Psychiatry & Psychotherapy Podcast - Exercise for the Brain

Episode Date: December 9, 2022

Exercise is an integral contributor to brain health. Physical activity has been proven to slow the rate of cognitive decline. In this episode, Dr. Puder invites four guests to discuss the importance of incorporating exercise into mental health routines.  By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. All right, welcome back to the podcast. I am joined today with some residents, some PGY2s and 3, 1 PGY3, Dr. Sonia Dela Cruz, Dr. Sarah Alam, Dr. Manoshna Kandada, and Derek Linuto. All right, and we are going to be discussing a paper called the Association of Cardio Respiratory Fitness with long-term mortality. among adults undergoing exercise treadmill testing. This was a 2018 cardiology study, which is a little bit of a different genre for this podcast, but I think it is very important to discuss.

So maybe we'll start with Sonia de la Cruz. Sure. Do you want to just kind of like open up some of the basics of this study? Yeah. So basically this study was a, The retrospective cohort study, it took data from January 1991 to December 2014, and they looked at adult patients and stratified them into different groups for age and sex. And they, you know, group them into like low fitness, below average, above average, high and elite.

And they basically looked at how cardio-respiratory fitness correlated. or was associated with all cause of mortality. Yeah. So basically there was five groups. And how did they measure fitness at the beginning of this retrospective cohort study? Derek. So they took patients that have been undergoing exercise treadmill testing, stress testing? Right.

So basically they stick them on a treadmill test and see how long they can last. increase the incline, increase the speed, right? How many minutes they can last? And does anyone remember what age, the average age of the group when they started? I think that's important to talk about, to mention. 53? This is the mean. Mean was 53, yeah.

So middle-aged adults, right, followed them for, on average, 8.4 years, okay? So, Sarah, let's talk about just some of the basic, like, before they're trying to control any of the variables, just the hard data of what percentage of this large group. Like, we're talking about 120,000 people were in this study, right? So what percentage of the people died in the lowest performance group, the bottom 25%. Yeah. In the lowest performance group, 6,9404 people or 23% of people died in the lowest performance group. Okay. And what about the below average?

In the below average group, it was 10.6%. Okay. And in the above average? It was 7.3%. And in the high? 4.7%. In the elite? 2.6%.

Okay. Does that like, let's just discuss that real quick. Like, have you ever seen data where the all-cause mortality? was that big of a difference? No. No. It's mind-boggling. Like, okay, so this is the difference between the low-performance group to that elite

was like 1,000% difference. So to get from 2.6% all the way to 23%, that's a 1,000% change in all-cause mortality. That's amazing. Like, so, okay, so think about, um, so think about like statins. I looked at the best statin research I could find and like the all cause mortality decrease for primary prevention. Staten's like Lipitor, those kind of things. It's like 0.6%. Wow.

So this is, um, this is reducing death a lot, a lot, a lot more than 0.6% right? Now you can't compare them side to side, right? But it's just like one big study versus another big study. Like, you know, this is a good way to think about like magnitude of effect, right? Like how much of a magnitude of effect does something make a difference? Yeah, it's shocking. It's shocking. So, you know, if you think about like all of the physiological things that are going

on with fitness, you know, metabolic health. Actually, maybe we should integrate the paper, the second paper a little bit with this, because I can ask you guys to kind of break down, what are some of the things that are going on that make a difference? Yeah, so anyone have anything off the top of their head from the second paper? Can someone introduce the name of the paper? Sure. So the second paper that we looked at is called the pathophysiological mechanisms, explaining

association between low skeletal muscle mass and cognitive function. Okay. So basically people, like, what happens when they don't have strength to their cognitive function? And like, what are the mechanisms that are going on between those things? Okay. So, yeah, the paper goes on to talk about cognitive impairment associated with low skeletal muscle mass. And then it goes on to talk about different things such as systemic inflammation, insulin metabolism, protein metabolism, mitochondrial function, and all these things that ultimately can decrease cognitive functioning. Right. So it's like if there's one thing that I have heard in studies, the more studies I read that makes the biggest impact that can slow the rate of cognitive decline,

It's like being physically fit, strength training, cardiovascular fitness. And so you just listed off a bunch of different things that are manipulated by being fit. Right. So what did you guys think of this idea in the paper that muscles are actually like an endocrine tissue? Was that kind of something that came through? Am I making that up? Did I get that right? Yeah.

Yeah, definitely. A neuroendocrine tissue? Is that? Yeah. I think I agree with that because, as we know, that most popular exercise studies kind of focus on adipose tissue and how it increases inflammation and how if you were to decrease adipose tissue or the amount of fat molecules, you would actually decrease inflammation,

which the study kind of targets. It basically says that when you have an increase in inflammation, you're also secreting like the cytokines that can cross the blood-brain barrier, which can lead to neurodegeneration and kind of exacerbate cognitive impairment, versus when you're exercising more, you're kind of decreasing the inflammatory markers and kind of preventing that inflammation from entering the brain. Very good. Yeah. Yeah, what are you thinking? So one of the parts that I really was struck by was that not only are we decreasing inflammation,

but that the muscles actually lead to increase in certain transomor or transmissible. that they dub myokines, that they even link to when certain myokines are increased in the central nervous system, it can lead to BDNF increases, which can increase neurogenesis and synaptic plasticity. Right. So you have BDNF, which if you look at a lot of different psychiatric medications, why they work, BDNF is like one of those things that we're seeing common, like with SSRI. ketamine, and exercise, right?

So, you know, and there's other drugs as well that focus on and specifically exercise with how it increases the neuroplasticity, the brain that can change, which is why I try so hard with my patients who are in the IOP partial program to exercise while they're in the IOP partial so that they can get that full neuroplastity.

effect from the therapy. And, okay, so what about the insulin? Does anyone remember the insulin and how that relates to things? Yeah, so basically as you age, you actually develop insulin resistance because the number of insulin receptors you have

decreases, and when you're in a state of hyper-insulinemia and you have less receptors, then basically the number of pathological markers in your brain increases. some of these being the tau phosphoryization, as well as just cerebral vascular damage at the microvessels, as well as an increase in the alpha beta plaques that we see, which is why we don't want to be in a chronic state of hyper-insulamia.

Yeah, right. And we know from data that people with type 2 diabetes have like a higher risk of, you know, depression, anxiety, different mental health issues, right? So we know that. And this is just like another layer of that. We know that increased risk of cognitive decline, dementia. And so, you know, why not attack it at the root of the issue, which is sarcopenia, sarcopenia being low muscle mass, right?

Anything else jump out on the study, like that you're just kind of like it's on the... Yeah, I think it was really interesting to point out at the very beginning of the study. they mentioned how sarcopenia was noted to be like it was found three times higher in patients with dementia than those without dementia. And I just thought that was an interesting find to see how low skeletal mass actually correlates to decrease in cognitive functioning. Right. And to be fair, it's probably, often patients who develop dementia do not want to exercise as much, do not want to move as much. They're going to be less mindful to engage

in physical activities that they enjoyed in the past. What struck out to me was kind of the concept of contracting skeletal muscle behaving like an endocrine organ. Yeah. Because I think that's not something that I have thought about personally before. And then the concept of the myokines, you know, like the cytokines and the peptides that they release. And in the study, you know, they talked about how peripheral concentrations of BDNF are increased, because of muscular contraction directly. So you have increased BDNF, MRNA, and protein expression, and muscle tissue.

And that kind of just kind of boggles my mind. And then we have, like, a competing kind of force with pro-inflammatory cytokines that reduces, like, central BDNF expression. So kind of, you know, how can we take ownership, you know, of health and kind of influence factors, physiologically is by exercise because we can imagine like our muscle contraction releasing those myokines

leading to increased BDNF, leading to neurogenesis and increased cognitive function ability. Excellent. Yeah. So it's a neuroendocrine, it's like a neuroendocrine promoting tissue muscle. And so when I'm working with the elderly, I'm often thinking,

how do I get them exercising? I have one patient in particular who's older, who's fairly bedbound, and I've gotten her to start deadlifting. And I have a friend in L.A., and he's a physical trainer, and he will go to her house a couple times a week. And it's made a huge difference. It really has.

And it's such a pivotal and important part in the brain's functionality. Mm-hmm. You know? So. I think that what you did is incredible too because a lot of times we hear about like aerobatic exercise and that's usually like the go-to kind of like to do cardio and stuff.

And that deadlifting and like getting your musk and getting patients to do that too and incorporate that into our lives is it's a very cool next step too. Yeah. I like deadlifting and I like squatting because you can. and with a barbell because you can progress it and it also helps with balance. She's had issues with balance. And so if you can add like one pound for an old person,

you can add like one pound to the bar every time you do it. And so you can start really light, like broomstick light, right? And you can even reduce the range of motion when you start with someone who can't do the full range of motion. And then you can slowly progress it. And it's just like, you know, three sets of five, and you can add one pound each time you do it. There was a time where I couldn't do chin-ups. And I got like a bunch of bands from Amazon. And I figured out how to kind of increase the weight about a pound or two pounds each time I did it.

So I'd do like three sets of five every other day for about six months. And I was able to get up to doing chin-ups with like 20 pounds dangling from me by the end of it, three sets of five. And so it's just like very, you know, two times a week is sufficient. And it's just slow progression adding just a very slight amount of weight. And if you're working with a small muscle group like the arms, like less weight, right? If you're working with a big muscle group and you're a normal human being who's like in their 20s or 30s, you know, you could probably add five pounds like deadlift or squat. So yeah, it's just a very, very thoughtful way to progressively do it. And you should definitely watch some videos on technique and maybe get some coaching by a good coach.

And if anyone wants to connect with one, just reach out to me. I hope I don't get too many emails. And it's a great way to also do behavioral activation. And I think when you encourage your patients to do one little thing, you know, whatever it is that they're passionate about. and they do more and more of it. It gives them a sense of mastery and empowerment, and it kind of starts this cascade, hopefully, of them living out the values that they have in their life.

It's goal setting. Like, they're setting little little goals that each time you're hitting. That's encouraging. And they can see the progress. I think that actually, I'm glad you brought that up because it's not just a pure mechanistic change that's happening when you progressively exercise. it's like, I did this for myself.

I pushed myself. I stepped out of my comfort zone. I, you know, and that sort of behavioral, right, activation. If you look at a lot of CBT studies, they have exercise as part of the B, behavior. So they have cognitive behavioral therapy. The behaviors are often doing something physical, getting out in nature, going for hikes, going for walks.

I have a lot of people who reach out and they're like, what is the perfect routine? And I'll often start with like, well, what do you enjoy? Right? Because if you're like, if you love cycling and that's your thing, I'm not going to tell you to not cycle as like the majority of your exercise. Right? Or if you love running, I'm going to say, yeah,

maybe one or two days a week, strength training, but the majority of your exercise can be running, right? So I don't think, yeah, I'm not like overly rigid with the type of exercise. And you can see in the first study we looked at, it was treadmill test. So this wasn't just pure strength training. But a treadmill test does look at strength

because of the incline increasing and because of the intensity increasing. But it's looking at the overall mitochondria functioning, like how much essentially like as the watts that you're forced to produce increases like how are how long are you able to go so how effective are you at moving in such a way against a load which is both combination strength and cardio essentially um okay so let's um i want to jump back into the first study real quick and talk about the other comorbidities that they found in the hazard ratio.

Okay, so this is C. Figure 2C. Do you guys see that? Okay, so they broke things into hazard ratios. So remember I said that before you adjusted for any comorbidities, the hazard ratio or the change between the low to the high group was 1,000, right? Now that's a hazard ratio of essentially like, 10. Okay. If you control for the variables, what did the hazard ratio become? And what did they control for?

So it came to about five from load to elite. Yeah. They control for comorbidity such as smoking, coronary artery disease, diabetes, hypertension, and stage renal disease. So even after controlling for all of those things, right, which we know exercise in and of itself will de-grimony. your risk of coronary artery disease, diabetes, hypertension, it's adrenal disease. But even after controlling for all of those variables, it still was five, which means like 500% difference, right? Okay, how big was the hazard ratio on smoking? 1.4, much less. How about coronary disease? 1.29. Diabetes. 1.4? Hypertension. 1.21.

End-stage renal disease. 2.70. Okay. So think about the magnitude of those compared to exercise. Did that surprise you? It did. It did. You know what surprised me?

It's like, think about all the effort as doctors in medical school. That we focus so much on not smoking, reducing the risk of coronary disease, treating people once they already have coronary disease. disease, right? Treating people when they have diabetes, right? And the hazard ratio on those for all-cause mortality is significantly lower than exercise, which makes me wonder, like, why don't we have gyms attached to almost every primary care office across the U.S.? You know, like, why don't insurance companies just provide free gym membership, but not just gym membership,

like free personal training, right? You think about like, okay, if you have group-based personal training, like I go to strength training in the morning, there's like six of us or so that are like squatting, deadlifting altogether, there's one coach, right? Think about the impact of that

compared to other types of treatments which are super expensive. And I think one of the problems is is that insurance companies are often not thinking 10 or 20 years ahead of time. And so I think this is really going to take more of a national approach to medicine and reducing risk of death, population health, right? It's like an intensive, you know, it's like we spend so much money on the last two years of life.

Whereas like if they took that money and invested it a lot into, like the 50 years of life that precede that, I think we would have a much bigger bang for the buck, longevity. Especially with this paper, which talks about how the muscle mass associated with dementia and older adults, we know dementia. Like, caring for that in memory care units is extremely expensive as well. So even if this paper somehow, you know, if this shows that exercising can be associated with dementia, I know in the paper it also discusses how there's 55 million people with dementia, and as we age, it's predicted the number will double every five years.

So this can show, too, that how exercise can help be preventative towards a very prevalent and very expensive psychiatric condition that we have. Yep. It's going to be a bigger issue as well in a lot of highly developed countries who currently, You know, if you look at the baby diaper to adult diaper ratio, have you guys heard of that? Yeah. I have not. No? No.

It's a good way of telling if a population is going to decline. So when countries enter into that sort of high development stage, they have less babies. And so it goes down from like trying to have like six babies to like 1.6, right? So then the population starts to decline. but there's some nations that have a large growing body of old people and not as much children. And so you imagine like when that group hits, the dementia needs are just going to be huge, huge, right? I think it's also like noteworthy to mention that they said that, you know, a greater increase in exercise can also cause like this inverse relationship and all cause mortality, but also the impact that it has on your mental help. just because you're exercising, your physical health does improve,

but also your mental health, how you feel by yourself, how you yourself definitely also takes a toll for the better. Right. I mean, this is like, I've covered this before, but just to reiterate, I mean, there was a study, one of my favorite studies was they looked at Certraline versus three times a week cardio with groups, and they found that they were equivalent, equivalently affective. other studies have looked at hand grip strength and how there's like a the stronger the hand grip

the less likely they are to be have future episodes of anxiety and depression there's a huge effect size for strength training a huge effect size for cardio and it seems to be like those are separate drugs that you can give someone so if you add them both together it has a huge impact on depression anxiety mood disorders So there's, yeah, there's so many studies and I'm going to do a future episode on like just an update, a yearly update. I want to get done on like exercise and the new studies coming out because they're just always coming out. And it's just further proves the point, you know? And yeah.

So how effective are you guys at getting your patients to exercise? It's hard. I think it can definitely be challenging, but I think what I tell my patients is it's like take it, one day at a time. It's not going to be like you're going to be the rock, you know, overnight. So I think just take it one day at a time. Personally, when I exercise, I try to gradually increase because I do cramp easy and I do get sore. So I remind myself to stretch and me and Derek actually started playing badminton on the weekends. So I think if you can find a friend to go exercise, it makes it a lot easier. That's awesome. Yeah. If you, I think if you can combine it with something

that's fun, like team-oriented, like that's like a total plus as well. In sports, I playing anything in sports-related or game-related, do you almost forget your exercising? Yeah. For me, I love dancing. So not only is it like a form of self-expression, but I get good exercise out of it. And then recently, I actually started taking salsa classes. So then that's also like a social component.

where you get to meet people, you have friends, you go to social events together. So it's an extra reinforcer to kind of go. So for me that I've found that to be my thing for exercise. And with patients, I like to kind of explore where do they get their joy from. Because I think it really has to come out of them, like for them to express, you know, what are they passionate about, whether their hopes and dreams, like how do they envision a life of vitality for them and kind of tapping into that and taking baby steps,

kind of setting few goals, like, you know, some activity scheduling throughout the week. Yeah, that's good. Meaning, you're talking about, you know, like enjoying, connecting with new people, learning new skills, but also, like, moving your body, you know, in the dance And it's, yeah, when I was a medical student resident, we used to go salsa dance all the time. Don't ask me to break down my moods after.

I was just there to give people a sense of humor. Yeah, do you have any exercise goals? Yeah, yeah. I go to the gym like three, four times a week. And the other days I walk. as a stress relief. I think that with patients too, it's like we've all talked about, like, you know, meet them where they want to be.

But I also think for, because when I went to your last talk, where we talked about this a little bit, I tried incorporating with some patients. And I found that the patients who may be a little resistant to medications or want to try the more, like, organic route, this was a great in between because it still felt like we're, you know, we always wanted to try to do something. And then the patient also feels like you're listening to them. Like maybe there has been some medications, and this is like the first step of them trying to meet a goal in psychiatry. So, yeah, I've really found in that population as well that this is useful.

And then it's a great adjunct to medications too. I feel like when we learn in med school a lot of times, a lot of treatments, whether it's for hypertension and diabetes, the textbooks and what we learn and the, you know, the PowerPoints all kind of will say like a little, at the very very, top, the very beginning, they'll say like, oh, lifestyle modification, and then they go on to the actual treatments we need to learn. And it's just kind of blown over. But, you know, I think, you know, with these studies, we're learning that it's not something to blow over. Like, it's, you know, the magnitude's huge. And I want my listeners to, like, not just think, like, oh, okay, I'm going to start to talk to my patients about it. No, I want you to think, like, what are you going to do? How are you going to sort of find joy in moving and exercise and strength training and really see it as like a

journey. Like, you know, it's a lifelong value, right? Of getting fit, staying fit. You're going to be sick less often. You're going to have better cognitive function as you age. You're going to live longer, you know, see your grandkids, great grandkids, be less depressed, less anxious, have less stress. I think about the way that we catabolize stress is impacted by not just like, are you exercising in the here and now, right? But have you been exercising strength training for a decade before that really stressful thing happens? So, you know, because essentially when I looked at, and I've done some lectures for medical students on like,

stress, a very simple way to think about it is we only have one way that stress gets triggered and gets impacted and floods us with like catacolamines and, you know, aldosterone and, you know, we retain salt. And it's like we, you may get puffy even a little bit when you're super stressed or, you know, like all of this stress system is triggered both by physical and psychological. So if we train the physical over time to progressively handle stress better, then it's like it also trains the psychological. Okay. So there's like an overlap in how we handle stress. Yeah, I definitely agree with that point. I think when you're training your body, you're definitely training your brain. Also, when you said earlier, how you gradually increase when you're exercising and setting those challenges for yourself.

I think you're also conditioning your brain. Like, I could do more. I want to see myself do more. Yep. Right. Yeah. So it's like, it's hard, but then maybe there's value in doing something hard. I was just thinking when we talked about the different variables that we talked about, different comorbidities, like smoking, diabetes, hypertension, not all of them.

We know there's a genetic predispitist to some of them. But for some of them, like smoking with obesity, hypertension, depending on a lot of this can be like if you're, doing something in habit. Basically, I feel like all these, like, kind of how we talked about, like, how they talked about with bad men and, like, group helps a lot. Like, a lot of these, like, it becomes a habit. Like, smoking becomes a habit. Eating, like, if you're, the way you eat is a habit as well.

Like, your diet is a habit. Smoking is a habit. And same thing with exercise is that this is a habit. It takes, you know, it's something that takes a while to get used to in this routine. Like, with all of us, when we stop working out, it's hard to get back in that routine. So I think that's also important to know, too, that there's, just like with our mood, it's going to fluctuate when we're able to keep these habits. But hopefully over time, it just becomes part of our lifestyle and not, you know, something

that we get accustomed to. So I think a big thing that I learned from this, too, is a lot of these variables are habitual. And we just, you know, have to be aware of that and kind of set that goal that, even on the hard days, that we need to make this a habit so that in the long run, like you said, 10, 20 years down the road is when we'll really try to see those long-term effects. Yeah. Yeah, I think that's really important is like what are the small habits? Like when I talk to someone about starting exercise, let's say they haven't been going for a while to the gym,

like the first thing that they want to do is get back to where they were when they like left off a couple years ago. and if you're a resident and the last time you worked out probably was like pre-medical school you're just not going to do what you used to do like let's let's be honest like I'm not training like I was when I was in college like it's just impossible um I used to do like an hour on the rowing machine now I do 20 minutes to half an hour if I'm like really pushing myself it's like it's like so when you and when you start up again maybe you do 15 minutes so I tell a lot of people, hey, when you hit the gym, you have 15 minutes. Get as much as you can done and leave and just do 15 minutes. Or like if you're a medical student and you're super busy, just when you wake up

in the morning, put your shoes on and set your timer for like 10 minutes and just see how far you can get away from your house in 10 minutes and then run back. You know, simple is better, repetitive is better. you know, can you get a group of people to work out in your garage? Can you get a group of people to go to some workout class and do it together and have it be repetitive, right? Yeah, yeah. I think it's also important to have grace for yourself and patience because I resonate with what you just said. Like, I used to do martial arts and I tried doing it again recently. and I just realized how my physical ability has declined over time.

And it's really frustrating because you remember what you could do and being, you know, usually medicine attracts type A people and you're very goal-driven and you want to get results quick. That, you know, it kind of makes that blow even harder. So then you kind of have to backtrack and realize, you know, it's okay. Like, you know, it's a process. There's grace for you. and start from the beginning and gradually go up again.

And there's no rush to things. Yeah, I'm always like, it's like I get very motivated and then I try to like lose weight while I'm starting to work out again. Which like those don't go well together. It's actually better to stay the same weight or maybe even gain a little bit of weight while you start to strength train. Yeah, so it's like we get in these cycles of super motivated. let's do something.

And then it's like, yeah, try to lose weight while you're lifting. It's like good luck. It's like so miserable. It's the hardest thing ever, right? So think about things like that in like phases. Like, okay, I'm going to like stay the same weight but get a little bit more in shape. Don't, it's like people can also get obsessed with like how much they weigh and they're like aesthetics and what they look like. And it's like, no.

Like I'm telling you from this data as this is doing it for your brain. You know, and that's the way I like to think about it's like I'm working out for my brain. That's awesome. Yeah. Should be a new motto or a slogan. I'm working out for my brain. Yeah. You're doing salsa for your brain.

Yes, neurogenesis, BDNF. Okay, yeah. Is there anything the big from these articles that we did not discuss that you wanted to make sure that you put out there as like a takeaway that you had? I think my biggest thing, kind of more big picture macro of the one article just, you know, talking about how like muscles can be like endocrine organs and everything was just how interconnected everything can be. We're so trained to thinking like mind and body or brain and body are separate. There's a blood brain barrier. Nothing crosses. And like even the all the mechanisms they show all tend to be, you know, they admit that they're all interconnected.

and just one thing can affect another. So to me was just kind of any one part of our lives that we improve kind of improve everything. Yeah. When it talked about what decrease in skeletal muscle mass and cognitive function, how we've been discussing, and the different IOL6 and cytokines, I think that's just a really exciting time for dementia awareness,

especially because of all these new medications coming out for preventative medication. So I just, this article got me thinking that maybe in the future they'll have like different types of cytokines or different inflammatory markers. I'll be related to this that in the future can potentially like help with preventative medications. I mean, also like this paper shows that one of the ways to help prevent, you know, dementia can potentially be exercised.

So I think that's also, you know, if you're more prone to it or you have family history, that it's also a great motivator to to start. you know, working out more and yeah. Yeah, I doubt, I doubt that there will be one drug that prevents Alzheimer's that they figure out. Because, I mean, just look at this, like there's so many different things going on with strength. And if you look at the all-cause mortality data, it's like there's such a big impact on metabolic function and longevity. So I just, I don't think that there's ever going to be a medicine that beats exercise. There's never going to be a pill that you can take that beats exercise.

And a well-thought-up, progressive, you know, habit, right? I just don't think there is going to be. So hopefully this ages well. Any, any? Oh. That's good. Dr. Cantata, any takeaways? I was going to agree with Dr. Allum with her advice on exercising and improving cognition.

I actually just finished my geriatric psychiatry rotation, and that was what he recommended as well. He said if there was one thing that can help with, I guess, progressing with dementia, it's that exercise can actually prevent cognitive impairment, at least slow it down. Yeah, yeah. Dr. Dela Cruz, did you have any other takeaways? No, not really. I think the most impressive thing that I've seen from these studies is, you know, that difference in the hazard ratio and just how much exercise really can do for us personally

and for our patients and how, you know, I think it would be really beneficial to think long-term that, you know, an ounce of prevention is worth more than a pound of cure and whatever little impact that we can make in our daily lives and talking to our patients, you know, it's cumulative, it's additive. And if we all do it, we can really make a difference. And I think, you know, that's a really empowering thing to do. And that's why we entered medicine. So it's, it's great to be, to use knowledge, to have knowledge like this and to be able to apply it to our daily lives. Okay. So in summary, like let's say every single one of my listeners, every one of my 40,000 people that probably listen to this in the next year. Take this seriously. And they,

over their course of their life, they each convince 1,000 people who are below average fitness, right? Providers will see many thousands of people over their life. Let's say they convince 1,000 that were below average to get to above average physical fitness. Now, we know that the low performing group, 23% died and the above average 7.3% died. So that's a 16% difference. Okay. So the amount of lives that would be saved, prolonged, would be 6.5 million. It's amazing. It's pretty cool. Nice.

It's pretty cool. So that's my hope. So take this seriously. Print out these articles for yourself. Read them yourself. Digest them. Rere them. You know, let them encourage you to talk to people about getting fit and staying fit.

and the important neuroendocrine tissue that we have, which is muscle. All right. We leave it there.