insights

Julie Foucher:
I think that oftentimes people will use an obstacle as not having enough time, which I think sometimes is a real obstacle, but sometimes it’s just how important they’re putting it on their scale of the other things that they need to do. Something that, I think, is often a misconception is that you need a lot of time to get effective exercise in, which is not always the case. So I think making it a habit, that’s a regular part of the routine, even if it’s just five minutes in the morning, so you don’t have time to go to the gym that day or to do something longer, maybe you can do something for five minutes, and then you’re still in that routine and you can still make it a part of your habit. Because the quicker you fall out of the habit, the harder it is to get back on.

So that’s one, I think, especially now with the pandemic—not being able to do the type of exercise that you want; like maybe you’re not able to go to the gym like you would like to or be part of the communities or teams that you normally would. I think that can be extremely hard for people and they can lose a lot of motivation that way. And so that’s where home workouts come in, some of these online communities or apps or things that can still help people feel engaged and have that accountability, even if they can’t be at the gym.

And interestingly too, it seems that the more we’re learning about the pandemic and transmission, that gyms are actually some of the lowest areas of transmission. I’ve seen a few studies from Europe, Australia—there was one from New York that showed extremely low transmission rates in gyms. That’s part of the conversation maybe to be having with patients. What’s the risk benefit of, we know exercise is really great for our immune system and for our health, there is some risk of transmission, but it’s relatively low when you consider other places that you may get an infection. What’s the risk benefit if you’re not able to exercise at home or in a way that you’re comfortable with, maybe it’s still worth it to go to the gym with appropriate precautions.

Yeah. Some of the numbers that I saw were even lower, like 0.06% or less than 1% of all transmissions happening in the gym. So it’s pretty surprisingly low, especially with the gyms that are taking really great precautions.

Kalea Wattles:
For patients, that setting piece really matters. “I can’t feel motivated without other people around me, or I need my group class, or I need the machinery that I’m familiar with.” So we’re hopeful that people will be able to be in the setting where they feel comfortable and safe and motivated to do these things.

Julie Foucher:
Absolutely. And especially now, as we’re in the winter, I think when the weather is nice, depending where you live, but when the weather is nice, it’s easier to get outside and go for a walk or do something active there. But especially now we’re in the winter, if you’re working from home, it’s cold outside, you can’t get out to exercise. It can be really hard. So finding some way to keep it fun and interesting and still change your pace or your setting can definitely be helpful.

I think another obstacle that I think people often have is maybe they have some injury or physical limitation that prevents them from doing the type of exercise that they want or that they think they should do. But I always encourage people to find something. There’s always something you can do, even if it’s not what you would prefer or what you would like, you can always modify different activities. You could try swimming or aqua therapy. If you’re having a hard time with your joints, there’s always some way that you can get your body moving. Even if it seems like maybe you have an injury.

So oftentimes I hear people say, like, “Oh, I have arthritis in my knees, I can’t exercise.” Well, there’s so many things that you can still do, even if maybe you’re not up for walking on a treadmill or doing something that’s putting a lot of pressure on your knees.

Kalea Wattles:
That’s awesome. Two follow-up questions came to my mind as you were talking. So, the first question is selfish just from my own curiosity. For someone like me who might be in a primary care setting and seeing patients but doesn’t have a lot of exercise background, for someone who might need to tailor their activity, like you mentioned perhaps for an injury, are there other members of a collaborative care team you might bring on to help with that, a personal trainer or an exercise physiologist? Are there some other members of your community who you work with to make those types of modifications?

Julie Foucher:
Absolutely. Physical therapists for sure can be allies in this and especially teaching patients how to move and teach them basic functional movements. I think definitely personal trainers. I think it’s important just to know your area in your community and who are the people that you can trust with your patient population and to start building those relationships.

Again, I come from a CrossFit background, so I know there’s certain gyms and certain trainers that I feel really comfortable with sending patients who may be more sedentary or may not have a lot of background exercising, because I know they’re going to do a great job starting from the basics and building them up to do these movements in a safe way. So that’s really, really important, because I think that can be discouraging for patients too. When they start exercising, they have a lot of motivation, especially earlier in the year, and they’re maybe pushing themselves too hard or doing a lot of new things. And then they end up with an injury and getting discouraged, and that can be a big roadblock for people.

Kalea Wattles:
Yeah. That’s super helpful. Thank you for giving us some insight into how you form a supportive care team. The second piece I wanted to loop back to is you mentioned time is a real limiting factor. And I think sometimes we do patients a disservice by separating exercise and nutrition when really there can be a symbiotic relationship there. So I’d love to talk about how nutrition can impact the effectiveness of exercise. Maybe we can get better bang for our buck since we only have a limited amount of time.

So I’d love to hear, from your perspective, how nutrition can impact exercise for things like improving strength and endurance. When we were looking into some background information, we thought maybe this is a conversation about carbohydrates or polyphenols and how those can affect athletic performance. So what’s the connection between exercise and nutritional status and our endurance, even thinking about things like inflammation?

Julie Foucher:
A great question. And even before I jump in, just, I love the point that you made about exercise and nutrition sort of being synergistic and how really a lot of these lifestyle changes and habits work together. So oftentimes, maybe a patient will start exercising and they’ll start feeling a little bit better; that will give them more motivation to make some changes to their diet or vice versa. Same thing with sleep, like if you’re super sleep-deprived, it’s going to be really hard to eat well or make changes to your diet and have the motivation to go exercise. So they all kind of come together. Obviously, you don’t want to just do it all at once, they come in waves, but being able to see how these things interact, like once you do one thing, the next step often comes a little bit easier.

With regard to nutrition, I think one of the most important things to address is probably protein intake, especially when we’re talking about strength training, because if you’re doing good strength training, you want to make sure that you’re getting enough protein intake in order for you to build the muscle that you need. Interestingly, a lot of people, when you look at how much protein we need, the USDA actually recommends 0.8 grams per kilogram, which is a little bit on the low side. So this is more of the intake that you need to prevent malnutrition. It’s not necessarily the ideal amount, but when you look at further analysis of that data, and then also the recommendations from like the Academy of Nutrition and Dietetics, or American College of Sports Medicine, they’re recommending higher protein intake, like 1.2 to 2 grams per kilogram of body weight.

So it’s a fair amount, and if people are not paying attention to how much protein they’re taking in, they’re probably not getting enough. So if someone especially is doing strength straining exercise, or really trying to build muscle mass or lean body mass, I might have them just measure, even if it’s a ballpark measure, how much protein they’re taking for a few days, just to get an idea of, “Am I close or am I way off? And can I eyeball how much protein I need for a day to make sure I’m getting enough?” And looking for obviously clean sources for that protein, like really good quality animal proteins. If you’re eating animal proteins, fish, eggs, or if you need protein powders that they are going to be from clean sources and that are good quality. So that’s sort of the first thing I think about when it comes to exercise and nutrition.

Then the next part is carbohydrate intake, which you mentioned, and there’s some really interesting studies of carbohydrate intake in particular with prolonged endurance exercise. So probably for someone who’s doing shorter, more high-intensity workouts, it’s probably not critical to be ingesting carbohydrates during the workout. But if we’re talking about people doing longer endurance exercise, it seems like it can be really helpful. Basically, it will increase your glucose and your insulin during the exercise, but then afterward, you’ll have less stress hormones and less inflammation, which can be helpful.

One study actually looked at exercise inflammation after exercise, and carb ingestion during the exercise decreased it by 30 to 40%, which was pretty remarkable. So that’s something to think about if you’re doing like a longer duration endurance exercise.

And then you also mentioned polyphenols, which seem to have some exercise benefits as well. Micronutrients that we can get through plant-based foods and lots of antioxidants can also help to counter some of the exercise-induced changes in inflammation and the immune system. So it’s actually really interesting how this works, but you ingest the polyphenols with your fruit and vegetables, and then they actually are not absorbed right away, but they go into our colon where they’re broken down into smaller parts by the bacteria in our colon. Then these smaller parts called phenolics undergo phase two conjugation in the liver and they’re reabsorbed in our circulation. Those can have a lot of great effects, and important effects for athletes, like anti-inflammatory effects, antiviral, antioxidant—and can help with our immune cell signaling.

So, of course, basically in summary, we want to eat good quality protein sources, we want to eat lots of fruits and vegetables. And then if you’re doing longer endurance exercise, it may be helpful to ingest some carbohydrates during your exercise.

Kalea Wattles:
This is so helpful. I think what I’m taking away from this is that it’s nuanced, and we have to tailor these recommendations to a patient’s routine and their goals. And so that’s super helpful. You talked about maybe you have someone start tracking their protein just to see what their intake looks like. Are the app-based trackers sufficient? Are you taking it a step further? How can we counsel patients appropriately to get an accurate tracking of their protein intake?

Julie Foucher:
Yeah, I think again, this depends on the patient, so I think it can be easy for the right patient, maybe you get a scale and you have them measure the weight in grams of protein that they’re having. Or you could use an app to track that as well. I think you just want to be careful—for the patient who may become overly obsessive about tracking and take it too far, or it’s not something that necessarily needs to be done forever. So just being mindful of who those patients might be. And for those, even just measuring like, “Hey, a palm-sized portion of protein is a good amount for one meal that might have like 25 or 30 grams of protein, if you’re going to have like chicken or salmon or something like that.” And maybe you just ballpark for those patients or what their preferences are.

Kalea Wattles:
Yeah. That is very helpful. I want to also go back and revisit the conversation about inflammation, because I think sometimes, we hear just in pop culture that exercise can be inherently a bit inflammatory, just because of the process of breaking down muscle and building new muscle. But exercise can be preventive medicine for inflammatory conditions. So you described a little bit about how exercise influences inflammatory pathways, but overall, would you say that there’s a net anti-inflammatory benefit from regular or moderate intensity exercise?

Julie Foucher:
Absolutely, and it does sound a little bit counterintuitive, because we know after exercise, we get sore and there’s muscle breakdown, and we actually see increases in inflammatory markers like C-reactive protein or other inflammatory markers. And so it’s kind of confusing. Well, if it’s causing inflammation, how is that actually anti-inflammatory in the long run? But it really comes down to the dose and the frequency and the intensity and the response.

You can kind of think about the difference between having an acute stressor like exercise versus a chronic stressor. So if you think about, just in general, when we have acute stressors and the way that our stress response system is set up in our body, a long time ago, if we were getting chased by a tiger or you slam on the brakes—you’re trying to miss a car accident—you feel this stress response come on. That’s an acute response where your heart rate goes up, you have changes in your musculoskeletal system. You’re pumping out more energy to your muscles so that you could run away from whatever attacker you have. You’re more alert. All of those things are happening. And then also you’re revving up your inflammatory system because, potentially, if you’re going to get attacked by a tiger, you may end up getting a cut or some sort of injury that you need to be ready to repair.

So all these systems are getting wrapped up in the acute state. And that’s kind of what happens when you are starting exercise. You’re kind of revving up your stress response, and that’s okay, because after you’re done exercising, things calm down, and that allows you to adapt better. So next time you are approached with the same stressors, so maybe the first time you’re going for a five-minute jog and you rev up the stress response. After you do that a few times, you could do the same five-minute jog, but your stress response isn’t going to be as robust, which is a difference between the acute stressor kind of building up and optimizing your systems versus a chronic stressor. If you’re constantly under this state of stress, or if you’re exercising for hours and hours every day, you could end up in this state of chronic stress or chronic inflammation, which could be problematic.

So I always like to think about it in terms of the dose, frequency, and intensity and what is going to give you the right response. And that’s going to change as you adapt to exercise too. It’s this concept of hormesis, where basically you can have this low level of cellular stress, whether it’s exercise, whether it’s some sort of toxin or change in temperature that stimulates our molecular pathways to improve the ability of ourselves to withstand greater stresses.

And so if you have these small little stressors like exercise, like maybe you’re just starting to exercise, you do five minutes one day, and then you do 10 minutes a few days later, and then do 15 minutes of jogging, you’re gradually giving yourself this dose that’s triggering a response, which is allowing you to adapt favorably. That’s basically how, overall, you can then develop a lower inflammatory response because your systems are more optimized. What might be the right dose for one person is not necessarily the right dose for another person, so if you have someone who’s just starting to exercise, they need small doses, lower intensity. And as they start to build up that resilience or that exercise capacity, then they can handle a little bit more versus someone who’s a trained athlete. Maybe they can train for hours and hours a day and their body’s able to adapt.

A part of the way that this works too is how much time there is for recovery. So you could have someone who is just starting exercise and they do five or ten minutes, and that works fine, but you could also have someone who’s just starting exercise, but they also have so much stress going on in the rest of their life. They’re not sleeping, they’re not fueling properly, there’s all these other stressors that are also putting a stress on the system. And so even then, maybe the five or ten minutes might be too much. You have to kind of look at the whole picture too to see what dose is going to stimulate the right response so that it’s actually a positive adaptation. Then you can end up with an overall anti-inflammatory effect.

Kalea Wattles:
I love that you just said the word hormesis. I’m just so happy, and our functional medicine audience will just love that you said that. In our IFM programs, we often talk about the concept of mitohormesis, which goes right along with what you’re talking about, where when we get small increases in oxidative stress, that’s going to ignite our endogenous antioxidant capacity. And so overall, it’s a net anti-inflammatory, antioxidant benefit. I love that you just brought that up in terms of exercise. I think that that is such a helpful mental model to help us understand how that can be overall an anti-inflammatory process. So fun.

Julie Foucher:
Absolutely. I love how you can think about it on a macro scale. When you’re doing a workout, maybe you’re doing like a weightlifting, like a bicep curl or something, right? And you know that in order to get the favorable adaptation, you want to be a little bit sore. Your muscle is going to have some muscle breakdown, and that’s great. And then you’re going to build up and you’re going to be stronger than you were before, but if you overdo it and you do too much or too much load, you could end up hurting yourself or you could end up not having that adaptation. So it’s about finding what the right dose is and intensity and frequency so that you get the adaptation that you want.

Kalea Wattles:
Yeah, that’s excellent. And you spoke a bit about how the dose really matters, especially depending on someone’s exercise experience level. Sometimes for practitioners who are just starting out in formatting exercise prescriptions, we’ll hear about this FITT, the frequency, intensity, time, and type. Is that something that you use with patients to help them structure what exercise might suit their needs?

Julie Foucher:
I think it can be really helpful. I think it just depends on the person. Some people already have things that they really like to do. And I think to me, the most important thing is finding the type of exercise that is something that the patient wants to do and that they’re going to do. So that’s always where I kind of start, and then really working up slowly on the frequency, intensity, and time. And that again, it’s going to be based on the patient and their previous experience, but it’s a good way to think about it. So you’re kind of agreeing on, “Okay, this is what you’re going to do. This is how often we’re going to do it, for how long, and then you’re going to slowly build up on that over time.”

Kalea Wattles:
Yeah, that’s great. Well, I think you’ve really done a fantastic job of helping us understand the more specific details about why exercise is important and how it can be helpful for chronic conditions. But the logistics of it, I think that’s really the hardest part for so many, is okay, we understand why exercise is so valuable, but it’s hard to really get going.

And one thing that we think about is when we are trying to induce sustainable change, leveraging community networks that someone might have, like making things a family affair. We see that when we do nutritional changes within families, if one parent, for example, is prescribed a Mediterranean diet, that those healthy eating skills can kind of spill out into other family members. Do you find that that’s true with exercise, when one family member starts doing more physical activity, do you see it roll out into the habits of the other family members?

Julie Foucher:
Oh yeah, absolutely. And I think that it’s true in families, but it’s true just in general for us as practitioners also, like if we set a good example, I noticed that other people, my coworkers, may start making changes. Or patients see that you’re practicing what you preach, and that goes a long way. But definitely within families, especially if you can get parents regularly exercising, it just becomes a regular part of life. The kids see that, and they grow up with it, and then it becomes something that they enjoy doing together, and that can be so powerful. Sometimes it can be a good motivator for parents too, just trying to be that example for their kids and creating those good habits.

And I see again with CrossFit, a lot of people who are really engaged in their CrossFit communities, it becomes such a normal part of their life. They’re there on the weekends, in the evenings, that’s where their friends are, that’s where they hang out with their kids. And their kids just start emulating what their parents do. It’s so funny to see, without even any instruction, the kids just start doing burpees, or they start picking up little weights and trying to pretend they’re doing whatever their parents are doing. And it’s so awesome to see that as a standard and something that kids grow up with and something that they just think is a normal part of life, because it’s going to then be with them forever. So whether it’s doing exercise together as a family, or just finding things that you enjoy doing that are active, like going on a hike or going skiing in the winter or doing things that you can do as a family that are also going to be active, I think can go a long way.

Kalea Wattles:
There does seem to be some benefit for some people with doing things in a group, that group mentality, and not only being the physical activity piece, but also the community building and the connection and the shared interests and values. So I think that that’s really beautifully said. Along those similar lines, we’re in this work-from-home era. And I think so many people are not getting the steps in that they used to, maybe their classes are closed. And we know that independently from just exercise habits alone, sedentary behavior can be a significant risk factor for developing chronic disease. I’d love to just get your opinion on how much physical activity is really needed to kind of counteract that potential harm of us sitting at a desk all day and working strange hours and maybe sitting at a desk into the night. Just want to get your thoughts.

Julie Foucher:
Yeah. That’s a tough question, because we know that—and even the most recent exercise guidelines suggest that is there’s really two parts. There’s one, combating sedentary behavior, so there’s trying to move more throughout the day. And then there’s two, making sure you get some form of moderate or vigorous physical activity in throughout the week. So I don’t know if there’s a certain amount that that necessarily counteracts sedentary behavior, but certainly, at least meeting the minimum requirements that we’ve seen a benefit for mortality, it would be like 150 minutes per week of moderate to vigorous activity. And then some strength training too.

But we know if you sit all day and then you just exercise for 30 minutes, probably you’re still going to have some negative impact from that sedentary behavior. So I always like to talk to people about both sides, like one, yes, we want to make sure you’re getting your heart rate up and you’re doing some exercise, but two, let’s kind of think about ways that we can break up what you’re doing throughout the day, so that it’s not just sitting at a desk all day. You’re not just sitting in one place. And it can be simple, it can be as much as setting a timer on your phone or your watch and making sure you get up or putting things in other rooms, you have to get up to go get them every so often.

I really like this technique called the Pomodoro technique, which there’s even different timers and apps you can get on your phone, and it helps with focus too. You work for 25 minutes, then you take a five-minute break, and you do three rounds of that. And then after three rounds, you take a longer break, maybe 15 or 30 minutes. So with that, it just helps you to focus for those 25 minutes because you’re going to get a break coming up. And then in the five minutes, you could do something like go for a little walk, do some squats, pick up a kettle bell, do some stretching, whatever it is so that you’re moving a little bit. I think that helps a lot.

And finding ways too where you can get up and move. So maybe if you have a meeting or a phone call, any opportunity, I know any opportunity that I have to be walking throughout the day, I try to take it. If it’s taking a phone call where I don’t necessarily need to be taking notes or on a video, or if I’m listening to a book or a podcast or something, I’m always trying to make sure that I’m moving, walking, or getting on a bike or doing something like that to break up that sedentary behavior during the day.

Kalea Wattles:
I think some primary care docs like myself who maybe don’t have a big background in exercise might feel some apprehension of taking a patient who’s been sedentary and prescribing an exercise routine. Like, “Is this even safe?” But is your general recommendation start slow, work your way up, see how people do, increase as they can tolerate?

Julie Foucher:
Yeah, absolutely. Just meeting the patient where they’re at. So if it’s someone who’s never exercised before and walking is going to be a big strain on them, then start slow, start walking, even if it’s walking down the driveway and back for a few days, and then start going a little bit longer. And I think from my experience too, once patients do that and they get some motivation, they say, “Oh, that wasn’t so bad. Let me go a little bit further today.” And they started pushing themselves further. And so just starting small and working up. And if it’s someone that maybe has a lot of physical limitations, like starting with a physical therapist or starting with a trainer who’s going to be able to supervise them, take them through in a safe way, can be really, really helpful and then give you peace of mind too as a doctor who’s recommending it.

And just not to be afraid to help them get moving. Even if it’s doing some squats, like having them stand up and sit down off a chair for squats and having them practice those a few times a day or during the commercials on a TV show, there’s so many ways that you can break it down into smaller pieces that are still going to be safe and then you can build on.

Kalea Wattles:
Yeah, that’s great. We just had our Cardiometabolic Advanced Practice Module. And some of the questions that we got from practitioners were, “Can I medically clear patients in a primary care setting to exercise, do I need to refer to a cardiologist for this?” And it sounds like with some careful monitoring and making sure that they’re starting at a level that’s appropriate for them, that most patients can be cleared just by their family doc in a primary care setting.

Julie Foucher:
Yeah, for sure. Unless they have some cardiac history or something that needs a specialist, but yeah, starting small and working their way up should be fine.

Kalea Wattles:
Well, Dr. Foucher, you have done a beautiful job illustrating how exercise really fits into a comprehensive care plan. We have to honor the role of physical activity as part of our modifiable lifestyle factors. It’s really the foundation for whole person health. And I think with the insights we’ve gained today, we’ll all be more able to do that. So thank you so much for joining us, and we look forward to seeing you all next time.

Julie Foucher:
Thank you for having me.

Kalea Wattles:
To join the conversation on this topic, visit IFM’s pages on Facebook and Instagram. For more information about functional medicine, visit ifm.org. 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.