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INSIDE HEALTH

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Programme 1. Health and Exercise Inside Health Special

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TX:Ìý 12.01.16Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý FIONA HILL

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Porter

We’re back, and kicking off the new series with a special programme dedicated to exercise. We all know it’s good for us – and that most of us should do more – so we have decided to take a lateral approach to the subject. And there is something for everyone – whether you are a keep fit enthusiast, or a couch potato.

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Coming up:

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Arthritis and exercise – why weak muscles, rather than damaged joints, are behind many aches and pains.

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Clip

How many people have difficulty undoing a jar, how many people have difficulty getting out of the chair and have to use their arms when they stand up?Ìý They’re the group of people we need to get at now and do some muscle strengthening with.

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Porter

And being weak and out of shape doesn’t just affect how you feel, it can influence your chances of recovery from serious illnesses like cancer too.

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Clip

There were concerns previously that if you’re unwell you should rest and that will help you recover but it actually appears to be the contrary in fact.Ìý Movement and exercise and mobilisation early after either surgery for cancer or during treatment can improve your long term outcome.

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Porter

And we’ll be answering this listener’s query about overdoing it in the gym.

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Clip

I’ve come to the idea of exercise fairly late in life.Ìý How can I push myself without actually killing me?

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Porter

We’ll discover how much is too much, and how hard you should push yourself later on.Ìý But first, an insider’s view from our special correspondent Dr Margaret McCartney, who hasn’t let the awful weather we have had recently stop her leading by example.

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McCartney

It’s pitch dark, it’s pouring with rain, in fact the rain is bouncing off the pavements and there are puddles everywhere.Ìý And I’m just going to go out for my five K run.Ìý I do think I’m slightly crazy actually.Ìý There we go – just got my Garmin on.Ìý Every bit of kit, not that that helps me anyway.Ìý Just splash into the lovely puddles of Glasgow.Ìý I’m going to sign off here because I don’t think I’ll be able to talk for much longer.

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Porter

Margaret, that’s you braving the Glasgow rain.Ìý I’m impressed by your dedication but you’re a relative newcomer to the running game aren’t you?

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McCartney

I am, I have to say it’s really just been in the last 12 or 15 months or so that I’ve really developed I suppose a bit of an addiction to it.Ìý And I absolutely love my running now.

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Porter

And what sort of benefits have you noticed personally – not a clinical trial, just what you’ve noticed personally?

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McCartney

No, just what I’ve done.Ìý Well I started running because I wanted to get a bit fitter, sleep a bit better, lose a bit of weight and just feel better overall and as you know Mark, because I can’t shut up about it, I am absolutely addicted to my local park run, and these are free five K events that happen in lots of local parks and I’ve had so much support and encouragement and just great fun through doing them that I actually want to do it, which for me and exercise is a bit of a first.

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Porter

Well the problem with five K is that if you’re a practiced runner it’s quite a short distance but if you’re somebody who doesn’t run at all it’s miles.

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McCartney

Well absolutely and I did not start off suddenly waking up one day and saying oh let’s run a five K, it took me ages, I [indistinct words] over a very long period of time and there’s all kinds of really great help you can get.Ìý For example the NHS couch to five K app is fantastic and it literally takes you from being able to walk and not go very far from actually being able to run a whole five K.

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Porter

And how far are you going to take it Margaret?

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McCartney

How far can I take it, this is my new question.Ìý Well you see to start of with…

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Porter

The bug has bitten.

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McCartney

Oh totally, I am now being devoured by this running lark, it’s just surreal.Ìý And I did a half marathon this year and I’ve signed up to do another one.

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Porter

What time did you do your half marathon in?Ìý He asked, pretending to be disinterested.

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McCartney

Well Mark, well Mark, yes, because you have also done a half marathon…

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Porter

Yeah but that was a long time ago and I am a lot older than you.Ìý What time did you do it in?

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McCartney

One fifty four.

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Porter

Exactly?

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McCartney

Fifty.

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Porter

Well I ask because I did it in 1.55, which means you’re 10 seconds quicker than me.

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McCartney

Yeah, that’s quite a lot of time…

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Porter

Thank you very much Margaret, we’ll be speaking to you a little bit later on in the programme.Ìý Bye.

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Ten seconds – pah.

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Later in the programme we’ll be challenging the widely held belief that it’s always good to rest when you are ill, but before that let’s tackle another popular misconception – that exercise is bad for your joints, and that people with arthritis should take it easy.Ìý

Philip Conaghan is Consultant Rheumatologist and Professor of Musculoskeletal Medicine at the University of Leeds, and we went along to one of his busy clinics.

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Conaghan

We’re in an early arthritis clinic at Chapel Allerton Hospital in Leeds.Ìý In this clinic we tend to see two sorts of patients largely.Ìý The first is the group who are at high risk of having an inflammatory arthritis.Ìý They’re a relatively small group of people but we have this clinic to try and pick up these patients, especially those with rheumatoid arthritis as soon as possible.Ìý However, we also see a lot of people with much more common problem of generalised joint pains, often they’re the sort of pains that give you five to 10 minutes of morning stiffness that gets worse as the day goes on, so the more you load your joint the more pains you get.Ìý So what I would call mechanical joint pains.Ìý And they make up an awful lot of what we see.Ìý And the root cause of a lot of that pain is maybe some joint damage but for most of us it’s muscle weakness driving the pain. What won’t surprise many people out there if I were to say how many have difficulty undoing a jar, how many people have stopped having baths because it’s too hard to get out of the bath, how many people have difficulty getting out of the chair and have to use their arms when they stand up?Ìý And you’ll find that’s an incredibly common group of people and they’re the group of people we need to get at now and do some muscle strengthening with.

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Actuality

Conaghan

Now come on in.Ìý Dorothy, take a pew.

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Porter

Dorothy is 61 and has been struggling for months.

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Actuality

Conaghan

Tell me about your joint problems?Ìý The doctor says in his letter you started off with hand pain.

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Dorothy

The fingers were getting stiff and it took me a few hours in the morning just to feel the movement in my hands.Ìý Gradually as I got warm they come back but I could have the pain all day, in the fingers the restriction is holding a knife and fork, holding a toothbrush, that is really hard to keep a grip.

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Conaghan

Is it in the fingers, is it in the wrist, whereabouts?

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Dorothy

Oh in the fingers, all the way up.

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Conghan

Tell me about your lower limbs then, what aches and pains are you getting in your legs?

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Dorothy

From the waist down it’s constantly aching, it’s like you’ve run a marathon and you get the burn out after, that’s the muscle pain, the buttock area and all the way down the side – down the outside especially.Ìý And I use mostly my hips to swing out to move the legs.

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Conaghan

What’s that done to your mobility in the last few years?

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Dorothy

I wouldn’t say it’s been a rapid decline, it’s been a slow one, I didn’t realise I was losing it because of my age, because I’d been told as you get older you get less movement in your body – as you get older.Ìý But it’s kind of took me down a little bit, ain’t it, this is my husband, yeah.Ìý My mind is fine, I’m just eager to go but the body won’t let me go.

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Husband

Show the endurance.Ìý We went to Whitby last year and she just walked round with sheer willpower.Ìý I could see her fading as we were walking around.Ìý Even a trip to supermarket and she feels it for a couple of hours later, it really saps her quick.

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Conaghan

Alright, I’d like to do a few things then just to assess your strength.Ìý Can you grab my hand for me, squeeze me hard, hard as you can?Ìý

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Dorothy

Yep.

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Conaghan

You’re right or left handed?

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Dorothy

Left.

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Conaghan

Left handed, that’s it, yeah.Ìý Squeeze hard.Ìý Yeah and it’s about the same.Ìý So when the two hands are the same we know somebody must have lost some muscle strength because you’re normally stronger on your dominant side.Ìý So that’s one problem is your grip is down.Ìý Let’s just have a look at the fingers.Ìý You’ve definitely got some osteoarthritis in these fingers, that’s all those nobbledy bits we can see and that’s sometimes the trigger for people starting to lose muscle strength is hand pain starts with this but over years it’s the muscle loss that leads to tendonitis pain.Ìý Now let’s just have a look, your elbows, are you tender round there?

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Dorothy

Yeah.

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Conaghan

Yeah and on the inside and…

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Dorothy

Oh that’s – that’s all gone, on that one.

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Conaghan

I won’t poke then too much.Ìý So you’ve got what would be called tennis elbow and golfers elbow, these are tendonitis problems in people with weak grip.Ìý So what we need to do is to start getting you strong.

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Dorothy

This last seven or eight month, phew, no strength which I feel kind of guilty about you know, I don’t want to sit in a chair all me life.

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Conaghan

This is not a problem if lazy people, this is a problem of people who haven’t learned a structured way of rebuilding themselves and that’s what it’s about, it’s about rebuilding people.Ìý And you can build muscle at 40, 50, 60, 70, 80 – you can do it.Ìý This is not a quick fix, it’s a slow fix and that’s why some people want a pill, they’re looking for a quick fix and unfortunately for many musculoskeletal problems there aren’t a quick fix.

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Dorothy

I’ve got to take each day and slowly build because if I don’t I’m going to go further downhill.

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Porter

Well I’m joined now by Professor Philip Conaghan, who’s in our Â鶹Éç studio in Leeds.Ìý Philip, you gave Dorothy a programme of exercises there, do we have good evidence that that sort of intervention makes a big difference?

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Conaghan

We’ve got excellent evidence, there’s probably as good evidence as we can get in medicine that if you do muscle strengthening you will reduce joint pain.Ìý Lots of trial evidence to show this is a good way to go and it’s almost not so important what exercise you do, so long as you’re doing something.Ìý You want to start when you’re very weak with just one or two things that you can do every day for 30 or 60 minute bursts.

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Porter

Dorothy’s story, as a GP, is depressingly familiar, I mean how common are patients like Dorothy where weakness is a major factor?

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Conaghan

In my practice they’re extremely common.Ìý We know that musculoskeletal problems make up about 20% of GP consultations and my feel and there’s a little bit of evidence to support this is that the very weak patients probably make up at least 30-40% of that group of patients.Ìý So they typically present with multiple joint pains, so if you, for example, start off with the knee pain you get weak in your leg muscles, you aggravate your back, you start to throw your leg funny, so then you start to get pain on the outside of your upper thigh that you think is your hip, so you’ve now got knee pain, back pain, hip pain and if that’s been going on over a couple of years and you’ve got these weak leg muscles you find you’re pushing yourself up out of chairs all the time, suddenly you start to get tendon and pain in your shoulders.Ìý And so now you’re complaining of pains everywhere and that’s often the patient you and I see, Mark, and this isn’t some sort of systemic illness causing this, it’s how we’ve been using our bodies over a period of time with weak muscles.

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Porter

But the problem is that when you suggest increasing exercise a. it’s painful for a lot of these patients so they find it difficult and b. I mean the thing I often hear is look I don’t want to wear my joints out faster doctor, won’t I damage them.Ìý How do you reply to that?

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Conaghan

Well the first thing I’d say is perhaps we’ve got messages wrong out there when we’ve tried to encourage activity for people.Ìý For most of the people I see who are so weak that they can’t get out of a chair without using their arms and that’s the majority of people I see or they can’t undo jars, that’s another sign that you’ve probably got generalised weakness but generally your upper body is weak for sure.Ìý For those people just telling them to walk round the block is not a good idea because they’re going to walk in a funny way, not walk fast enough to burn calories or do any other aerobic benefits, so first get strong and getting strong you won’t damage your joints but you’re often lying flat, doing straight leg raises or using a squeeze ball to strengthen your forearm – none of that is going to damage joints.Ìý And it does hurt, there’s no question it does hurt when you start doing it but most of us who remember the days when we went to gym will remember that their muscles ache after they do appropriate exercise and that’s the sort of ache we’re looking at.Ìý Then when you get a bit stronger the things you need to start on are things that are low weight bearing.Ìý So, for example, for the very weak patients I love them walking laps in a swimming pool – it’s non weight bearing and it’s fantastic exercise for your lower limb muscles.Ìý Then if you get stronger you might move to an exercise bike or a cross-trainer where the impact is very low.Ìý So in short starter exercises don’t involve any damage to joints at all and then as you get stronger low impact’s the way to go.

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Porter

Do you think there is enough awareness amongst both your colleagues, people like me, and the general public that exercise or weakness is such an important factor in many cases of arthritis?

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Conaghan

I really don’t think there is a great generalised awareness of this issue and I think the problem is that not all the joint pain people have is coming from their joints, it’s often coming from tendons.Ìý So the typical patient I see they’ll have a mixture of pain from arthritic joints but a lot of their pain might be from tendons around the back of the hands, their fingers, their elbows, their shoulders, around the outside of their thighs – that’s all tendonitis pain, all reversible with muscle strengthening.Ìý Whereas the true arthritis pain of the joint may not be as reversible but will still reduce a significant amount with muscle strengthening.Ìý But no I don’t think we’ve got this concept out there that if you can’t undo a jar or get out of a chair or get out of the bath easily that you’ve got a problem, I think there’s a terrible acceptance that I’m getting older I’ve got to expect this.Ìý We’ve got to push back on that and say no, no it’s not acceptable, you’ve got to stay strong.

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Porter

Professor Philip Conaghan talking to me earlier from our studio in Leeds.

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So keeping active – and strong can both help ward off joint problems, and alleviate them when they develop, but what about other health issues? Well, over the last decade or so there has been growing interest in the relationship between activity and the risk of developing cancer. Studies have demonstrated that exercise appears to have a protective effect against at least four different cancers.

Dr Denny Levitt is Consultant in peri-operative medicine and critical care at the University Hospital Southampton, and she has a special interest in the relationship between exercise and health. So which cancers might it help with?

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Levitt

That’s breast cancer, in particular, postmenopausal breast cancer; colon cancer; endometrial cancer and some of the upper gastrointestinal tract cancer.

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Porter

Endometrial cancer being cancer of…

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Levitt

Of the uterus or womb.

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Porter

And what sort of degree of protection does it offer?Ìý I mean let’s use breast as an example.

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Levitt

Well there have been some epidemiological studies one published recently suggesting that about 10% of postmenopausal breast cancer in Australasia could be attributed directly to physical inactivity.Ìý So that’s one tenth of the cases of breast cancer can be related to being inactive.

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Porter

And what sort of level of exercise are we talking about?

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Levitt

Well the WHO guidelines and also the UK government guidelines suggest that we should be doing around 150 minutes of what we call moderate intensity exercise each week.Ìý And moderate intensity exercise would be going for a brisk walk or a cycle ride and we suggest that on the whole you should try and do this in bouts of exercise of 30 minutes or so, so five times a week, 30 minutes of exercise.Ìý Alternatively with high intensity or strenuous exercise such as running, playing a game of football perhaps only 75 minutes of exercise a week would be sufficient to reduce your health risks.

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Porter

Do we know the impact of exercise on people who’ve already got cancer in terms of their chances of recovering?

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Levitt

Yes it appears that exercise and fitness and physical activity have an important effect on survival rates from cancer.Ìý So individuals who are fitter have improved survival rates at five years and at 10 years and this is even when you control for other risk factors such as obesity or smoking.

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Porter

Denny, do we have any idea what the mechanism may be?

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Levitt

Well there may be several protective effects of exercise and fitness.Ìý In the first instance individuals who are fitter are likely to be more able to tolerate some of the cancer therapies.Ìý So first of all major surgery is common as a treatment in most cancers and we know that individuals who are fitter are more likely to survive major surgery and are less likely to have complications.Ìý Also individuals who are fitter are more able to tolerate chemotherapy and there are some early suggestions that individuals who are fitter have less toxic side effects from chemotherapy.Ìý The specific biology underlying this protective effect is still being studied very actively currently, there is some suggestion – we know that exercise is anti-inflammatory, by which I mean it damps down our immune response in the long term and we know that in the long term having chronic inflammatory processes increase the risk of cancer coming back and reduce the risk of survival.Ìý So it may be that there is some interaction between cancer inflammation and exercise but that is very much at the research stage at the moment.

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Porter

Most people will see exercise or being active as an important part of healthy living but often when people get ill, whether it be with cancer or with other conditions, they tend to think that rest is very important and we probably do too little, do you think that’s a problem that needs addressing?

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Levitt

Absolutely, I very much believe that.Ìý I think it’s very important that we tell patients that even if they have a diagnosis of cancer rest is not the answer, being active is the answer.

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Porter

Because many people might think that if you exercise or push yourself too hard trying to get fit that might have a knock on impact on your general health, possibly your immune system, but what you’re saying is that we don’t think that’s the case?

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Levitt

We definitely don’t think that’s the case and the advice about that has changed in the last 20 years as a result of this increasing evidence base suggesting that exercise is beneficial.Ìý There were concerns previously, exactly as you suggested, that if you’re unwell you should rest and that will help you recover but it actually appears to be the contrary in fact.Ìý Movement and exercise and mobilisation early after either surgery for cancer or during treatment with chemotherapy can improve your long term outcome.

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Porter

You seem to be suggesting that in many respects exercise is something of a panacea?

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Levitt

Yes I think you’re absolutely right and if someone invented it as a drug therapy I’m sure it would be extremely popular.

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Porter

Dr Denny Levitt who certainly leads by example having, among many other things, climbed Everest with her husband.

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Inside Health listener David Heathcote may not have scaled such heights, but he is certainly determined and has been in touch to ask for guidance on how hard he should be exercising?

Heathcote

Hello Mark, David here.Ìý I’m a 66 year old retired science teacher.Ìý I’ve come to the idea of exercise fairly late in life but I want to keep my health and fitness now for as long as possible.Ìý I like to concentrate on cardio work in the gym, I like treadmill running because I find that’s easier on my joints and I’m trying to extend my time and my speed progressively.Ìý The question is how do I know when to stop?Ìý So Mark, how else can I push myself without actually killing me?

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Porter

Well to answer David I am joined by Sanjay Sharma who is Professor of Clinical Cardiology at St George’s, University of London. ÌýSanjay, David’s obviously enthusiastic but how hard should he push?

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Sharma

I think the answer to how intensively one should exercise depends on how much they’ve exercised in the past.Ìý If someone’s been exercising all their life since youth the intensity doesn’t really matter as much because the chances of them having anything particularly wrong with them are quite small.Ìý But if people are exercise naïve, say, for example, you’ve got someone who’s 45 years old and decides that they’ve become a little bit overweight, are leading a very sedentary lifestyle and want to make changes then I would say that provided they don’t have any symptoms of cardiac disease, such as chest tightness or breathlessness that is disproportionate to what they’re doing or a family history of cardiac disease then I would say that they should exercise to a point, initially, that they are just about able to hold a conversation but not sing properly – that would be a crude method.

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Porter

Let’s look at the risks of doing too high an intensity because one of the things that’s been in vogue recently is high intensity training where people, like David, might do 30 seconds flat out on the treadmill followed by a couple of minutes of gentle jogging and then repeat the process and they are pushing themselves quite hard, what could go wrong if you’re doing that?

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Sharma

The big concern is is someone sitting on a quiescent heart problem that may show itself during the stresses of exercise, such as the surges of adrenaline associated with physical intensity.

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Porter

And by a sort of sleeping heart problem is this an electrical abnormality?

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Sharma

It could be an electrical abnormality or a structural abnormality but as we grow older this could be an abnormality that’s been acquired from ageing and lifestyle such as longstanding high blood pressure or hypercholesterolemia that individuals may know nothing about because these things don’t actually cause symptoms.

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Porter

Furred up pipes.

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Sharma

Absolutely.

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Porter

David mentioned in his email to us that he regards it as bad form to keel over on the treadmill.Ìý I just wonder how common is it for people to run into trouble when they’re exerting themselves, for instance on a treadmill in a gym?

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Sharma

It’s relatively uncommon, I’m only giving you data from studies in athletes.Ìý Let’s just give you some figures.Ìý If we look at sudden death in say our football players that play Saturday and Sunday league, who are aged under the age of 35, then death rates are about one in 50,000.Ìý And if we look at marathoners, let’s use the London Marathon data, then the risk of sudden death is about one in 48,000.Ìý So death rates are generally low in people who have been exercising regularly.Ìý Now the big question is what about the exercise naïve individual who is starting to exercise out of the blue?Ìý And the only sort of information we have there is from the Rhode Island Jogger Study that suggested that death rates in casual joggers who have been exercise naïve is considerably higher and it’s about 13 per 100,000.

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Porter

But it’s still pretty unusual though isn’t it, I mean you get this impression – probably the media – people always hear the stories of somebody dropping dead in the gym or on the squash court.Ìý I mean as a jobbing cardiologist when you’re working I mean do you see these people coming in or is it a rare occurrence?

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Sharma

Well put it this way, as a cardiologist working in one of the busiest cardiology departments in the country, the vast majority, I’d say 99% or more, occur in people who don’t exercise, we see very few exercise related sudden cardiac deaths.

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Porter

Professor Sanjay Sharma talking to me earlier.

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And for the joggers and runners among you, Sanjay reckons the sweet spot for maximum reward in return for minimum effort -Ìý in cardiovascular terms at least -Ìý lies around training for about 2-2.5 hours a week, at speeds ranging from 15 minute miles, to around eight minute miles for the more fleet of foot.

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And talking fleet of foot, Margaret McCartney is still here – as is Inside Health listener David Heathcote who is on the line from Nottingham – David was that helpful?

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Heathcote

Yes indeed.Ìý I was greatly encouraged.Ìý I’d always suspected that the most important bit of exercise was the first step through the gym or the first step out of the garden gate to start running and from what I’m hearing from Sanjay that’s basically it.Ìý Get out there, be sensible and start doing the exercise, that’s the important thing.

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Porter

Or I suppose the other way of looking at it, David, is that people like you perhaps worry a little bit too much and it’s the people who are doing nothing who should be worrying more.

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Heathcote

Yes, indeed.Ìý And there’s a great feeling of camaraderie I think amongst joggers, cyclists, people in the gym, it’s a case of yeah you nod, nice to see you here again this week and that keeps us going.

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Porter

Well thank you very much David.

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Margaret, that point there that we concentrate too much on the safety of exercise when perhaps we should be worrying more about the dangers of doing too little.

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McCartney

It’s very interesting and I think we get this kind of thing a lot, that we tend to sometimes worry about the wrong things.Ìý And exercise is one of these almost invisible things and I think particularly as a GP I do ask a lot of people about exercise but it’s not obvious whereas a medication list is very obvious.Ìý And sometimes it’s much easier for a doctor to prescribe a tablet rather than to say to someone okay what would really help you is a little bit more activity.Ìý And of course it’s not all about high stress running or jogging, there’s lots and lots of types of exercise that are really good for you.

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Porter

What do we know about how much people are doing on average across the country?

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McCartney

Well probably not enough, so I’ve found one review that have suggested that people in the UK aged between 65 and 74 only 20% of men and 17% of women are getting enough exercise and that falls after the age of 75 to only 9% of men and 6% of women.Ìý So really you’re unusual if you are getting what the NHS are recommending.

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Porter

Looking at that age group, I mean the other clichéd question you often hear about exercise is well is it too late for me now, I should have started much, much earlier.

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McCartney

It’s never too late.Ìý I’m a major optimist here – no, no never ever too late.Ìý There’s some really wonderful studies looking at the effects of exercise in elderly frail people, so the very people that you might think oh it might be quite risky for them to exercise and certainly no one’s going to recommend that someone goes off and runs a marathon for the first time without having done the relevant training over a period of time but the exercises that are concentrated on are strength, balance and some weight training even, as well as walking activities.Ìý And these do help to improve lots of things, not least mortality, as well as cutting down the number of falls and since that has quite often a devastating impact on people I think they’re really well worth considering.

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Porter

So Margaret, to sum up, basically it’s never too late, anything’s better than doing nothing and it’s possibly the best free medicine we’ve got?

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McCartney

I think it is but to me, you know, William Morris said don’t have anything in your house unless you know it to be useful or believe it to be beautiful.Ìý I think the same is true about exercise, it’s really worthwhile to look for something that you actually like doing or is functional – gets you to work – because it’s the long term that is important here, it’s not so much about what you do in the first couple of weeks of January, it’s what you really enjoy doing and will therefore keep doing hopefully forever.

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Porter

Very true and thank you Margaret, we must leave it there. Just time to tell you about the next programme when I will be asking how low to go when it comes to treating high blood pressure. And, while no mention of the strike today, next week we question the science behind the weekend effect in NHS hospitals – would a truly seven day service really make weekend admission safer?

ENDS