Episode 105

Robert Sallis, M.D.


We’ve all heard the term, “you can’t out-exercise a bad diet.”
But, in a recent conversation with my friend Dr. Bob Sallis, he made an interesting point: “Think about it, you also can’t out-diet a sedentary lifestyle.”
Many of us are searching for a magic bullet to improve our longevity. It could be a supplement, a medication, a superfood, and yet when it comes to enhancing our health span and preventing cognitive and physical decline, it turns out that exercise is one of the most potent tools we have at our disposal, more than nutrition, more than even sleep and medications.
Nobody knows that better than Dr. Robert Sallis. 
It’s a pleasure to have Dr. Robert Sallis back as a guest on this NEW episode of The Art of Living podcast Bob is a visionary physician who launched the groundbreaking initiative Exercise is Medicine in 2009 while he was president of the American College of Sports Medicine. 
Bob is a visionary physician who has been at the forefront of discussions about staying younger, longer.
In today’s episode, we delve into the numerous benefits of movement, going beyond the obvious to explore lesser-known advantages that you may have never heard about, including the profound effects that exercise has on Covid outcomes. 
Bob was the lead researcher on a groundbreaking study that found a strong correlation between sedentary behavior and increased risk of hospitalization and mortality from Covid-19. 

During our conversation, you’ll discover:

• The pros and cons of Ozempic, a medication used to treat obesity, and its potential role in addressing the obesity epidemic

• The impact of income levels on physical activity, and the concerning physical activity divide in our country

• The benefits of being fit, no matter your weight. 

• Lifestyle changes so your healthspan and your lifespan match. 

• The brain-elixir effect of exercise on memory, and how it can enhance cognitive function.


Kathy Smith: Hi, I’m Kathy Smith, and welcome to On Health, The Art Of Longevity, where I bring you the latest research and information on how to live a healthier, more vibrant, more passion driven life. Okay. Many of us are searching for a magic bullet to improve our longevity. It could be a supplement, a medication, a superfood, and yet when it comes to enhancing our health span and preventing cognitive and physical decline, it turns out that exercise is one of the most potent tools we have at our disposal, more than nutrition, more than even sleep and medications. Exercise is a key to living a longer, healthier life.

And nobody knows that better than today’s podcast guest Dr. Bob Sallis. Bob is a visionary physician who launched the groundbreaking initiative Exercise is Medicine in 2009 while he was president of the American College of Sports Medicine. Now by introducing a new approach of focusing on lifestyle, [01:00] specifically exercise to extend your health span and to prevent chronic disease, Bob help really start the game-changing discussions that there’s a new approach to aging. So, I’m glad to have him back on the show. Bob, welcome.

Bob Sallis: Thank you, Kathy. It’s a pleasure to be here.

Kathy Smith: So, we’ve been friends for a long time, even skied together, we just mentioned it was maybe a whiteout the last time we were skiing or close to it, and again, one of my first podcast guests. So it’s always great to have you back. And before we jump into this topic, let’s just discuss two terms about longevity that keep popping up, lifespan and healthspan. And we know that lifespan, we’ve talked about it before, is a quantity of yours a person lives, and then healthspan is kind of the quality of those years. Now, I’ve watched you in your presentations talk about a concept called squaring off the curve. So can you explain that to the audience [02:00]and maybe with these terms and why health spans may be a more important indicator of the quality of our life?

Bob Sallis: Well, you know, I think that most of us, if we’re asked, we would pick quality over longevity, right? If you are living in a nursing home, you’re debilitated, that’s no way to live. I think we would all choose the quality over quantity, and ideally, you’d have both. But this, this whole idea of the geriatric curve, which is sort of a measure of your functional capacity with your years of aging, I think is really telling, and we know that while exercise may only help you live seven or eight years longer, someone who does regular exercise, they tend to maintain a much higher functional capacity for the years that they’re living.

And what can happen is when you are not active, and also when you make other poor choices, [03:00] you eat poorly, you smoke, other high risk lifestyle things, you begin to develop chronic diseases at an early age that impair that functional capacity. And what we see is people kind of enter into a state that we call deficient survival, where they’re sort of alive but not really living. And I think that’s something we wouldn’t wish on our worst enemy. If you look at people who are in nursing homes, who are on disability, one of the common denominators is they’ve led an unhealthy lifestyle, and chiefly among those been physically enacted.

Kathy Smith: Yes, and interesting you talk about nursing homes, but I start to see the changes in lifestyles that happen even starting in your fifties and your sixties and your seventies. So that’s an important to note, because sometimes we think, oh, that’s way off when things start to change, but I see people that their worlds start shrinking because they can’t anymore, or they think they can’t, and then they don’t.

Bob Sallis: I think the goal ought to be for all of us to die young, [04:00] but just do it as late as possible. I think that’s really what exercise can help you achieve.

Kathy Smith: Well, okay, so we were talking maybe about a month ago, and talking about how there’s so many discussions about what’s the right diet, should you be vegan, keto, paleo, Mediterranean, et cetera, et cetera. And there’s this term you can’t outrun, an unhealthy diet. You said something that really woke me up and that was, yes, but you can’t out diet a sedentary lifestyle. Can you explain that?

Bob Sallis: Yes, I think we have so much data that shows that exercise can eliminate or at least mitigate most of the harmful effects of being overweight and obese. And it’s interesting that if you look back on a lot of the studies on obesity, they did not control for physical activity. And I think you can’t rely on any study showing adverse health effects from obesity [05:00] that doesn’t control for physical activity. I think it’s very important to parse out the contributions of both of those. And we have so much data starting back, kind of one of the seminal studies was done by Andrea Dunn back, I believe in around 1995, along with Steve Blair from the Aerobic Center Longitudinal Data clearly showing that when you controlled for physical activity, increasing levels of obesity didn’t really affect mortality much at all.

And we’ve seen this in just study after study, and I think clearly diet and exercise are both important. It’s kind of ridiculous to say, one without the other, they’re obviously both important. But I think that we often put all of the focus on weight, particularly on BMI, which we know is not a great measure, and we don’t in turn put a lot of emphasis on being physically active, which is free and so easy. And especially now with some of these new drugs coming out, it’s a little scary that it’s all about getting a shot [06:00] every couple weeks, and that’s going to take care of it, and very little about the importance of maintaining physical activity.

Kathy Smith: So Bob, I know that obesity is such a big epidemic in this country, and now there’s all these drugs out there that supposedly are going to solve this epidemic. What do you think about it?

Bob Sallis: Yes, I’m worried that the focus is going to move to entirely pharmaceuticals, that the whole weight to deal with obesity is going to be to get a shot, and that’s all you’ll have to do. And people always want the easy way out. It kind of goes back to our discussions earlier about are you better off being fit and fat than skinny and unfit? It’s very possible to be skinny and very unhealthy, but I’ve never seen a person who is fit and unhealthy.

That is really unlikely. I think that’s the most important thing. And if we don’t couple using these medications that simply reduce your appetite, if we don’t couple those with exercise programs, I just think that [07:00] this focus on weight loss in this fashion is not going to improve health. It may help people lose weight, but I don’t think they’re going to get healthier just by doing that. You’ve got to combine it with physical activity.

Kathy Smith: Well, it’s pretty mind boggling, the drugs out there, and then is now WeightWatchers getting involved with selling these drugs now, or are some of the other companies going to be selling drugs, or did I hear that correctly or not?

Bob Sallis: Yes, I’m a little concerned about that. Recently, WeightWatchers announced that they had purchased a company that basically is a telephone medical group that you can get prescriptions called in, just do a little phone consult, and they’re going connect these people trying to lose weight in the WeightWatchers program with this company to simply prescribe them the drugs for weight loss. And I’m worried that they’re going to take even the emphasis off eating healthy and certainly off of physical activity, and you just simply go on Ozempic or one of these drugs or Wegovy or Saxenda, [08:00] the new ones that they’re injectables every week or two, and just, we’re going to simply focus on reducing hunger, and then let everything else not worry about, and I think we’re going to do more harm than good.

Kathy Smith: And there’s side effects to these drugs besides what you just mentioned, there’s other side effects, possible side effects.

Bob Sallis: Yes, a lot of GI side effects. We talked about the loss of lean muscle mass, that’s a concern. A good portion of the weight loss has to do with the loss of muscle mass in using these drugs, and so there are concerns. And I’ve been around long enough when we had the Fen-Phen craze and everybody was using that and it seemed to be this miracle drug, and then a year or two down the line, we begin to see all of these people with heart valve problems.

And my God, we had to stop it, and people that died because of long-term side effects, these haven’t been around long enough to really know the long-term effect, that worries me. They have very exciting potential, but I think right away people want to jump on them as a simple solution that they don’t have to do any work. [09:00] And we all know that when you don’t put the work in, oftentimes these benefits are not what we think they are.

Kathy Smith: Yes, I’m glad you’re jumping over to that because I think it’s one of my biggest pet peeves is that people do equate exercise with losing weight. Just within our culture with our infomercials, everything, and I’ve been a part of that, it’s like, you want to lose weight, you exercise, you want to lose weight, you diet. And yet, through the years, and especially the last 10 years, the studies that have shown all the other benefits of exercise, which I’d like to dive into a few of them, between lowering stress, and I’m going to throw it back to you because you have a biggie that I want to talk about that you came out with last year. But there’s lowering stress, there’s bone density, of course, lowering risk for chronic diseases, there’s stability, there’s falls, there’s mitochondria action that helps improve your use of oxygen. [10:00] And I’d like to hear more of your list of benefits, but I’d like to also, if you wouldn’t mind sharing with the audience, the studies that you were involved in last year with regarding COVID and COVID outcomes.

Bob Sallis: Yes, it was fascinating. From the very beginning of the pandemic, I noticed the CDC early on had this risk factors for severe COVID outcomes. Meaning you’re either going to get admitted to the hospital or die should you get COVID. And these risk factors were correlated with an increased likelihood you would have these bad outcomes. And every single one of them, for the most part other than age and sex were associated with an unhealthy lifestyle. Chiefly a lack of physical activity, a poor diet. And so early on in the pandemic, it was actually in October, we pulled all the data from our Kaiser Permanente electronic medical record, and we have a physical activity measure, we call it an exercise vital sign. Every patient when they come in at every visit is asked two questions about exercise: [11:00] on average, how many days a week do you exercise? They click zero through seven.

The follow-on question is on those days, how many minutes? So we have minutes per week of self-reported exercise. We’re obviously looking for adults to meet the US physical activity guidelines of 150 minutes of moderate to vigorous physical activity each week. Well, at that time we had about a hundred thousand COVID patients, and we divided them using their exercise vital signs into three groups. Those who were doing 150 minutes a week consistently, those who were doing nothing, and then those who were doing somewhere in between, those three groups and. We whittled it down to patients who were adults who’d been with us at least a year and a half and had three or more exercise vital signs on their charts. So we got about 50,000 patients in our analytic cohort. And what we found is those who were doing regular exercise, should they get COVID, were almost two and a half times less likely to die from it than those who weren’t doing anything.

And it just made perfect sense, [12:00] and it was very frustrating that we had such a hard time getting the CDC, getting Anthony Fauci, all these people talking about COVID to mention that, oh, by the way, in addition to getting a vaccine, you need to be walking 30 minutes a day. And it’s just frustrating even now, it took a year for the CDC to put physical inactivity on their website as a risk factor for severe COVID, but they didn’t do a press conference, they haven’t made a big push about it, and now we’ve got over 25 studies showing the same thing that we showed in that first study.

And by the way, we’ve got three or four studies now showing that the vaccine works better if you’ll do regular exercise. So once again, we add this to the list of all the things that can help. And what’s interesting is when you controlled for physical activity, being overweight or obese, did not affect mortality at all in COVID-19, except when you got to real extreme BMI over 40 extreme levels of obesity, then there was some effect, but it was very much attenuated by being physically active.

Kathy Smith: So what you’re saying is that [13:00] if you are overweight and active, you’re probably healthier than if you are moderate weight or lean and not exercising at all.

Bob Sallis: Absolutely. The data clearly shows that. I think that the data is a bit mixed, but clearly the best thing to be is in the normal weight range. But what’s interesting is the BMI that has the best longevity is not 18 and a half to 25. like a lot of us are led to believe, it’s actually kind of around 25 to 30, has a lower mortality, and in fact, we get concerned about the lower ends, patients who are very skinny that have BMIs below 18, they’re at a higher risk. It’s kind of a U-shaped curve. So the ideal weight range, the ideal BMI would be around 25 probably in terms of just looking at longevity. So

Kathy Smith: Yes, and I’m sure, and I know for myself I think about that [14:00] as far as even muscle reserve, we talk about having a bank account and you put money in the bank so when you retire that you can withdraw that money and you’ll have enough for the rest of your life. Well, it’s really, I think, important for everyone, but especially women to understand to have this muscle reserve and having muscle on so that as we get older and as we start to lose muscle mass naturally, but then if you do get sick or you do have a fall or you do have an injury, the atrophy that happens, it won’t put you into that critical area where you’ve lost too much weight.

Bob Sallis: Right. And we all lose muscle mass as we age, it’s called sarcopenia, it’s very much like osteopenia, as the bones thin, the muscle also lessens. The problem is we don’t talk much about sarcopenia because there’s not a drug for it. The focus is on the bone density with the DEXA scan and osteopenia, but I’m more concerned often by the loss of lean muscle mass, [15:00] especially in women that can be very dramatic.

We also know that a lot of these new drugs actually look like they’re causing a loss of muscle mass. Is some of the weight loss, a good concerning proportion of the weight loss has to do with loss of muscle mass. And we know that diabetes and some of these other chronic diseases contribute to that loss of muscle mass. And at the same time, muscle is essentially an endocrine organ, and the more muscle mass you have, the more strength you have, the better you are processing foods and lowering blood sugar levels because that muscle consumes a lot of the glucose. So there’s so many reasons that it’s important to maintain lean muscle mass as we age, and that’s something that’s often not pointed out to people.

Kathy Smith: Do you have recommendations? I am doing a lot of heavy weights, and I also do something called blood flow restriction training for weight training. And then, I alternate that with lighter weights, [16:00] but do you have a heavyweight lightweight repetitions, anything like that that you’d like to share with the audience on what is the best weight to maintain that muscle mass?

Bob Sallis: Well, I think for the majority of the population, I love you’re on the cutting edge of the latest things and trying different things. I know that’s part of your role is experimenting with these different workouts and what works the best. But quite frankly, for most of my patients, I recommend just body weight exercises, sit-ups, squats, pushups, pullups, those kind of things, done two to three days a week kind of on non-consecutive days, doing maybe seven or eight different exercises that work the major muscle groups.

For most of my patients, that’s my recommendation. That coupled with a simple cardiovascular program, whether it’s walking or jogging, for most people that is perfect, and we’re really looking mainly just to get the health benefit from it. [17:00] The curve is very steep at the beginning, and that as you go from doing nothing to just little bits of activity, you get tremendous benefit. And then when you go from active to highly active, you get more benefit, but the curve starts to flatten out. It’s just getting people to do the recommended amounts of 150 minutes a week and resistance training two to three days a week.

Kathy Smith: Okay. So you think that’s enough? Going from getting off the couch to doing nothing to something as we’ve said before, that’s where you take the major leap into their health.

Bob Sallis: Exactly.

Kathy Smith: For those of, and people listening that are exercising already and have been and are kind of fine tuning, we can maybe talk a little bit more about that another time. And I do talk about that on other podcasts which I can refer people to like even Pete McCall on Ageless Intensity. But this idea of, well, how do– like even with VO2 Max, [18:00] how to increase that lung capacity through a little hip training.

And something I’m doing right now, and I don’t know what you think about this, but one day a week I do a four by four, which is basically four minutes of like pushing, really going into high intensity, pulling back, moderate for four and doing four sets of that. And I’ve noticed something like a pattern like that has really helped my vitality, my energy, and then that’s also helped my regular longer hikes and my more moderate exercise. So any word on HIT training,

Bob Sallis: HIT training’s an exciting area that’s relatively new, that shows a lot of promise in terms of the benefits and perhaps even enhanced cardiovascular benefits over just doing regular aerobic training, just getting out for a walk. The problem is, it’s uncomfortable, a lot of [19:00] people don’t like that. My elderly patients, they won’t push themselves that hard, and I have some concerns about the risk of injury trying to do high intensity training, especially when they’re not experienced and not real supervised.

But the beauty of it is you can get a significantly good workout in, in a lot less time. And for my patients that are really pressed for time, and probably if you ask most people, why don’t you exercise? I’m too busy, I just got too many things going on, I think HIT training is a great option. So I think it’s a great workout, but it’s certainly not for everybody. And then the patients I deal with as a family medicine physician, I got to have things that are a little more basic. And usually my go-to is just a walking prescription, throwing in some body weight exercises, that’s what I recommend to most my patients.

Kathy Smith: Making it simple and accessible is obviously the most importance, so people will do it, and fun, and not costly.

Bob Sallis: And really trying to socialize it, [20:00] it’s really interesting. You remember Tony Yancy, right? Tony would have this saying, she was a brilliant physical activity researcher at UCLA, and she would talk about how did physical activity go to being so hard to get people to do. When you’re a kid, if you ask what’s my favorite subjects, it would be recess, closely followed by PE, and now we become adults, and we can’t get people to go out and walk. And I think it’s because when we were young, it was a social thing, we did it with our friends. And I think that’s the key to maintaining a physical activity program is finding a walking partner, whether it’s your spouse or your dog or somebody, a best friend that’ll go out for a walk with you.

I think we’ve taken the fun out of exercise, and I think that’s where it really needs to be. We know that if you’re dancing, you’re gardening, you’re at the club playing tennis, you’re going to get the same, or doing work around the house in a vigorous intensity, [21:00] they all give you the same benefit. It doesn’t matter which form of exercise you choose, they all give the same benefit if you do it at the same intensity for the same amount of time. So I think we really need to work, and especially patients who are having trouble with compliance on staying on an exercise program. I think if we socialize it, you have a much better chance of sticking with it.

Kathy Smith: Yes, and there’s so many competitions now, and not competitions, but fundraisers, that sort of thing where you can go out and raise money for a cause and start walking or running or biking, and those type of things become a way, as you say, to train with people to have a cause, to have an end point. And it’s gotten obviously millions of people involved with movement. I love that. Also, I love the fact that there’s stuff popping up all the time. Like the Peloton craze came through, and now everybody’s getting into pickleball. And people are searching things. And when people ask me what’s the best [22:00] form of exercise, I always kind of shoot back the question, what do you like to do? Because what you like to do is what you will get out there and do.

And I don’t even like to call it exercise anymore. When people say, how much do you exercise? I go, I don’t exercise at all. I like the word movement because I move, I’m a mover. And whether I’m shoveling snow, because we have so much of it here, to make sure I can get it out of the driveway or I’m going up for a hike, I am all, everything in between. But even at the gym, that is funny, I was talking to somebody the other day, and I love the gym, I have a social network there, and it’s not a high end, it’s the most exclusive or whatever, but it’s just a group of people that come in, somebody to say hi to, share a story with, and get you over to a weight machine and keep you on track and a little bit [23:00] accountable. And I was out of town for two weeks on my one daughter, Kate, Kate Grace had a baby, and I am now a grandmother.

Bob Sallis: Congratulations.

Kathy Smith: Thank you. But I was in Boulder for that, and then I flew to South by Southwest for the conference down there. And so I was going a couple weeks, and I had a couple people come over, they go, Kathy, we were worried about you? Where were you? But it’s that type of thing of people looking out for, oh, they missed me. And that’s what keeps it lively. I do want to say that there is a group and there’s a lot of people that listen to my podcast. So I know that there’s the whole global perspective on the spectrum of people from age to fitness levels.

But there is a group of people that really do like to move their bodies. And sometimes they’ve just fallen out [24:00] because they got an injury, or they are letting things, the only thing that I’m going to do a little pushback with you, if you don’t mind, but it’s obviously you have your opinion. But I do see that when you hit 45, when you hit 47, and you don’t have a good night’s sleep, whatever, and the limitations of people saying you can’t do it, or this isn’t what we do anymore, we don’t dance anymore, pushing yourself, maybe it’s not, I’m taking the opposing view because I believe everybody at every age. Now, again, people listening to the podcast, we’re talking about pretty much 45 to 65 year olds.

I’m 71 now, so I’m going to push that to 75, athletic 75-year-old people. But we’re not talking about people in nursing homes or something [25:00] like that. And I do believe that there is a point where, yes, you know what, it can be minimized a little bit too much, and you can make excuses why you can’t. And I think that everybody can do hot training, HIT training is just a term.

Bob Sallis: Absolutely.

Kathy Smith: HIT training is like, HIT training, if you’re walking a 20-minute mile or if you’re walking a 30-minute mile, then, HIT training for you is to do a 25.

Bob Sallis: Absolutely.

Kathy Smith: So I’m just going to put this in balance that it’s not like, because when you send that message out, and especially coming from a doctor, it gives people permission. Like, oh, the doctor said that that might not be.

Bob Sallis: No, I certainly didn’t mean to sound like you can’t do that or you shouldn’t do that. I’m just saying that some of my patients, they’re not comfortable with going that hard, and there is a concern about injury if they don’t go into it right. But I think what’s important to note around HIT training [26:00] is it can just be a relative high intensity. It’s simple as what I recommend to patients is if they’re out for a walk between streetlights, walk your normal pace to one streetlight, and between the next, maybe double your speed, go from three miles an hour to four miles an hour. Just a relative increase in the intensity we know is very good for health, for your fitness level. And I think challenging yourself is very important with an exercise program, no matter what you do. But it doesn’t have to be crazy higher intensities that a lot of these call for, just a relative increase in the intensity is very good for your workouts. And I wouldn’t recommend everybody do that.

Kathy Smith: Right. And in total agreement, it doesn’t have to be all the time. I think the other mistake people make is that they feel like they have to push all the time. The benefit from it, and where I’ve gotten the most benefit, and I’ve seen the most benefit with people that are on my Fit over 40 program, it’s when you balance that regular study state training, [27:00] it’s called zone two training now, but the zone two training, which is basically you can carry on the conversation, you might not want to carry on a long conversation, but you carry on a conversation, and that zone two training that builds that base is where you want to spend most of your time. And then [00:27:23 – crosstalk] on a weekly basis, maybe only one day a week. If I do a big heavy HIT training, I might be only doing it one day a week. But that then impacts the other days of the week where I’m increasing my VO 2 max, I’m working on my cardio respiratory system, and now everything else works better. So, that’s my little speech

Bob Sallis: I would agree. And you know that as we age though, just getting my patients, and again, I’m coming from a perspective of family doctor seeing patients in a clinic who often have chronic diseases and other [28:00] disabilities and I’m just pushing them to be a little bit active. And when they get up in their seventies, I’m often just encouraging them to do a walking program and maintain their walking pace or even increase that. And I always go back to what we call the grim reaper study, where they looked at about 2000 Australian men and measured how far they could walk at a normal pace. And then they correlated that with mortality. And what they found out is that the grim reaper walks at about three miles an hour. Actually, it walks about two miles an hour.

Kathy Smith: I was going to say you better pull that one back.

Bob Sallis: Yes. Two miles an hour, men who walks —

Kathy Smith: That’s a 20-minute mile. I go, oh my God, I better tell some of my friends.

Bob Sallis: The grim reaper walked to two miles an hour. Men who walked three miles an hour or faster in that study, none of them died. So they were never caught by grim grim reaper. So my point being is when you can’t walk three miles an hour, then I got to have some concern, that’s when I want patients to come see me when you have something that’s keeping you from walking at that speed.

Kathy Smith: At two miles per hour?

Bob Sallis: Well, at three, actually [29:00] at three miles an hour, which is not a rapid pace.

Kathy Smith: Right. At 20-minute. Okay. Got you. So let’s just clarify because we’ve gone back and forth probably confuse everybody.

Bob Sallis: So the grim reaper walks at two miles an hour, in the study, men who could walk at least three miles an hour, none of them died. Three miles an hour or faster, none of them died. So that kind of ensures if you can stay at three miles an hour or faster, you’re not going to die.

Kathy Smith: And died for how long though? Died for a ten-year period?

Bob Sallis: They followed them about 10 years, and in that time, none of the men who walked three miles an hour or faster died. We know that walking speed correlates with mortality, as does grip strength. These are all [00:29:38 – crosstalk].

Kathy Smith: And tell me about grip strength because I’m having Katie Bowman on in a few weeks, and she’s really about hanging from a bar, and the whole idea, like upper body, but also the hang and the science behind that, but also the grip strength. So talk about grip strength.

Bob Sallis: Well, grip strength in my world is using it as an indirect measure of [30:00] muscle strength. And I don’t think that necessarily training your grip strength is going to make you live longer, but we know that people who have a stronger grip, if we look at large cohorts of patients, it’s a simple and indirect way to get a measure of physical strength. And we know that it correlates with longevity, as does walking speed. If you can walk fast, obviously your heart and your lungs are working, your muscles are working. And so it’s kind of the same thing. It’s kind of an indirect measure of your fitness level and your health.

Kathy Smith: I want to jump into two other topics before I let you go. One is just this idea of, we talk about physical decline as it relates to exercise, but let’s talk about cognitive and also emotional side of it because as I know people that know my story with how I got involved with exercise, I got addicted to exercise after I lost my parents and I was going through [31:00] anxiety and sort of a depression, and running changed that for me and opened up a whole new world for me. And I see now on two sides with COVID and with all of the information, I mean all of the news about young people, everybody suffering from some kind of anxiety.

We now have TikTok and Facebook and Instagram and everything, the comparison game and people not feeling confident and how that’s impacting the kids all the way to the adults with loneliness and perhaps not having enough friends or partners or whatever. So let’s talk about the emotional side, but then also the cognitive side with Alzheimer’s, and how fitness impacts those two areas.

Bob Sallis: Yes, that’s a great question. The longer I’ve studied this, I’m here to tell you that we always think of exercise [32:00] in the cardiovascular system, but I think the most powerful effective exercise is on the brain. And we know that it seems to be mediated by this protein called BDNF or brain derived neurotropic factor that kind of acts like a miracle growth of the brain.

And we’d always believe that you had a certain amount of neurons, and as you aged, you lost those, and brain function would automatically sort of deteriorate, you couldn’t regrow the brain. But we have studies to show that those who engage in exercise even late in life, can see changes in the brain where it actually grows, particularly in the hippocampus, which is sort of the area that governs memory and executive function, the ability to multitask and do the things you want to do. It’s actually been shown that with exercise, that will actually grow. Typically, after about the age of 40 or so, the hippocampus begins to shrink.

And when it shrinks faster, that’s associated with a much higher rate of Alzheimer’s disease and other forms of dementia. And exercise [33:00] really has been shown to retard that, so particularly important with brain health. And really, you got to start it even in middle age, those who in middle age are regularly exercising and fit, much less likely to develop that.

And then the whole other effect is on your mental health, particularly on affective disorders, anxiety, depression, which have absolutely skyrocketed with the pandemic and the shutdown. We are seeing rates of anxiety and depression like we’ve never seen before. There are simply not enough mental health workers, and yet we have this medication, got a lot of notoriety, this recent meta-analysis that was published in the British Journal of Sports Medicine, I believe, which was a meta-analysis of meta-analysis, meaning it had multiple studies.

They pooled all those patients together and found that using exercise to treat anxiety and depression worked as good as the drugs or as good as psychotherapy for both conditions. Yet it’s one of these things we don’t often think of prescribing. [34:00] When a patient comes in with depression, our go-to is a medicine. The first thing we ought to do in patients who have anxiety and depression is get them walking. And so I think it’s more important now than ever with these skyrocketing rates since the pandemic that we need to get folks walking for their mental health. And I think when you add in a gym, like you pointed out, I’m convinced that the effective exercise with all of these conditions are enhanced when you socialize it.

And we’ve done some studies where we compared what was done in a lab on a bike and its effect on various diseases, and you do the same study in a gym setting instead of a bike in a laboratory, you put them in a spin class with all these people around them, the effects are amplified. And so I think the socialization of a gym, of working out with friends even enhances these exercise benefits that we see.

Kathy Smith: If you want a study of one. For sure. So, we’ve been talking about reduction in risk [35:00] of so many adverse conditions when it comes to different diseases, and before we leave this, I just want to highlight, because this is the one thing that I was reading yesterday, the four horsemen of chronic diseases, metabolic dysregulation, cardiovascular disease, cancer, and neurodegeneration, and each of these, and the metabolic one is like type two diabetes, insulin resistance, metabolic syndrome, and even non-alcoholic fatty liver syndrome, and each of these, you can talk about– and each of them have a medication, they have this and that, but exercise has an impact on each and every one of them.

Bob Sallis: Absolutely. And if you look at the guidelines for treating any of those conditions for both treating and preventing, it starts with getting people more active. Even the experts all agree. I’ve just part for the non-alcoholic fatty liver disease, we just did a huge position stand, I was involved in it, basically reviewing the literature on exercise and non-alcoholic fatty liver disease, [36:00] and it’s astounding, the effect of exercise. And so it’s on the guidelines, but unfortunately most physicians are trained to skip right over lifestyle changes and go right to the first drug, unfortunately.

Kathy Smith: Well, let’s jump back into it then, let’s get back into it, because in 2009, and we’ve been talking about this on and off for over a decade, you started this initiative Exercise is Medicine, and we would sit around and I know you’d be like why aren’t the fitness people getting more involved with the hospital? And I’d be going, why aren’t the doctors like respecting the fitness professionals more, and we kind of banter back and forth about it. Where do we stand now when it comes to the medical profession with the experience of this?

Bob Sallis: So there’s been some interesting things going on. I’m just back from the IHRSA meeting, which is the Trade Association for Health Clubs, International Health Racket and Sports Club Association. And boy, they’re finally, I think, really showing an interest. And it’s interesting, you know, only less than 20% of the population [37:00] ever belongs to a gym. And let’s face it, my patients who belong to a gym, I’m not worried about. I’m worried about the patients who never get to the gym and get all those benefits. And I think they really want to work around increasing their demographic, obviously, and with COVID especially, there’s so much benefit that could be had there. But I really think we’re beginning to see some inroads where the fitness community really is getting interested in helping me manage my patients with chronic disease by supervising their exercise program.

And I’m very hopeful we’re going to start to see some changes there. And when I started the Exercise is Medicine initiative, one of the first things we did was what we call an exercise vital sign that I talked about with my COVID study we use at Kaiser and try to get that as a standard of care. And I think we’re really close. It sounds like that’s going to happen hopefully within the next couple of months that every electronic medical record will have to include an assessment for exercise, the exercise vital sign. And I think then we’re going to begin identifying all of these patients [38:00] who are not meeting the physical activity guidelines and who have these chronic diseases. And I’m hopeful it’s going to open up reimbursement for fitness professionals to be able to work with these patients who need them so badly. So I’m very hopeful that-

Kathy Smith: I hope so because that’s what we talked about again years and years ago. It’s what’s in it for– we know that money talks.

Bob Sallis: Exactly.

Kathy Smith: We know it’s one of the reasons why in the medical profession, you can charge a lot more for —

Bob Sallis: Bariatric surgery than you can for getting them to exercise and eat right.

Kathy Smith: Exactly. Or even medication type two diabetes, insulin, other medications and whatever. So yes, how do you incentivize, and especially for fitness professionals, what’s in it for them to get involved? So reimbursement would be great.

Bob Sallis: That’s the hope.

Kathy Smith: That’s the hope, Bob. Well, listen, we’re going to have to have– you’ve come [39:00] a long way and you’ve now spawned, they’re books that are coming out now, Peter Attia. Outlive, Mark Hyman, kind of stay younger, longer type of thing. What is one of the centerpieces, if not the biggest centerpiece? Exercise. And so I’m glad that that we’re having this conversation at this point. But let me finish with this question. New York Times center article this week, the income gap is becoming a physical activity divide.

So they did this across the country, households that are making 105,000, about 70% were involved in sports, the kids, Middle income families, 51% of the children. Low income, but below poverty line, 31% of the children. So we know that school participation leads to better grades, [40:00] we know that it boosts physical and emotion, we know everything that happens now, but think about what’s happening right now with this physical activity divide, when it’s starting when you’re in elementary school, and how are we going to solve this?

Bob Sallis: Yes, that’s a great question. What I see from my standpoint being a family medicine, sports medicine physician, it’s a crazy conundrum that we’re in now because I am seeing this huge cohort of kids that aren’t doing anything. And then I have another cohort that are involved in five different travel teams, they’re playing multiple, they focus on one sport at an early age.

So at the same time I’m seeing this explosion of inactive kids, I’m seeing an explosion of kids that are doing too much exercise. It used to be that the leagues, we had youth leagues that everybody sort of played in. Now it’s all about the travel team and competition and trying to get a scholarship and very early kids specializing in sports and developing overuse injuries that I’m used to seeing [41:00] in collegiate or professional athletes, I’m seeing them in 12-year-olds who are playing way too much baseball.

And so it’s kind of sad, and we’ve taken PE for the most part out of school. So kids are allowed to not do anything, and then I have this other group that’s doing way too much. Somehow, we’ve got to bring it back to the middle, where kids play three different sports, there are more leagues that are more about fun and competition, not trying to get a scholarship and have professional coaches at a young age. I think we’ve gone crazy with that. We just have two ends of a spectrum that I’m seeing that I think we’ve got to come back to a more sane level that every kid ought to have PE, every college student.

It’s insane that a person would graduate from a college or university and not have a lifetime plan for fitness. That seems to me like the number one thing a college or university ought to be responsible for in addition to teaching kids how to balance their checkbook and things like that. They ought to be preparing them for a lifetime of exercise and figuring out what sports they enjoy [42:00] and that they can do for the rest of their life to stay fit. I wish we could get the colleges and universities to get behind that in a bigger way.

Kathy Smith: Yes. You know what? I think we’ll end on that because that’s powerful. I think you’re right. It’s just like this is a lifetime journey and it’s your body, it’s your home. You think about your home like I live at such and such address, but your home is right here in your body. This is what’s going to take you through life each decade. And if you think that each decade is worse than the next decade, then you just don’t have the plan, you’re not looking at all the possibilities and maybe you’re not taking care of the body well enough.

But to be able to start that when they’re– again, this is going to be my passion [00:42:45 – inaudible], it always has been with the Women’s Sports Foundation to help get girls involved with sports because we know that girls that get involved in sports in elementary school, and by seventh, eighth grade, by the time 15, if you haven’t picked up a sport [43:00] with all those awkward years and popularity and not feeling right in your body and embarrassment, a lot of times it doesn’t happen. And that’s why getting to kids at a young age, helping them throw balls. I was always out with mothers, they always go, well, boys can throw better than girls. I go, how many times have you thrown a ball with your daughter? It’s not really men, not necessarily. Probably haven’t done much of it.

Bob Sallis: And you make a great point because we know that girls who are involved in sports have better mental health, lower rates of suicide, lower rates of pregnancy, drug use, on and on, and all the risky behaviors are lower, particularly in girls when they’re involved in sports.

Kathy Smith: So it was such a pleasure having Dr. Sallis on the show today. Now my big takeaway is to think of exercise as a tactic that can help you stay younger longer. So you see, by preserving physical function and tapping into that muscle reserve we talked about, [44:00] you can enjoy more years of life in good health, free from all the burdens and many of the burdens of chronic diseases and of the disabilities that can come along. That means that you can play pickleball, you can go out walking the camino if you want to, you can pick up your grandkids, you can lift your luggage for vacation, you can do the things you want to do.

So you go into the next decades thinking that you can be vital and you have this unlimited potential, and exercise is what helps you get there and helps you realize that potential. Everybody thinks about losing weight and looking your best, but honestly, that was really just the side benefit, that’s the icing on the cake, that’s the bonus, because exercise impacts every single thing in your body, physically, mentally, and emotionally.

You see, regular movement improves your heart function, [45:00] your bones, your muscles. It helps reduce stress, it helps lower blood pressure, it reduces the impact that so many things around you have on your body. You’re able to be more resilient when you exercise. And there are studies that show it makes you happier. I know it makes me happier, sharpens your brain, and really that’s just the beginning. We talked about type two diabetes, cancer, metabolic syndrome, fatty liver disease, everything that’s going on in your body is impacted when you move your body. So exercise will keep you feeling younger, longer. And you know what, it’s one of the reasons why I created Reshape.

So Reshape is an app, and it has three parts to it. It’s daily workouts, it’s daily meal plans, and daily recipes. [46:00] And each month, there’s a different focus. So April is slumming down and getting stronger, there could be months where we focus on fat burning, other months we focus on body parts, lower body, upper body, total body, mind body, but it’s three components that make it all come together. And I’m really passionate about Reshape. We put a lot of work into making sure that every meal has a plant-based version as well as a regular protein version. So you have a choice, and we know that plants are healthy, they’re healthier for you, and the more you eat, the better you feel and the healthier you are. So it’s an easy way to make a transition to a more plant-based diet.

And I really want you to know that I want everybody to be able to use Reshape. So if you’re not able to afford it for whatever reason, and you know somebody else that could use it that can’t afford it, just send us an email at customerservice@kathysmith.com and we can offer you [47:00] Reshape at a discounted rate or even free. So take advantage of that because I really do want everybody to be healthy and have access to good quality meal plans and exercise. So I hope you enjoyed the show. Now, if you did, check out the episode with Pete McCall.

It’s number episode number 99, and it’s called Ageless Intensity. And it’s really about some of the things we talked about in the show. I think I got Pete McCall’s name wrong in the show, but hopefully he’ll forgive me. Pete McCall, episode 99. Now you can find the podcast and the whole library of all the other podcasts at kathysmith.com/podcast or wherever you listen. So stay healthy and stay active, keep exercising, and until next time, here’s to your health.