Here I take another look at exercise in a blog that first appeared on Wigwam Cancer Support Groups blog - a Yes to Life charity project.
There are many people that embrace and love a lifestyle rich with exercise, but there are many, who like me, have never liked the word or the idea of ‘exercise’. The US ‘Peanuts’ cartoonist Charles M. Schulz once said; “Exercise is a dirty word. Every time I hear it I wash my mouth out with chocolate.” Yes give me a bar of that organic raw 90% cacao chocolate any day.
It is clear that I’m not alone in responding to the word with a negative reaction. Was it an experience at school? Or perhaps something to do with the picture of exercise in gyms with sweat, lycra and dumbbells? For some exercise might be associated with a negative reinforcement; we exercise to reduce shame around our health or weight. Yet shame is linked to poorer motivation and wellbeing and can lead to repeated failures to embed more activity in our lives. For others it might be pain or not having found the ‘right’ exercise?
There are no doubt many reasons for a negative view of exercise - and some of those will be contributing and reinforced by the fact that for many of us, our lifestyles are becoming more sedentary. Our muscles, bone strength and density are much less than a hundred years ago. In the UK obesity affects more than one in four adults and one in five children (aged 10 to 11) while nearly two thirds of adults are ‘overweight’ and one third of children.
A 2015 report by the Academy of Medical Royal Colleges, 'Exercise – the Miracle Cure’ (i), said, that regular exercise can assist in the prevention of strokes, some cancers, depression, heart disease and dementia, reducing risk by at least 30%. Many of us know this on some level, yet we still find exercise hard.
Cancer and exercise
You can see in the box below a whole host of benefits from exercise not least significant reductions in both cancer progression and reoccurrence. It is worth looking at some of the research and there is lots of it. Back in 2012 Macmillan published an evidence review entitled; "The importance of Physical Activity for people living with and beyond cancer”. To give a flavour it is worth noting three research papers, all had the highest level of research for a patient-oriented outcome (ii) and since then the evidence has only grown.
Some of the research
Breast cancer: a systematic review of six studies indicated a reduced mortality risk of 34% related to leisure-time physical activity. A subsequent review supported these findings. Results of the two largest studies suggested that women reaching the equivalent of the recommended minimum levels of physical activity (ie 150 minutes of moderate-intensity activity per week) had over 40% lower risk breast cancer-specific mortality, and breast cancer recurrence, compared with women active for less than one hour a week.
Colorectal cancer: results of two studies suggested that the risk of cancer mortality was reduced by about 50%, by performing the equivalent of six hours of moderate intensity physical activity per week.
Prostate cancer: findings from two studies indicated a lower risk of prostate-specific mortality of approximately 30% and a lower rate of disease progression of 57% with three hours per week of moderate intensity physical activity (eg brisk walking).
Exercise needs to be a higher priority
One of the things that now so surprises me, following my diagnosis, was the complete failure of my medical team to talk about exercise - and from talking to others this is still the experience of most people. Researcher, exercise physiologist, and chair of the Clinical Oncology Society of Australia (COSA) Exercise Cancer guidelines committee, Dr. Prue Cormie, has said - what many others have also said in different ways: “If we could turn the benefits of exercise into a pill it would be demanded by patients, prescribed by every cancer specialist and subsidised by government. It would be seen as a major breakthrough in cancer treatment.”
There are over two million people living with or beyond cancer in the UK. Many of those have never been told about the huge impact exercise can have on their diagnosis. It is time this was made a priority by our health services. Many other countries are ahead of us, like Belgium where when you are first diagnosed you get taken down to the gym for an assessment and tailor-made plan. While in Germany after an operation patients get proper rehab - indeed they call it ‘die Kur’ literally ’the cure’. Love that!
How much is enough?
There is considerable debate about the definition of exercise and how much is enough. Macmillian have a useful general guide on ‘Physical Activity and Cancer’ (Jan 2019). Their chart (see right) is a good place to start and includes details about the weekly 150 mins aerobic activity, muscle strength, balance and stretching work(iii). However it is important to get advice as I was merrily increasing my aerobic exercise only to find many months later that strength exercises are critical for improvements in some cancers. Why did no one share that information?
There is other interesting and growing research; here are some I found interesting:
High Intensity: The benefits of short bursts such as 2-4 minutes, of high intensity exercise(iv). A 2016 Canadian study looked at previously sedentary individuals who did strenuous exercise three times a week for 12 weeks; they did bouts for ten mins total with only three twenty-second episodes of flat-out exertion. These people were found to have similar improvements compared to those who exercised forty-five minutes a week for the twelve weeks.
Rebounding. Chris Wark, of Chris Beat Cancer, notes that ‘rebounding’ (bouncing on a mini-trampolines) can give those with cancer some of the best exercise as it is not so hard on knees and also pumps the lymph system (v). I can actually quite enjoy this!
Before and after treatments. In Gloucestershire for the last four years, a number of us have been working with the health authority to try and enable more people with cancer to have access to information and support around exercise (vi). We have seen an exercise rehabilitation project start to roll-out and now at last a prehabilitation project is being launched (vii). This is where components of rehabilitation are introduced to patients prior to undergoing intensive medical intervention in order to optimize function and improve tolerability to the intervention. Both these projects are small and miss many people, but are a start.
During treatment. Some exercise during radiotherapy and chemo seems to significantly improves outcomes (viii). Indeed even pharmaceuticals are getting interested as some of their chemo drugs seem to be working better when combined with exercise. One study I found fascinating was at the University of North Carolina where they have found that curative chemo caused an increase in molecular age that was equivalent to fifteen years of ageing. Incredibly exercising is being found to neutralise this ageing impact from chemo.
Finding out more? One of the best videos I’ve seen for those wanting a great overview is the 'Industry-Presented Webinar: Exercise as Medicine for Cancer’ with Professor Robert Newton (ix). While those wanting a general introduction they need go no further than a previous forum on Wigwam with Lizzy Davis (x). Certainly is well worth getting advice for your own particular situation - indeed just as too little exercise can be a bad thing so can too much exercise.
Being more than an active coach potato?
In recent years research suggests that how much time we spend sitting is likely to be just as important as how much time we spend exercising. There is even a new term to describe those who exercise, but spend the majority of their days being sedentary; 'active couch potatoes’. A couch potato is someone who prefers to sit around and watch TV, this new term, an active couch potato, is someone who is inactive for most of the day, but manages to get in their 30 minutes of exercise most days. No doubt many of them (like I have been) are seated at desks for large parts of the day plus seated commuting, having meals and then watching TV at home.
Over the years, many studies have looked at the lifestyles of people in 'blue zones' where people live the longest in health. Researchers found various important factors including not smoking, a sense of belonging and purpose, eating a predominantly plant-based diet, but interestingly, exercise was absent in many cases. Further research has indicated that it is being sedentary that is the problem and that key to health is sustained, low-level activity (xi).
The Lancet in 2016 found that “high levels of moderate-intensity physical activity (ie, about 60-75 min per day) seem to eliminate the increased risk of death associated with high sitting time”. While it also seems that aiming for 10,000 steps a day is a good idea, but 15,000 better resembles the distances likely covered by our prehistoric ancestors, and some of those ‘blue zone' centenarians.
The World Health Organization (WHO) have now identified physical inactivity as an independent risk factor for chronic disease development, and it is estimated to now be the fourth leading cause of death worldwide.
Update 21/01/23: Positive news report here that a small piece of research indicates that 'a five-minute light walk every half-hour was the only strategy that significantly reduced blood sugar levels, reducing the blood sugar spike after eating by almost 60 per cent compared to sitting down.'
Visualisation
Have you come across Dr David Hamilton’s blogs (xii)? I so like them - and his new book 'Why Woo-Woo Works' (Sept 2021) is also excellent. One of the pieces of research he quoted that I particularly like looks at visualisation and how the brain doesn’t distinguish real from imaginary. One famous Harvard University study compared the brains of people playing notes on a piano with the brains of people who imagined playing the notes. The region of the brain connected to the finger muscles was found to have changed to the same degree in both groups of people, regardless of whether they played the keys physically or mentally. In another study imagining flexing the little finger for 15 minutes daily for 3 months was shown to increase muscle strength by 35%.
Sports players have utilised this approach of imagining to good effect to increase muscle strength. The technique is also now seen as a ‘viable intervention’ to help people recover faster from a stroke. As David Hamilton writes (xiii): "The benefits rely on the fact that when a patient visualises movement, the brain processes it as if they really are moving, and so imagined movement becomes like extra physical practice as far as the brain is concerned”.
I am guessing imagining can’t replace the importance of movement but it sounds like it can certainly enhance and can probably play a key role in recovery after treatment?
One more study of interest comes from 2017 looking at individuals who thought they were less active than other people their age. Incredibly they were more likely to die, regardless of their health status, body mass index and more. This is the so-called negative placebo effect, that Hamilton also writes about. So even when those perceptions are in our head this impacts on our health.
Our relationship with exercise is complicated
I started this blog with the suggestion that exercise is something that many of us persistently struggle with - we also instinctively know it is important. It is not a fad or an add-on to our busy lifestyles, it actually keeps us alive.
So how did I start to to think differently and build it into my daily routines? I guess that rather than seeing exercise as a challenge to fit in with my busy life, it was time to view it in what I was already doing. When children run and play in a playground they are not thinking about aerobic conditioning. It is all about having fun.
I’ve always enjoyed, gardening and regular walks, but now instead of meeting people for a coffee I will go for a walk together and have the coffee (can’t miss my espresso!), the rebounder has become a chance to catch up on podcasts while an exercise or yoga class has become a place to meet others - somehow in a group it all feels easier and more fun. My computer desk has a raiser that allows me to stand up in zoom calls, I no longer try to park nearest the shops I’m visiting and I take the stairs not a lift for my Mum’s flat. I can also perhaps thank my prostate for needing the loo more often; I rarely sit for as long as I used to without visiting the loo upstairs!
I guess there are dozens of ways we can incorporate more movement into our lives. A friend has one of those bikes that fit under a desk so you can peddle while sitting and working while another now has an electric bike to get to work on.
It has surprised me that much of the increased ‘exercise’ and movement has been easy-ish to fit with my life. I suspect one of the reasons for that is that I have taken on board a lot of what I wrote in a previous blog about changing or embedding new habits - in particular, one technique, ‘tagging’, where behaviours are tagged onto an existing behaviour. For example rebounding is now something I do every morning after brushing my teeth (xiv).
Lastly I seem to use the word 'movement’ more than exercise - they have different meanings but somehow movement has a softer, less threatening quality - 'almost lyrical’ as one writer suggested (xv). Anyhow this blog is already longer than I meant and it is time for me to go on one of those walks. Happy moving but don’t forget to also 'exercise' kindness to yourself….there may well be days when it is all too much.
Update 30.12.22: Great article on how to get motivated for exercise: https://www.positive.news/lifestyle/health/how-do-i-improve-my-motivation-to-exercise-10-science-backed-tips/
Notes
(i) http://www.aomrc.org.uk/reports-guidance/exercise-the-miracle-cure-0215/
(ii) Research has been graded using the Strength of Recommendation Taxonomy (SORT) which rates the body of evidence for a patient-oriented outcome on quality, quantity and consistency. This research quotes was all Grade A is 'Systematic review of RCTs (or cohort studies for prognosis outcomes), or high-quality individual RCTs/cohort studies with clear consistent results.’
(iii) https://cdn.macmillan.org.uk/dfsmedia/1a6f23537f7f4519bb0cf14c45b2a629/1656-source/physical-activity
(iv) High-intensity exercise interventions in cancer survivors: a systematic review exploring the impact on health outcomes: https://pubmed.ncbi.nlm.nih.gov/29210001/
See for example this research into prostate cancer: https://www.health.harvard.edu/mens-health/exercise-may-slow-prostate-cancer-growth
(v) Chris Wark video: https://youtu.be/1dgvg5hCar0
And his blog: https://www.chrisbeatcancer.com/rebounding/
(vi) http://gloscancerexercise.org.uk
(vii) Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC8765744/
(viii) Various examples in Pub Med including this one using exercise during radiotherapy treatment:
https://pubmed.ncbi.nlm.nih.gov/32074040/ and https://pubmed.ncbi.nlm.nih.gov/28189100/
And here is one with High-intensity exercise during chemotherapy inducing beneficial effects 12 months into breast cancer survivorship: https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6482129/
(ix) Industry-Presented Webinar: Exercise as Medicine for Cancer: https://youtu.be/mS7g9VVy-Pk
And a more recent video: https://youtu.be/1n-Z3LVT37I
(x) Scroll through to find link at: https://www.wigwam.org.uk/podcast-and-videos (You need to sign up free to get access).
(xi) https://www.theguardian.com/news/2019/jan/03/why-exercise-alone-wont-save-us
(xii) https://drdavidhamilton.com
(xiii) https://drdavidhamilton.com/real-vs-imaginary-in-the-brain-and-body/
(xiv) https://www.wigwam.org.uk/post/the-challenge-of-embedding-new-behaviours
(xv) https://carlospattersoncoaching.com/movement-vs-exercise-is-movement-better-than-exercise/
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