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Melanie Cole (Host):  The American College of Sports Medicine and the World Health Organization suggests that adults 18-64 do at least 150 minutes of moderate exercise or at least 75 minutes of high intensity physical activity each week. Guidelines also recommend adding muscle strengthening exercises into the routine, two or more days a week. My guest today is Dr. Neel Chokshi. He is the Medical Director in Sports Cardiology and Fitness Program at Penn Medicine. Welcome to the show Dr. Neel. So, exercise, people hear this 150 minutes, they don’t know which to do, how much of it to do and what kinds to do. So, let’s start with what kind of exercise is the best for your heart?

Dr. Neel Chokshi, MD, MBA (Guest):  Sure Melanie. So, you know really what I tell my patients is that anything that they enjoy doing is appropriate. So, that is usually the best advice I can give. Because we want to make sure it is sustainable activity. So, most people maybe have never been to a gym or they don’t really know where to start; so, walking is entirely appropriate for this kind of activity. And it is the simplest thing to do because many people don’t have access to a gym or a bike or something more intense. So, really, we say anything you enjoy doing up to including walking for up to 150 minutes per week and we say that you can – what also matters here as you mentioned; was the intensity of the exercise. So, we don’t want you just to walk around but to make it count. We like you to do – make sure you are getting your heartrate up or you make sure you are working your heart hard enough. And so, what I usually tell people if they are starting beginners; I tell them to start walking. Walk three times a week; 45 minutes at a time to get to about 150 minutes or walk 30 minutes a day for five days a week; that is usually sustainable. And I tell them to start out slow if they have never started walking but to walk at a pace where if somebody was trying to talk to them; they would get a little short of breath while they were talking. That usually is about moderate intensity. And then I tell them to start from that and progress and so as time goes on, if that becomes easy for them; I tell them to walk a little bit faster and then we start to build in more intense activities for them as they tolerate.

Melanie:  Does somebody need to have a heart checkup before starting, even if it is just a simple walking program?

Dr. Chokshi:   Sure. So, it used to be the case that we told people that yes, you do need to have a heart check-up before you start walking. But they changed this guideline recently because we realized that this creates an obstacle to people beginning exercise programs. They used to say that I need to see a doctor before I start doing things and obviously, it is already hard enough to exercise as is. So, we sort of backed off of that and there are certain guidelines where we say if people are high risk enough; where they have certain cardiac risk factors like high blood pressure, high cholesterol, diabetes, kidney disease; that we may suggest things but in general, my advice is that you don’t need. If you are feeling okay, you don’t have symptoms, you don’t have a history of heart problems, you don’t need to get a check-up. As long as the general tenet is that if you start slow and increase gradually; that your heart adapts and you are just fine without having to see a doctor. It’s usually when people are looking to do something more intense, some more intense activity and starting from doing nothing; that’s when they get into trouble. So, I tell people don’t go from zero to 60; start slowly and go gradually and as long as you feel well, it is entirely fine. If you do have a history of heart problems or many risk factors and you are not entirely sure or you are really having symptoms if you tried to go and exercise and you get chest pain or shortness of breath or lightheaded and you are not entirely sure; then it is good to at least touch base with your physician to figure out if it is safe for you. Whether you need to have some testing or you are good to go without any more intervention.

Melanie:  So, if they have just begun, what are some red flags, Dr. Neel, that you would like people to keep an eye on; especially if they do suffer from heart disease or peripheral vascular disease, they are on some medications for blood pressure, they have diabetes, whatever it is; what are some red flags you would like them to keep in mind when they are doing some heart smart exercises?

Dr. Chokshi:  Sure so, in general, the first tenet is start slow and the second is that if you do have any real history of heart problems or peripheral vascular disease; then I would definitely consult with your doctor to figure out where is the right starting point for you and many times, we prescribe the exercise for symptoms. So, in those scenarios, where for example you may be having pain in your leg due to peripheral vascular disease, you may be having chest pain due to a blockage in one of the arteries of your heart; in those scenarios, you want your doctor to tell you what’s the right amount of activity. But if you are going along and you are feeling fine and then you start to develop symptoms; well that’s a different story.

Things to be concerned about, are really new symptoms at activity levels that were previously okay for you. So, you walk on the treadmill every day and now suddenly at the same speed, at the same incline; you might start to feel some chest pressure. Typical symptoms related to heart would be chest pressure that radiates down your arm, up your jaw, maybe associated with shortness of breath. You may just feel generally lousy and it gets better if you were to stop pretty promptly. That’s a little bit concerning. Unfortunately, everyone’s chest pain is a little bit different. But also, if you get more short of breath in general compared to what you used to be able to do and you have been maintaining your exercise tolerance; that might be a sign that you may be just need to consult with somebody as well. And of course, if you are having heart racing or palpitations when you are doing activity; that might be a sign. Of course, this is always a little bit tricky because we expect your heart to go faster and for you to feel your heart racing when you are exercising, that’s normal. So, that’s appropriate. We also, if you are pushing yourself a little bit above what you normally do, we expect you to get a little bit shortness of breath. So, that is also appropriate. So, it is often hard to tell; but if you are not entirely sure, it is always worth a conversation with your doctor.

Melanie:  Dr. Neel, since exercise has an insulin like effect for diabetics and it can lower blood pressure for people with high blood pressure, up to a few hours post one bout of exercise; what would you like people to know about adhering to their exercise program and gradually progressing so that it gets a little harder each time and they can make great strides?

Dr. Chokshi:  Sure, so I would say for the purposes of high blood pressure and diabetes; one of the things that our patients always think just maybe from media or their own intentions, that you don’t actually need to kill yourself. It just takes very little routine exercise at moderate intensity to have an effect on your blood pressure, to have that reversal effect on your diabetes and sometimes people feel a little overwhelmed because they feel that they need to go running or they need to do some high intensity - what we would consider high intensity and long duration activity; but really, it doesn’t take much to have an effect on high blood pressure, diabetes, on weight loss. It’s really about making – doing as you mentioned, what is sustainable for you and that is why sometimes people don’t realize that it doesn’t take as much as they think to have a positive effect on their cardiac health.

Melanie:  So, give us your best advice. What would you like to tell people about exercise and even including some other types of exercise Dr. Neel, that might also be good for our heart like yoga or mediation, flexibility, and strength training? Kind of wrap it all up in a nice picture for us about exercise as a whole and why it’s so good for not only our heart, but the rest of us as well.

Dr. Chokshi:  Sure so, I think the most important factor that entails to all the things you mentioned is finding something you enjoy. So, making sure that the activity is something that you enjoy doing, that you are willing to go out and do it repetitively and you really need to build it into your day to day life as a habit. It is just like brushing your teeth, you need to do whatever it is you do for your heart every day or every other day.

As far as activity is concerned, so sometimes the simplest activity as we talked about is best, but there are a lot of other beneficial activities that we can talk about and I usually base the advice on the person’s goals. So, if your goal is just to get by and do the minimal amount to make sure your heart is healthy, then you can do moderate intensity activity. A lot of our patients are looking to lose weight; well in that case, you don’t have to – what’s more important is the duration of activity not necessarily the intensity and you want to burn more calories with your activity. So, you want to try to find something that you can do longer periods of time that you can do every day to create that caloric deficit to lose weight. Other things as part of the recommendation you said that I usually say if you want to do a little bit more, part of the recommendations include some weight training, at least twice a week, twenty minutes at a time, some sort of resistance training. So, this is easiest done at the gym, but there are a lot of things that you can do around the home that even including just work around the house that count for this and I think in addition to your heart, there are a lot of benefits to this. So, I tell most of my patients that if you want to do more, the resistance training has a lot of benefits for your bone health, for preventing frailty as you get older. It also increases – if your muscle mass goes up, it increases your metabolic rate so that you could essentially consume more calories that can help you with burning calories for reducing weight. So, that’s really important to me and then if you really enjoy activity, then I think and you want to stretch your cardiac fitness; well then that is when I get into the more high intensity activities so things that you may – people come to me and they want to train for a race as a goal and it doesn’t have to be maybe a 5K or a bike race and that’s when we start to talk about more complicated regimens where they entail high intensity interval training so we know that there has been more and more research about doing just 10 minutes of high intensity activity a day; it has some benefits on your cardiovascular fitness and there are lots of regimens out there but as little as 10 minutes has shown to provide some benefits to your overall fitness level. I tend to reserve that as sort of an advanced technique if you haven’t started exercising. But in people who are just looking to get the most bang for their buck and they don’t have a lot of time, those are also very valid regimens for them.


Melanie:  Thank you so much Dr. Chokshi, for being with us today. You’re listening to Penn Medicine Heart and Vascular Update. For more information, please visit www.pennmedicine.org , that’s www.pennmedicine.org . This is Melanie Cole. Thanks so much for listening.