May 8, 2012

Get Up & Go for Cancer Wellness: Exercise & Nutrition Choices

Mary L. Hardy, MD

About the Lecture

Exercise integrated with good nutrition choices are an essential part of care both during and after cancer diagnosis and treatment. Conventional thinking about “rest” versus “activity” during cancer treatment is changing based on emerging research that shows that exercise AND nutrition have benefits during active treatment as well as during recovery. Research is discussed that emphasizes the benefits of staying or becoming active throughout the continuum of treatment and recovery in order to improve response to treatment, reduce some side effects and to decrease the risk of recurrence. Complying with exercise recommendations is hard, even when cancer is not part of the landscape; it seems like the last thing to try and start during cancer treatment or recovery. However, growing evidence suggests that increasing activity has many benefits. In addition to building strength and helping to control weight, participating in an exercise program during and after treatment can help people feel mentally stronger, more relaxed, and more in control of their treatment and their bodies. The research as well as practical strategies to integrate exercise into one’s wellness program will be discussed and demonstrated. We encourage families to come, because making good nutrition and exercise choices is more successful when done with the support of others.

Speaker

Mary L. Hardy, MD, is an integrative medicine physician who educates patients and family members about complementary medicine choices, nutrition and dietary supplements. She was the Associate Director of the UCLA Center for Dietary Supplement Research in Botanicals and the founding Medical Director of the Cedars-Sinai Integrative Medicine Program. Her clinical practice for more than 17 years has focused on integrating the best of western conventional medicine with appropriate complementary therapies for a wide variety of patients, including people with cancer. She has a special interest in botanical medicine and has trained with scientists and herbalists all over the world including China, Peru, Kenya and South Africa.

Lecture Summary

This is a summary of a lecture presented on May 8, 2012.

Exercise has a helpful role throughout the cancer journey, from prevention and risk reduction, during active treatment, through the transition to recovery and as risk reduction for a new cancer or recurrence of a previous cancer.  Not only is exercise critical in cancer survivorship, it is also important for the health of caregivers as well. 

Exercise can impact cancer in both direct and indirect ways 

·         Exercise can decrease the risk of getting a cancer.

·         Exercise can help to decrease some of the symptoms caused by treatment for cancer.

·         Exercise can increase longevity after a cancer diagnosis. 

·         Exercise helps to maintain normal body weight.

·         Exercise improves quality of life.

·         Exercise is useful in reducing fatigue, and breathlessness.  

·         Exercise improves cardiac fitness and, thus, will improve performance status which is a general measure of overall wellness and functional ability.  

·         Exercise helps with stress management. 

·         Finally, for individuals who are cancer survivors, exercise reduces the risk of other illness such as heart disease, hypertension, stroke and osteoporosis.

It is important to aim to have a healthy weight throughout life. To help achieve this and reduce cancer risk, be physically active for 20 minutes or more most days and choose a mostly plant based diet, limiting red and processed meat. The American Institute of Cancer Research in 2007 -2012 published papers integrating weight, diet and physical activity to increase cancer prevention.  On their website, you can find good resources and tools to help you assess your personal status and address these issues as well. (http://www.aicr.org/reduce-your-cancer-risk )We estimate that approximately one third of the most common cancers could be prevented by healthy life style changes that include staying lean, eating smart and moving more.  Approximately 38% of breast cancers, 45% of colorectal cancers, 36% of lung cancers and 70% of endometrial cancers are believed to be preventable based on lifestyle!

Exercise affects the characteristics of cancer development, especially in hormone driven cancers such as breast, prostate and endometrial cancer.  Exercise modifies hormones and the binding qualities of hormones as well as influencing the glycemic index of the diet.  Exercise increases the insulin sensitivity of skeletal muscle and therefore decreases the amount of insulin and glucose circulating in the body after eating food.  High insulin levels and insulin insensitivity are components of metabolic syndrome. Metabolic syndrome can develop into diabetes, a very negative metabolic state in the body that is associated with increased cancer risk. Individuals with metabolic syndrome accumulate fat around their waist also called central obesity impaired glucose intolerance, hypertension, and high blood cholesterol.

Metabolic and endocrine changes arising from obesity, affects hormones, insulin and glucose storesall of which can lead to increased risks for many different types of cancer.  According to a recent study, a 200% increased rate of breast cancer recurrence occurred in women with metabolic syndrome and higher serum testosterone levels.

Excessive weight is also associated with greater risk of developing many types of cancer, especially pancreatic cancer, esophageal cancer, colon cancer, breast cancer and endometrial cancer.    Not only does excess weight affect insulin and glucose metabolism, but central obesity promotes inflammation, a final common pathway for cancer and many other chronic diseases. It is essential to maintain a healthy weight, in part by increasing lean muscle mass rather than fat.  Use the table below to see what constitutes a normal weight for you height. Where do you fall?   The information in this article is empowering because it provides us with recommendations and activities within our own control that we can implement to reduce our risk and make our body less cancer friendly. 

The importance of exercise to breast cancer development has been shown in a number of recent studies. Breast cancer risk was substantially lower in athletes versus non-athletes.  Exercise appears to be most protective for women who develop their breast cancer after menopause.  For post-menopausal women, staying fit and maintaining weight may reduce the risk of death by 40% from breast cancer.   The amount of physical activity after a breast cancer diagnosis also seems to influence breast cancer mortality.  Women with the highest activity levels had substantially lower mortality than their sedentary cohorts.   

Recommendations have been made for people to exercise 150 min per week of moderate exercise or 75 minutes per week of vigorous exercise. So, how do we measure activity levels?  With MET’s. MET stands for metabolic equivalent task.  One MET is the amount of energy expenditure and caloric requirement when someone is at rest and just breathing.  Walking at a leisurely pace increases energy expenditure to about 2.5 METs per hour of walking while vigorous activity can increase MET’s to much higher ranges of 6-12.  Walking at a very brisk pace for an hour, 1 mile every 17-18 minutes is 3.5 MET’s.  The desirable level is at least 8 MET’S per week. This measurement allows a more precise exercise goal to be set for an individual but an easier rule of thumb states that moderate exercise allows you to be able talk while you are doing it and vigorous exercise does not allow you enough breath to talk.

In a very important study called “Women’s Healthy Eating and Living” (WHEL), survival was evaluated over a 9 year period for four groups of women.  The four groups were assigned to eat a diet that was either high or low fruit and vegetable intake combined with high or low levels of physical activity, i.e., women who had both low fruit and vegetable intake and low physical activity, those with high fruit and vegetable intake and low physical activity, those with low fruits and vegetable intake and high physical activity and the women who had both high fruit and vegetable intake and high physical activity.  The greatest survival rates were those who had high fruits and vegetable intake and were high in physical activity and this group had significantly fewer recurrences than the other three groups. Obesity is an independent risk factor for recurrence. The obese subjects who were in high fruits and vegetable group plus high physical activity group had the same recurrence risk as their non-obese cohort. Thus, it appears that high physical activity coupled with a diet high in fruits and vegetables provided protection from the negative effects of obesity. This is a highly significant finding- it means that you can modify risk even before you lose weight or change all of your lifestyle habits.

There are more than 20 studies demonstrating the positive effect of physical activity on colon cancer.  As the rate of activity goes up the rate of colon cancer goes down.  This does not, however, appear to be the case with rectal cancers, where there seems to be no correlation.  All studies showed that high occupational activity, activity that is engaged in all day long, was also a preventive factor in colon cancer risk.  For stage III colon cancer patients in active treatment, there were benefits in longevity and longer disease-free time for patients who walked 45 minutes per day. Modest benefits have also been seen in individuals who exercise with endometrial cancer, pancreatic cancer and aggressive types of prostate cancer. 

Structured exercise programs are beneficial both during and after treatment. Reduction in cancer-related fatigue was seen with both aerobic exercise and strength training.  In general, individuals who participate in a structured program and people who exercise with a partner tend to do better than those who try to do it on their own.  To maximize chances of success, structure your exercise and have social support for physical activity to meet one’s exercise goals.

Recommendations for Exercise

The American Cancer Society has developed physical activity recommendations.  They include:

·         Adults should get at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity each week (or a combination of these), preferably spread throughout the week.  We suggest that you try to exercise most days as this increases the likelihood that you will develop this as a regular habit and actually achieve the goal. 

·         Children and teens should get a least 1 hour of moderate or vigorous intensity activity each day, with vigorous activity on at least 3 days each week. We have a serious problem with our youth no longer getting enough exercise and becoming more obese and less healthy than ever before.  There are benefits to doing exercise in your early years and carrying it throughout your life time. 

·         Limit sedentary behavior such as sitting, lying down, watching TV and other forms of screen-based entertainment.  Do not sit in front of the TV, your computer or other device all day.  Being a couch potato is unhealthy for you! 

·         Doing some physical activity above usual activities, no matter what one’s level of activity, can have many health benefits. 

Exercise is not an excuse to eat more and needs to be done in addition to a healthy diet.  Exercise does help to burn calories; however, it takes a lot of exercise to burn off something that is unhealthy and highly caloric.  For example, to burn off one large order of French fries (400 calories), it will require 95 minutes of moderate walking, scrubbing floors for 89 minutes, dancing for 75 minutes, bicycling for 35 minutes or running for 28 minutes.  IT REALLY MAKES THOSE FRENCH FRIES LOOK A LOT LESS ATTRACTIVE!

There are many different ways to get exercise and to increase MET’s.  Some of these include aerobic activities that increase your cardiac fitness by increasing your pulse and cardiac output  (walking, swimming, running, dancing, biking, spinning or aerobic exercise classes), strength training (lifting weights, doing isometric exercise or using high intensity stretchy bands), balance training, stretching, household activities (weeding in the garden, mowing the lawn, scrubbing floors), transportation (walking, running, roller skating, biking, leisure activities (golfing without a cart), tennis, basketball and finally occupational activity (construction, getting up and down and walking in a workplace, digging, landscaping, heavy manual labor).  Some aerobic exercise is weight-bearing which has additional benefits.  However, keep in mind that joint protection should always be considered; especially for individuals with osteoarthritis, metastatic bone disease and/or for those who are at high risk of injury. 

Getting Started with Exercise

Motivation is an important part of exercising and having a reason to exercise is important in terms of setting a goal.  You have to make time in your schedule and commit to doing it in the same way that you approach your day—your need to include exercise as part of your day in the same manner as eating meals, brushing your teeth, or going to work.  Set a goal that you can succeed at by making it reasonable and increasing your goals over time as you reach them.  Setting too high of a goal can be a good way to keep yourself from succeeding because it may lead to feeling of defeat and self-criticism which reinforces the wrong choice.  Choose the easiest thing first.  Make a regular time to exercise, and find a partner or participate in group activities to increase the likelihood of success.  Have a back-up plan in case the first time does not work.  Do not give up!

Here are some ideas to get started:

·         Limit the time spent watching TV and using other forms of screen-based entertainment.

·         Use a stationary bicycle or treadmill when you do watch TV. 

·         Use stairs rather than an elevator.

·         If you can, walk or bike to your destination.

·         Exercise at lunch with your coworkers, family, or friends.

·         Take an exercise break at work to stretch or take a 15-20 minute walk at lunch.

·         Walk to visit coworkers instead of phoning or sending an e-mail. 

·         Go dancing with your spouse or friends or take a dance class.

·         Plan active vacations rather than only driving trips.

·         Park farther away and walk a little extra to your office, to the grocery store, to your doctor’s appointment.

·         Wear a pedometer every day and increase your number of daily steps. 

·         Join a sports team.

·         Get an exercise partner to help you.

When getting started, it is important to remember that safety comes first.  See your doctor if you have not exercised in a long time or if you have any heart problems.  Start slowly.  Gradually increase the duration, intensity and frequency of your exercise.  On the first day, do less rather than more to see how this affects you, if you get too sore the first time out you will not want to exercise again.  Take your pulse several times during exercise to check to make sure that you are not exceeding your maximal heart rate.  Remember to warm up properly and cool down with stretching.  Rehydrate frequently in hot weather and protect your skin if exercising outside with a hat and sun block.

To take your pulse, find one of the pulse points on your wrist or neck.  Place a finger firmly, but do not press if you are using the pulse in your neck.  Count the number of beats during a 30 second period and multiple that number by two.    To determine your maximal heart rate, subtract your age from the number 200 and that is your maximal heart rate.  For example, if you are 50, then 200-50=150.  Keep your heart rate in the range of 50-70% of your maximal rate for moderate intensity activity.  Vigorous intensity activity is defined by keeping your heart rate in the range of 70-85% of your maximal rate. 

Below are some lists of activities that fall into moderate intensity and vigorous intensity although there can be differences even within these categories depending upon the intensity of effort that is invested: 

Moderate Intensity Activity

·         Walking, dancing, leisurely bicycling, ice and roller skating, horseback riding, canoeing, yoga.

·         Volleyball, golfing, softball, baseball, badminton, doubles tennis, downhill skiing.

·         Mowing the lawn, general yard and garden maintenance.

·         Walking and lifting as part of the job (custodial work, farming, auto or machine repair.

Vigorous Intensity Activity

·         Jogging or running, fast bicycling, circuit weight training, aerobic dance, martial arts, jumping rope, swimming.

·         Soccer, field or ice hockey, lacrosse, singles tennis, racquetball, basketball, cross-country skiing.

·         Digging, carrying and hauling, masonry, carpentry.

·         Heavy manual labor (forestry, construction, fire fighting).

It is very important that you start slowly if you do not exercise regularly.  Even experienced athletes need to warm up to prevent muscle injury.  Stretching loosens muscles and tendons and prevents injury.  Stretching during the day can also relieve muscle strain and aches associated with tension, repetitive movement and poor body mechanics.

Summary

Our goal is to improve your health, prevent cancer or recurrences, or get through your cancer treatment with minimal symptoms. Exercise combined with diet will help lead to improved health, both physical and mental.  Try to pick activities that you like and can stay with.  Having an overall wellness plan is good for everyone, whether you have cancer, you are trying to prevent it or prevent a recurrence, or you just want good quality of life.