplish for us. Of course, no one is suggesting we go back to being hunter-gatherers. So how do we reconnect with the patterns of exercise that are intrinsic to us as humans and accrue the enormous physical and (yes) mental health benefits of exercise? That's what we will show you in this chapter. And we will go beyond the conventional wisdom that you may have heard. We'll show you why physical activity is good for both your heart and your brain—including some interesting new aspects of the fitness equation that can have profound effects on both. Perhaps most importantly, we'll also show you how you can start incorporating this into your life and how, in tandem with other essential components of brain/heart health, physical activity, you can lower your risk of getting both heart disease and Alzheimer's disease (not to mention many other afflictions) and significantly improve the quality of your life. ***** The 2008 guidelines, released by the Health and Human Services Department, were updated in 2018 to reflect the latest thinking. The basics, however, are still the same. Here's what they advise: For health benefits, adults should do at least 150 minutes (2 hours, 30 minutes) a week of moderate-intensity activity or 75 minutes (1 hour, 15 minutes) a week of vigorous-intensity aerobic activity. It's further recommended that adults should perform muscle-strengthening activities—exercises involve all major muscles groups—two times a week. Older adults should also include balance training. We'll talk about all of this—and more. But let's underscore some of the guideline's other key points: Adults should move more and sit less throughout the day: At this writing, many of us have spent weeks indoors because of the COVID-19 epidemic. While necessary to stop the spread, some public-health officials also reminded citizens to get out regularly for socially distanced exercise, even during the lockdown. They knew that long periods of sitting could create its own, slow-burning health crisis. (As one wag put it, “Television can be a weapon of mass destruction." The same could probably be said of the cell phone, the internet and social media!) Some physical activity is better than none: Many people still think the only way exercise is going to be effective is if it's long, sustained, and intense. Go out and run or cycle or swim as hard as you can for as long as you can. When you drop to your hands and knees at the finish line, gasping for air, you've done what you're supposed to. No! That old no-pain, no-gain guideline is a recipe for how to quit or avoid exercising. While vigorous exercise has great value, research over the last few decades has really opened our eyes about the value of what could be called "small" exercise—moderate intensity, shorter duration, especially for those just starting out. Got a Minute to Take Some Important Steps for Your Health? Epidemiologist Steve Blair, professor emeritus at the University of South Carolina and the former president of the Cooper Institute for Aerobics Research, was a pioneer in establishing the value of short bouts of moderate-intensity activity. Dr. Blair has spoken about the Power of the Two Minute Walk, which he uses as a rejoinder to those who claim they don't have time for exercise. While two minutes is not sufficient to meet the guidelines, it is enough to surmount the largest hurdle facing most of us, when it comes to exercise: simply getting started. Oh, and just by doing that two-minute walk—okay, maybe a couple times a day—you're already accruing some basic health benefits. Dr. Blair and the national guidelines talk about minutes, but today many people like to count steps, on a pedometer or an app on their phone. A review of studies in the journal Medicine & Science in Sports & Exercise found that about 7000-9000 steps a day can result in health benefits similar to the federally recommended 150-300 weekly minutes. As for the oft-heard recommendation of 10,000 steps per day, the American College of Sports Medicine offers this tidbit: Research supporting the 10,000 steps a day guideline is limited, and some believe the recommendation was actually derived from the name of a Japanese-made pedometer sold in the 1960s called Manpo-kei, which translates to “10,000 steps meter.” Should you choose to count steps, which is a convenient and fun way to keep track of your activity, that's fine. So is keeping an eye on the clock, as you rack up your federally recommended minutes. And many pedestrians and runners still like to think in terms of miles. After all, there's something satisfying about saying you've walked a mile—or three or five. It makes you feel like you're really going places with your exercise regimen. Regardless of how you measure it, your goal should be consistent, regular activity, which has innumerable benefits for both your heart, and your brain. Let's examine those more closely now. Exercise: Good for Your Heart     When physicians and public health officials talk about the health benefits of physical activity exercise, they're largely although not exclusively referring to its effects on the heart and cardiovascular system. They are significant, as exercise can: Reduce the risk of heart attack and stroke. The Harvard Alumni Study and the Nurses’ Health Study both found that about three hours a week of walking reduced heart attack risk by 35 – 40 percent. Strengthen the cardiac muscle, thereby reducing strain when the heart pumps. Increase HDL cholesterol, which is protective for heart health. A study at Stanford found that walking two miles, three days a week would raise HDL by 10 percent. Reduce coronary inflammation and blood clotting. Prevent the development of high blood pressure. Build muscle and bone strength, as well as balance. Regular exercise is also a key to weight loss and weight control by burning calories, elevating metabolism, building muscle and helping to manage stress. It usually takes about three months of consistent activity to achieve these cardio-protective benefits. We'll talk about the "fitness formula" to help you get there a little later in this chapter, but first here's how one man—Joe Piscatella, co-author of this book and a nationally recognized expert on heart health—used exercise to transform his own life. A New Life Through Exercise: Joe's Journey     "I was always an athlete, playing sports in high school and college. But in those days, once graduated, married and with children, a lot of us just stopped. Oh, there was social tennis and golf, but aerobic exercise wasn’t part of my routine. Both my weight and my cholesterol went up. “After undergoing coronary bypass surgery at age 32, the alarm clock of reality rang. On one hand, I had a young family, children just 6 and 4. On the other hand, I had a doctor tell me that because I was so young and the disease so aggressive, I probably would not live to age 40. As my wife, Bernie, stated, ‘That is not an option!’  “So, I began my journey to discover how lifestyle habits could impact my heart health positively.  Obviously, not smoking (I was a non-smoker) and eating a healthy diet were priorities, as well as managing stress and developing a positive attitude. But for me, exercise became the starting point. “At that time, however, there was a curious dichotomy. The running boom was starting to take off with the general public, but heart patients were told to ‘take it easy.’ Many were put to bed. After researching exercise and the potential for cardio benefit, I decided to start running. My doctor went through the roof. ‘You can’t do that,’ he said. ‘It will put too much strain on your heart. I forbid it!’ “I responded that the last time I checked, it was my heart and so it would be my decision. Clad in an early edition of Nikes, cotton running socks and (short) running shorts, I began my treks around the neighborhood, eventually running 4 miles, 5 days a week. Six months later I was in my doctor’s office for a follow-up exam. All of my biometric numbers—cholesterol, weight and blood pressure—were excellent and my doctor was well pleased. That evening as we were seated at the dinner table, the phone rang. “It was my doctor with a simple question: ‘Joe, where do you get your running shoes?’  “I ran for the next 30+ years until orthopedic problems in my 60’s turned me into a brisk walker. Now I walk 5 miles a day, 6 days a week. My biometric numbers are still excellent.  “Three things have kept me motivated over all these years. Initially, I exercised faithfully because of my young family. I did it for them…and me.  I didn’t want to miss my son’s graduation from college, walking my daughter down the aisle at her wedding, or growing old with Bernie. As much as we could, we made exercise a family affair. The kids would often join me on my run. “As time went on and my heart health became more secure, I was lucky enough to find excellent exercise partners to keep me committed, on track and accountable. And I did the same for them. Here is an example. I exercise early in the morning. Up at 5 o’clock, by 5:15 I’m laced up and out the door. This past February the weather was terrible where I live in Seattle. As my radio alarm went off, I could hear the driving rain pelt the windows horizontally. The radio announcer told me it was 38 degrees. And I was under a down comforter. “’I’m not going,’ I said to myself. ‘Who would go out on a day like today? I’m staying in bed.’ Then I realized that I have a training partner. I can’t call him at 5 a.m. just to say I don’t want to walk. So, I got up, got dressed, met him at the corner and off we went. I was glad that we had done it after it was over, but I never would have done it without my exercise partner. “And finally, I have found exercise to be motivating for other aspects of my life, such as eating healthy, managing stress and thinking positively. For me, exercising regularly forms a foundation of success that allows me to build on with my other lifestyle habits. “Throughout my life, exercise has been as natural as brushing my teeth.  Once you get into it, it takes on a life of its own." Exercise: Good for Your Head, Too!     By the time Joe began his comeback from bypass surgery in the 1970s, the link between exercise and a healthy heart was well established. But it is only in the last 20 years or so that researchers have discovered the many ways physical activity can help our mental and brain health too. These include: Stress management Mood enhancement Improved self-esteem Reduction in anxiety and depression Better sleep Improved memory Greater levels of creativity Regular exercise, said the Harvard Health Letter in 2018, "has a unique capacity to exhilarate and relax, to provide stimulation and calm, to counter depression and dissipate stress." "A walking brain is a more active brain," wrote neuroscientist Shane O'Mara in a recent Wall Street Journal column, praising this most basic form of physical activity. "Walk we must and walk we should." You would think, then, that most people—particularly those facing cognitive decline and senile dementia—would embrace physical activity. But that is not often the case, notes the co-author of this book, neurologist Marwan Sabbagh, M.D. Dr. Sabbagh on Exercise and Dementia: FINGER, EXERT and The BDNF Factor I am still surprised by how deeply sedentary behavior is ingrained in many of my patients’ lives. When I encourage them to start walking, or to try yoga or a senior aerobics class, they roll their eyes. "Yeah, yeah," they say. "We've heard this." What they haven't heard is how this can help the condition I'm trying to treat as their neurologist. They don't equate exercise with having a beneficial effect on the health of their brain. When I start speaking about exercise in relation to their brain health, they sometimes assume I'm talking about doing crossword puzzles. Yes, that's good, I tell them. But those kinds of cognitive-stimulation exercises—which we'll address in a separate chapter in this book—are different from physical activity and have a different effect. We know from a number of studies that regular physical activity may be one of the most important things you can do to promote brain health. For example, we know that cognition—which is essentially all aspects of thinking (memory, concentration, language, processing speed, and so on)—improves up to 10 - 20 percent after a structured program is implemented. We also know that exercise has the potential to reduce the risk of developing dementia. The two-year study known as FINGER (FINnish GERiatric Intervention Study to Prevent Cognitive Impairment and Disability) examined healthy lifestyle interventions among 1,109 people in Finland, aged 60-77, who had genetic risk factors for memory disorders. Researchers at the Karolinska Institute looked at diet and cognitive training, and some other interventions that we'll discuss in other chapters of this book. But one of the most striking findings from this investigation was the importance of exercise. Participants in the study engaged in the kind of structured, multi-faceted exercise program we are recommending in this book, including aerobic and balance training for the heart and brain. The results: Regardless of their genetic risk, the subjects in the study improved in all cognitive domains, including the speed with which they could process information and their ability to perform complex memory tasks. Another important investigation, known as the EXERT study, looks at the value of exercise in adults with memory problems.  This national 18-month clinical trial is testing whether physical exercise—aerobic training, or stretching and balance exercise—can slow the progression of mild memory loss and/or mild cognitive impairment in older people.  One of the test sites is the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Nevada. As the Center's director, I can tell you we're excited to be part of this nationwide investigation, the results of which so far are promising, and may lead us one step closer to the point where we can, as an NPR story about the EXERT study described it, prescribe exercise as a drug to forestall or prevent Alzheimer's disease. Wouldn't that be marvelous? But we already know enough to be convinced of the one-two punch of exercise in heart and brain health. One reason exercise has such a powerful effect is that it promotes blood flow from the heart to the brain— the intersection that, as we say in this book, represents an important new dimension of overall health. But there are other reasons, too: Exercise can help reduce or avoid such conditions as hypertension, hyperlipidemia and diabetes, all of which have been associated with dementia development—again, showing how improvements in the heart and cardiovascular system can often be linked to brain health. Studies have also shown that in those who exercise, the volume of the hippocampus—the brain's memory center—is increased, and that exercise is key to the production of something called the Brain-Derived Neurotrophic Factor or BDNF. It has also been referred to, in more pungent terms, as fertilizer for your brain. Here's the science behind it: Your brain, like every other part of the body, has the ability to regenerate itself. These growth and healing (also known as trophic) agents, or factors, are a family of proteins. They include NGF (Nerve Growth Factor) and HGF (Human Growth Factor) and BDNF, which has been linked to improved learning and memory, elevated mood and the ability to acquire new skills. BDNF has also been associated with lower levels of certain types of inflammation, and there is evidence that those with higher levels of BDNF have lower rates of Alzheimer's disease and dementia. As the National Medical Library describes it, BDNF is active in cell-to-cell communications, helping to regulate what is called "synaptic plasticity"— meaning that it helps the synapses (the nerve endings that connect the neurons of the brain) to adapt and change over time in response to experience. It is nothing less than nourishment for the brain. So how do you get more of this nourishment? Contrary to the claims of some supplement marketers, you can't take BDNF in a pill. You can't sprinkle it on your Wheaties, either. But what you can do is exercise. Because we know that, unlike some of the other growth factors, BDNF production is stimulated by as little as 30 minutes of vigorous exercise, three times a week. But even greater gains, writes exercise physiologist Louise Pontin, have been found when you combine that with a more complex activity, which requires you to build or acquire a skill—exercise that challenges your balance or thinking. And that's the kind of exercise we're going to look at now. Exercise at the Nexus of Heart and Brain Health          A group of 25 older adults at the Linwood Senior Center in Wichita, Kansas are standing on three-inch thick foam pads, each of them holding a yellow wiffle ball. “I’d like you to hold the ball in one hand and then drop it into the other,” says the class leader, Dr. Michael Rogers, an exercise physiologist at Wichita State University, as he begins releasing his own ball from the fingers of his right hand into the palm of his left. The class follows his lead. “Now, expand the distance,” he says, raising one arm and, thus, the distance that the ball must fall. “Change hands.” Arms swing up and down, brows furrow, and a few balls go rolling on the floor to titters of laughter. As the balls are collected, Dr. Rogers directs their attention to an image projected on the wall of the rec room. “Okay,” he says. “I’d like you to read the words.” “Red. Green. Yellow. Blue,” the group says in unison, still while standing on the unstable surface the foot cushions provide, as they read a series of words that appear each in the appropriate color. “Good,” says Dr. Rogers, as the next PowerPoint slide is projected. The words appear again, but now in different colors, so that “blue” appears in green type, the word “red” is in yellow and so forth. “Say the color of the word, but ignore the word,” Dr. Rogers reminds them. There is hesitation, as participants, still standing on their foam pads, pause for thought. The unison of response is not quite as crisp now. “Blue....no, wait, yellow.” The brain-teasers are part of the Stroop Test, a series of drills typically used in laboratory settings to test a person’s capacity to direct attention. Incorporating these mental exercises into what is ostensibly a fitness class is based on the idea that so-called “cognitive distraction” drills can help improve balance. "You're trying to accomplish two things at once here," explains Dr. Rogers. "That's what we've done. We're distracting the person from focusing on their balance." And in the process, you're putting greater demands on their neural system, forcing it to attend to two tasks at once, which in turn can help make it more efficient. We are, to refer back to our previous section, pumping up the BDNF. “This is pretty cutting-edge stuff,” says Robert Topp, Ph.D., a professor of nursing at Marquette University, who has researched the effectiveness of various forms of exercise among older adults. Standing strong, he says, goes beyond what is typically used to improve balance. “Mike,” he says, referring to Dr. Rogers, “is trying to train people to concentrate on what they’re doing as well as retrain their balance. I think he’s onto something really important." So, do we—and not only for falls prevention, which is of course is a concern for older adults. But the kind of activities that Dr. Rogers has developed—some call it neural-pathway-activation, others refer to it as sensory motor training or dual-processing activity—represent a potentially new genre of physical training, beyond the usual fitness triad of aerobic exercise, resistance training and flexibility. We believe that this kind of neural-physical exercise is very much part of heart-brain health. Now you might be thinking: What? Another kind of exercise, on top of what these guidelines are already recommending? Am I supposed to spend my whole day working out? Not at all. The kind of training that challenges your brain and neural system, as well as your heart, isn't difficult to incorporate into a basic exercise routine. In fact, these movements are kind of fun! You can get a sense of this kind of training immediately. When you brush your teeth tonight, try standing with one foot in front of the other. Then close your eyes. Requires a little adjusting, right? Feels different, even a bit strange? That's your brain reacting to and then reprogramming to perform an activity, in a new and unfamiliar position and with one of its key senses—sight—suddenly unavailable. How do we incorporate this into your overall program of physical activity? To do that, let us return briefly to the guidelines. Exercise for Your Heart and Brain: Piscatella's Pointers on Putting it All Together     How do you construct an exercise regimen that works for you? Like a lot of fitness and health professionals, I like the formula called FITT. The “F” stands for Frequency. The American College of Sports Medicine says that it takes three days a week of more vigorous exercise to attain cardiovascular fitness. For heart health, I suggest that as your goal (although you need to build up that goal gradually). The “I” stands for Intensity. How hard are you exercising? If you are walking, for example, it should be more than a casual stroll. One hundred steps a minute is “moderate” intensity while 130 steps a minute is “vigorous.” I also believe that a combination of moderate and high intensity exercise (HIT) can be beneficial. An example would be to walk five minutes at a moderate pace, then two minutes at a vigorous pace, then back to five minutes at a moderate pace, etc. (Breaking up your exercise like that also helps keep you focused and motivated). I'm not saying you should be doing all-out sprints here—just intense enough that you can feel the effort. (One oft-used cue to gauge ideal aerobic intensity is that it should be easy enough that you can still converse but hard enough that you can't sing.) By the way, to step back into the research for a moment, one Dr. Sabbagh's colleagues, Jeff Burns, M.D. of the University of Kansas Medical Center, has done some very impressive research on the link between exercise and Alzheimer's showing how this variable in the fitness formula—intensity—matters. In a 2015 study on the link between exercise and brain function, Dr. Burns and his KU colleagues found that those who exercised with greater intensity had the most improvements in visual-spatial learning, the ability to perceive where objects are in space and their distance from each other, as well as increased attention levels and ability to focus. The first “T” in the FITT formula stands for Time. While we noted earlier that overall health benefits can be derived from very short bouts of activity, the gold standard for achieving the kind of heart health results we outlined earlier is 45 minutes. While a little more aggressive than the Health and Human Services guidelines, that should be your goal. Not at first, though: You don't start by trying to exercise nonstop for 45 minutes. Dr. Sabbagh recommends something closer to the federal guidelines to start out with. He recommends to his patients that they begin with 10-15 minutes of brisk walking and gradually build up from there, adding 1-2 minutes per day each week. "Consistency over strenuous," he says—and I agree.  The second “T” in the FITT formula stands for Type. There are many flavors of exercise out there. We talk about walking and running because they are the most available. Of course, you could also ride a bike or take a Spin class; swim or row; participate in an active sport. To build strength, there are many forms of resistance and core training, plus wonderf...