As a follow up to the last article I wanted to provide some information on how to combat heart disease with exercise. There are a couple myths worth dispelling and some very good science on what methods work best for people who are at high risk for an event or who are coming out of hospital, post event
Though nutrition and medication will move the needle much quicker than exercise, having the right approach will, without a doubt add years to your life. The benefits go above and beyond preventing or reversing heart disease. Many of my clients who have come to me after a long life of staying relatively sedentary are amazed at just how much better they feel on a day to day basis. For many of us, the daily achey, low energy struggle just seems normal and you don’t realize that it doesn’t have to be that way. This only gets worse as you get olde – the soreness turns into chronic pain, the “bad shoulder has new company in the “bad knee”, and all of a sudden you can predict rain with all of your joints yelling at you that the air pressure is changing.. It will not improve without some effort and so it is very important to foster appreciation for exercise. Playing sports is one way but often times we need some kind of functional exercise programs to fast track health and prevent or reverse disease. This is probably the biggest part of my job – creating an evolving program that is challenging, focuses on what needs work while emphasizing things that are fun and emphasize strong points so that it is engaging. I won’t be able to provide details on how to turn the following information into something like that for you here, its too much of an individual process. But this will be a good place to start.
Myth #1 – Continuous cardio training is best for heart health.
Cardio is important, you need to incorporate it in your routine for a total health approach but it is not the most valuable tool when concerned with heart disease, it is just one of them. One recent study (1) has shown that limiting your workouts to cardio – after already having had a heart attack.- did a poorer job in reducing risk of another cardiac event. Results showed that doing circuit training where you include resistance training with short intervals of high intensity cardio improved many more of the biomarkers linked to a risk of a cardiac event. Mixed training or circuit training study groups also had much lower waist circumference measures than the continuous cardio group. Visceral body fat is correlated to a significantly higher risk of heart attack and so this is an important factor.
Subcutaneous fat is less of an issue than visceral fat but both have a threshold before they become problematic. You can have extra body fat and still be healthy or you can have extra body fat and be at a higher risk of disease. Same goes for people who do not have extra body fat; being skinny does not equal being healthy. Often times the worst evaluations I have have seen were with regular or under weight individuals. But in general, obesity is linked to electrochemical issues in the heart and the best way to address this particular risk via exercise is to include resistance and high intensity cardio intervals.
Calories in vs calories out is NOT a universal equation for weight management and so It is the unfortunate reality that cardio does very little for weight loss. I and many others have spent years repeating this and yet the myth holds strong. Cardiovascular exercise does lower heart rate and improve blood pressure. Certain protocols will also increase your V02max which is the maximum amount of oxygen your body can use during intense exercise. This is a very good marker for health and longevity and something I encourage everyone to work on, no matter how old they are. But at the end of the day, focusing on cardio is not the only or best thing for heart health, especially for those who are at risk of an event, or are recovering from one.
Myth #2 – You need to start slow when at risk for heart disease or post cardiac event.
Mixed training or high intensity interval training has been shown to be safe for most people. Indeed the above mentioned study (1) compared continuous cardio to strength training mixed with interval training and showed that a high intensity mixed training protocol was safe, feasible and most effective for the study group. All of the participants entered the study post hospitalization for acute myocardial infarction and had reduced left ventricle function. The trial lasted 6 months and the results showed improvements in ECG and HRV measurements, peak oxygen consumption as well as reduced BMI and waist circumference. These are all important in reducing risk.
Another study (2) showed that resistance training as early as 2 weeks post operation was achieved without any significant pain or negative consequence. A broader collection of studies (3) suggests that most modern protocols are much too restricted in getting patients up to desired daily activity levels. Getting moving is part of what prevents heart disease and limiting that while at risk is a grave disservice to the public. That said, it is always worthwhile to have a plan of action which includes managing blood pressure, being cleared for exercise by your doctor and building a foundation before strenuous activity. Working with a personal trainer is highly recommended.
Overcoming anxiety of over stressing the heart
I know as well as anyone that most people aren’t psychologically ready to jump into an intense exercise program after (most likely) being sedentary for quite some time. This anxiety can be even more intense after having a life threatening cardiac event. The reflex is to not tax: the heart too much with exercise. But this just isn’t the case. NOT exercising is what is taxing your heart. You definitely want clearance from your doctor and you want to make sure your blood pressure is under control but once you are ready to move, it is imperative that you start.
If you read my previous article then you probably got the message of urgency I tried to impart. If you have not read it, then I want to make sure I get the message across here – you are your best advocate. You need to take control in preventing or reversing disease and part of that is to recognize that the older you get the closer you are to having a serious issue so seek out your best tools and use them. The meds will reduce risk, as will a favourable nutritional program but there is more you can do , and you should do it all.
Taking walks is fine and dandy and sometimes it is the best way to get used to moving regularly but by no means should it be considered exercise at least not for very long. Walking is a great way to reduce stress and keep extra active but I want to impart information that really moves the needle. If you are starting from absolute zero and if you are eating well then you will see a reduction of weight for a short while. You should know that It is most likely due to a change in eating habits and less from the walking. I do highly recommend adding walking to your day but it is not necessarily improving your actual heart health by any significant measure. Most general practitioners are not going to be reading sport science papers and most likely are not up to par with training protocols but they can clear you for exercise and then you can take control. If they are telling you to just walk 45-60 minutes every day then they are not giving you all of the tools you need.
As a coach, I want my clients to feel like they are safe and ready for the challenge and so, we often do start off at a moderate pace. It is important to prevent other kinds of injury when beginning an exercise regimen so we still need to work on basics. Not every session is high intensity. We build stability, work on functional movement patterns and slowly build strength and endurance. But as often as they can, they break a serious sweat. We’re not effing around. This is literal life or death.
Effort level is very important. The day to day average is going to waiver but consistently challenging yourself is where people often fall short. If it is uncomfortable (but still done correctly) then you are in the zone you need to make changes. For example, if you do 10 repetitions pf a weighted squat and all 10 are done without too much effort then you are not creating the struggle your body needs to adapt to harsher environments. Thats what training is – creating a harsh environment. and using the struggle to cue your body to adapt. All of that is achieved in the last few, increasingly difficult repetitions or in the last seconds or minutes of your interval. There are a number of ways to increase intensity while keeping things safe, efficient and effective. Once again I urge you to seek out a profession for some guidance.
Where to begin
My best advice is to get a proper evaluation. It is impossible for me to outline a program here that is one size fits all. Every program on the internet that suggests it will work for you without knowing what you need is 100% bullshit. If you can’t afford to have regular sessions with a trainer, thats totally fine but invest in getting an evaluation done and a set of programs that will evolve and last you several months. Avoid any trainer that is not spending at least a full hour doing an assessment. The eval should include posture assessment, stability, gait, balance, functional movement screen, body weight strength, cardio test and maybe a few free weight lifts. If you can find a trainer that can also understand your blood work and the general mechanics of your injuries and health condition that is also ideal. This is not an easy ask, so shop around! Anyhow, lets talk a bit about general program ideas..
Dr. Peter Attia likens cardiovascular training to a triangle where the base is your steady state cardio capacity (zone 2) and your peak is your high intensity capacity or your maximum oxygen utilization ability (zone 5). You want to increase the general area of the triangle- wide base, high peak. The general rule to do so is to break it up into an 80/20 protocol – where you spend 80% of your time working on your zone 2 and then 20% on your zone 5. This can look very different from person to person but here is an example –
You have 2 hours per week dedicated to cardio –
- 1.5 hrs should be zone 2 or steady state cardio – this can be done on any cardio machine, by jogging or uphill walking if you need to start slow. Intensity level – you should be able to keep a conversation going but it should be somewhat challenging.
- .5 hrs should be zone 5 or peak interval training. I would suggest by starting off doing any intervals that you find manageable like a 20/40 split – 20 seconds full tilt and 40 seconds slow or at rest.
Remember, while very important this should not be your only focus. In fact I would omit this completely at the beginning of any training program for people at risk for heart disease or post cardiac event. I would do something closer to the following set of guidelines and then work towards adding this into my long term programming.
Mixed Training protocol – based on the results of this study (1)
- 4 days of paired training sets (30-60 minutes depending on intensity)
- 1 cardio or plyomteric exercise interval followed by 1 resistance training exercise
- Example – 20-60 second sprint on the rowing machine followed by push ups or bench press.
- You can repeat this pair 3-5 times. The breaks, weights, sets and interval lengths all depend on where you are at with your fitness.
For long term programs focused on longevity, disease prevention and general fitness I will often suggest alternating days for resistance training and interval training. You can mix them as outlined above but depending on what you are focusing on in your fitness, you may want to hone in on one aspect for more time. For disease reversal I would stick with the mixed protocol though.
Stability Training – This is absolutely crucial to include, especially if you are getting on in years but I would add it to everyones program.
- 1 day per week of 45-60 minute s of stability work. Down the line this kind of work can be included in your Strength training days. As mentioned above, I would separate these days at some point once your health has stabilized. Off loaded weight bearing exercises are a great way to work on stability while building core and general muscle strength.
- Stability exercise example – Step ups, off-loaded split squats or lunges, etc.
Recovery –
Make sure that you include recovery days. Most likely, you will be starting off relatively slow but you will still feel it. New trainees have the potential of reaping the rewards more quickly than regularly trained people but they also suffer more soreness and are at higher risk for injury if not given the right instruction. So make sure you have 2 full rest days. On these days you can add some stretching, light yoga, breath work or meditation to really maximize your recovery and add benefit to the rest day.
Mindfulness / Mindset –
This is often a huge lifestyle overhaul for most folks dealing with heart disease. Most of us, including myself are not built well for drastic life changes. Exercise may feel like pure suffering – like torture and you may walk around feeling like a sack of grumpy potatoes but it doesn’t have to be that way! I can’t guarantee that this will change for you but I can tell you that the chances of it becoming something you love drastically increases if you take the time to appreciate the tough moments.
Take note of the kinds of thoughts you have while pushing through the challenging moments. Are they overly negative? Is it mostly just you bargaining with yourself to get out of doing it or stopping early before it gets harder? Are you calling yourself names? This is common at first but very important to fight against. Try and recognize that it is both normal and hilarious. It really is comedic how much we try and escape the things that will bring us more joy later in life or even later in the day! If you can begin to notice it happening and try and switch over to a more grateful space – it will make room for more enjoyment. You can have gratitude that your body is capable of doing these kinds of movements rather than being in a place of sedentary suffering. Try and hold in your mind that all the effort you put in in the very last moments of the challenge amounts to more time with your family, more time being able to be active in your community, more time being pain free and more time feeling strong and confident. Each time you overcome a particularly hard challenge don’t just have gratitude that it is over, stay with the fact that you made the effort and succeeded. Every time you overcome a challenge and sit with it, it rewires your brain so that you are more prepared for the next challenge – be it another exercise or something else in your life. This promotes real, physical changes in your brain.
On your rest days if you are doing meditation work, try and reinforce this by sitting with it: accepting the challenges ahead, maybe even looking forward to it! I promise you that it will make a huge difference in how consistent you will be in this endeavour and that might very well translate into more healthy time on this planet doing the things you love.
Good luck out there! And if you need help in your nutrition or training protocols please feel free to hit us up for in person (Montreal) or online training (contact info)
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