insights

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Advancements in technology and the ever-shifting landscape of business culture have fostered changes in many nations that have led to increasingly sedentary lifestyles¹—defined as any waking behavior characterized by a low energy expenditure while in a sitting or reclining posture.² Major studies suggest that the prevalence of insufficient physical activity, which is a risk factor for cardiovascular disease risk and cardiovascular-related mortality,^3-7 is particularly high and still rising in high-income countries. Worldwide, women are less active than men.⁸

Some studies have suggested that the risk conferred by prolonged sedentariness is mitigated only by high levels of moderate to vigorous physical activity, with the recommendation of at least 21 minutes of physical activity for seven days (150 minutes per week), coupled with reduced sedentary behavior.⁹ However, dedicating this amount of time to exercise each week can be challenging for some patients; the time commitment alone might even dissuade some from integrating any physical activity into their lives at all.

Would shorter bursts of physical activity, coupled with lower sedentary time, also impact cardiovascular disease risk? In a recent study, researchers asked this very question and found that physical activity and sedentary time interact to impact the risk of premature death.⁷ They discovered through meta-analysis that in fact just 11 minutes of moderate to vigorous physical activity a day, when combined with low sedentary time (less than 8.5 hours a day), reduces the risk of cardiovascular disease to similar levels of those seen in the most active people with low sedentary time. The findings also suggest that accumulating time in moderate to vigorous physical activity—equivalent to the upper level of the 150-300 minute per week recommendation—alone may also be sufficient to attenuate the detrimental association between sedentary time and risk of premature death.  In other words, while 11 minutes of activity combined with low sedentary activity is one way to reduce cardiovascular risk, doing 150-300 minutes per week may reduce risk even at high levels of sedentariness.⁷

However, there is still debate in the medical community about whether even high levels of physical activity can fully counteract the harms of sedentary behavior.¹⁰ Some research suggests that sedentary behavior, particularly cell phone screen time, can compromise an athlete’s body composition, regardless of weekly training time.¹⁰ Most clinicians agree, however, that some movement is better than no movement at all. So what can we recommend to patients as substitutes for sedentary time to impart health benefits that doesn’t seem too overwhelming or difficult?

Support for Patients & Mindful Movement

Patients who are at first hesitant to embrace an exercise regimen might find it helpful to begin by integrating small steps into their daily lives to reduce sedentary time. Functional medicine clinicians often recommend incorporating mindful movement into everyday routines in place of sedentary behavior, such as wall squats, seated leg extensions, static lunges, and standing bicep curls, just to name a few. Small physical activity sessions of about 5-20 reps, or holds and stretches for one minute, can be integrated into the workday in hourly increments. Many smartphone and desktop applications available on the market allow patients to set reminders to move during the day; some of these include StretchClock, DeskActive, Break Pal, and OfficeFit.

IFM’s Increasing Movement With Office Exercises handout also provides a written schedule that can be downloaded and provided to patients for use at home; the schedule provides patients with ideas for various types of movement throughout the work week and can be customized for the desired level of activity.

The functional medicine model emphasizes the importance of helping patients identify what types of physical activity they enjoy the most to create sustainability. To be truly effective, a functional medicine exercise prescription must not only help the patient develop an exercise routine but also help them replace a certain amount of sedentary time each day with standing, stepping, or walking.

For patients who can tolerate high-intensity activity, it is well-acknowledged that high-intensity interval training (HIIT) is a time-efficient and safe exercise modality that has positive effects on cardiovascular, mental, and cognitive health.^11-13 A 2017 systematic review and meta-analysis suggests that HIIT (as opposed to moderate-intensity continuous training) may improve peak oxygen uptake and should be considered as a component of care for coronary artery disease patients.¹² Another interesting study from 2019 suggests that HIIT results in significant reductions in total fat mass, abdominal fat percentage, and improved lipid profile in patients with myocardial infarction who underwent cardiac rehabilitation.¹³ HIIT has also been associated with improved mental health and cognitive function, particularly when combined with health education.¹¹

Conclusion

As research continues to evolve, clinicians are seeing new opportunities for safer and more effective interventions to prevent and reverse cardiometabolic disease. Functional medicine teaches clinicians how to effectively motivate patients to view exercise as a comprehensive physiological benefit, not just a means for weight loss. The patient’s path to wellness may include structured exercise programs, unstructured interruptions of sedentary behavior, or both. The Exercise Goals and Tracking Journal is a downloadable worksheet from the IFM Toolkit, which contains more than 370 clinician resources that can be accessed and used in practice; it includes intake forms, patient handouts, and assessment questionnaires.Learn more about tools and strategies to help patients achieve sustainable lifestyle change and improve their well-being through IFM’s new course Lifestyle: The Foundations of Functional Medicine.

The Cardio-Focused Physical Exam 

Lifestyle Interventions to Modify Cardiovascular Disease Risk 

Improve Health and Longevity for Your Patients 

References

1. Edwardson CL, Henson J, Bodicoat DH, et al. Associations of reallocating sitting time into standing or stepping with glucose, insulin and insulin sensitivity: a cross-sectional analysis of adults at risk of type 2 diabetes. BMJ Open. 2017;7(1):e014267. doi:1136/bmjopen-2016-014267
2. Diaz KM, Duran AT, Colabianchi N, Judd SE, Howard VJ, Hooker SP. Potential effects on mortality of replacing sedentary time with short sedentary bouts or physical activity: a national cohort study. Am J Epidemiol. 2019;188(3):537-544. doi:1093/aje/kwy271
3. Edwardson CL, Henson J, Bodicoat DH, et al. Associations of reallocating sitting time into standing or stepping with glucose, insulin and insulin sensitivity: a cross-sectional analysis of adults at risk of type 2 diabetes. BMJ Open. 2017;7(1):e014267. doi:1136/bmjopen-2016-014267
4. Thivel D, Tremblay A, Genin PM, Panahi S, Rivière D, Duclos M. Physical activity, inactivity, and sedentary behaviors: definitions and implications in occupational health. Front Public Health. 2018;6:288. doi:3389/fpubh.2018.00288
5. Patterson R, McNamara E, Tainio M, et al. Sedentary behavior and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol.2018;33(9):811-829. doi:1007/s10654-018-0380-1
6. Colberg SR. Key points from the updated guidelines on exercise and diabetes. Front Endocrinol. 2017;8:33. doi:3389/fendo.2017.00033
7. Ekelund U, Tarp J, Fagerland MW, et al. Joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middle-aged and older individuals. Br J Sports Med. 2020;54(24):1499-1506. doi:1136/bjsports-2020-103270
8. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health.2018;6(10):e1077-e1086. doi:1016/S2214-109X(18)30357-7
9. Solomon TPJ, Eves FF, Laye MJ. Targeting postprandial hyperglycemia with physical activity may reduce cardiovascular disease risk. But what should we do, and when is the right time to move? Front Cardiovasc Med. 2018;5:99. doi:3389/fcvm.2018.00099
10. Júdice PB, Hetherington-Rauth M, Magalhães JP, Correia IR, Sardinha LB. Sedentary behaviors and their relationship with body composition of athletes. Eur J Sport Sci. Published online January 8, 2021. doi:1080/17461391.2021.1874060
11. Zhang Y, Zhang B, Gan L, et al. Effects of online bodyweight high-intensity interval training intervention and health education on the mental health and cognition of sedentary young females. Int J Environ Res Public Health. 2021;18(1):E302. doi:3390/ijerph18010302
12. Gomes-Neto M, Durães AR, Reis HFCD, Neves VR, Martinez BP, Carvalho VO. High-intensity interval training versus moderate-intensity continuous training on exercise capacity and quality of life in patients with coronary artery disease: a systematic review and meta-analysis. Eur J Prev Cardiol. 2017;24(16):1696-1707. doi:1177/2047487317728370
13. Dun Y, Thomas RJ, Medina Inojosa JR, et al. High-intensity interval training in cardiac rehabilitation: impact on fat mass in patients with myocardial infarction. Mayo Clin Proc. 2019;94(9):1718-1730. doi:1016/j.mayocp.2019.04.033