The implementation of exercise prescription and dietetics

Podcast transcript

INTRO
Welcome to Docs in a Pod, presented by WellMed. Over the next half-hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-host Olivia Rahma, NP and former television broadcaster Gina Galaviz will share information to improve your health and well-being. And now here are Gina Galaviz and Olivia Rahma.

GINA GALAVIZ EISENBERG
Welcome to the award-winning Docs in a Pod presented by WellMed. I'm your host, Gina Galaviz Eisenberg, sitting in today for Ron Aaron, who is on assignment. We're pleased to have you with us. Docs in a Pod is available on podcast wherever you get your podcasts. We're also on the radio in several Texas and Florida cities. Each week we talk about a variety of health and wellness-related issues as they impact Medicare-eligible seniors and others. Our co-host today is nurse practitioner Olivia Rahma. She works at the WellMed 9th Avenue clinic in St. Petersburg, Florida. She earned her nursing degree at Florida State University in Tallahassee. She then earned her master's degree in nursing at the University of South Florida in Tampa. She's board certified in family practice, and she was a competitive show singer growing up and still sings today. She's our unofficial Taylor Swift. We're both Swifties, so I had to put the Tay-Tay plug there. She's a proud mom of two fur babies, a yellow lab and a golden retriever, and she's from the great state of Michigan. So glad to see you again.

OLIVIA RAHMA, NP
Yes, glad to see you, Gina.

GINA GALAVIZ EISENBERG
Florida, Texas. Is it muggy there too?

OLIVIA RAHMA, NP
It's kind of nice today, actually. It won't stay this way.

GINA GALAVIZ EISENBERG
No, I mean, when I walk outside, I feel like I've exercised and that's what we're talking about today. We've talked about that recently about the importance of exercise, but Olivia, have you ever given a prescription for exercise to any of your patients?

OLIVIA RAHMA, NP
Sure. Maybe like an unofficial prescription. I'm not going to hand you a piece of homework and make it sound really intimidating or anything. But I usually will give small goals to my patients that we make together. I'm not just going to randomly give you a goal. Then the next time you come, I will ask you if we have completed that prescription or homework assignment, for instance.

GINA GALAVIZ EISENBERG
Well, we're going to talk to our guest, Edwin Davila, Dr. Davila. I'm sure he has given many prescriptions as well. He's a senior resident physician of internal medicine at the Texas Institute for Graduate Medical Education and Research in San Antonio, Texas, and is a member of the WellMed Physician Pathways Program. He obtained his medical degree from the University of the Incarnate Word School of Medicine, and his master's in exercise physiology from Baylor University, and he also earned his bachelor's degree in biology from Baylor. He's a certified clinical exercise physiologist. And he is also a certified sports nutritionist. I think that's fascinating. He has also served as an officer in the U. S. Navy. Thank you for your service. And his primary interest is in obesity medicine and developing methods of incorporating lifestyle medicine and exercise science. For patients to just make us better. Tell us more. How many prescriptions have you given?

EDWIN DAVILA, DO
Well, first off, thank you for having me. It's been a wonderful opportunity to speak about this, I love this conversation. I'll try to keep it within the confines of our time because if you don't keep me, we could talk about this forever.

GINA GALAVIZ EISENBERG
Don't worry. You'll come back again. You're at risk of coming back.

EDWIN DAVILA, DO
Beautiful. Several hundred, I would say, and different variations and different patient populations ranging from when I was active duty to the high-impact with high-speed, low-drive warfighter to the weekend warrior to the severe decondition patient who had been hospitalized for multiple weeks, trying to just regain functional capacity. So, several very different forms and fashions.

GINA GALAVIZ EISENBERG
When your WellMed patients come and see a doctor and you hand them one of these prescriptions, what's the reaction because they probably never seen one before?

EDWIN DAVILA, DO
Absolutely. At first they are a little surprised, but they're actually quite happy. Reason I say is because so many of our patients are used to getting the level of detail of knowledge when it comes to our pharmacologic medication interventions. They get dosage, they get milligrams, they get how much to take, how many given time things to look for measurements that we want them to do at home and give us feedback for adjustments, things that we'll look at, and then a plan for adjusting later. This is the detail that we give, but so often that when it comes to the lifestyle aspect of things, they're usually the standard, well, you should probably move more. Hey, you should probably hit 150 minutes of moderate to vigorous activity, which we never described what that actually means. And then the worst of it all is, well, you can go to a gym and they usually have people there that can help you. And what I've come to notice over the years of doing this is in the mind of the patient. It creates this kind of structure of well, the physician, the practitioner, the clinician gave all this detail about this part of my care, so it must be the important one. Then they kind of gave me some quick little recommendations and some cute little things here and there. I guess I'll get around to it, because if it was that important, the physician would have been just as detailed. So, it changes the approach and the mentality in which the patient has to this care, and they really start to feel that it's actually medicine just as much as the medications are.

GINA GALAVIZ EISENBERG
And that is important. We're going to talk more about that in just a minute but let me reintroduce all of us. For those of you who may just joined us right now, you're listening to the award-winning Docs and a Pod. Our podcast is available wherever you listen to podcasts. I'm Gina Galaviz Eisenberg sitting in for Ron Aaron. Our co-host is nurse practitioner, Olivia Rahma. And our guest is Dr. Edwin Davila with the WellMed physician pathways program in San Antonio, Texas. We're talking about the critical importance of exercise prescriptions, and you were just mentioning to us that we get all these recommendations. Oh, and you need to exercise, and you get a little bit. So, you're like, well, maybe it's not as important as all the medications. How do you break it down and how do you get patients to change? It's not just about the pills that you're taking. Maybe the goal is to not have to take so many if you focus more on exercise and preventative.

EDWIN DAVILA, DO
Absolutely. So, the first thing I do is to try to get an idea of what they define exercise to be. So many times, we have this mentality of exercises in a gym and it's a bunch of weights and it's a treadmill and it's a bike. And then the buck stops there. So, if I recommend exercise but I do not understand the definition of that to the patient, they may not want to do any of those things. They might not find joy, or they might not find a comfortable environment in that.

GINA GALAVIZ EISENBERG
It is so overwhelming, don't you think, doctor? You tell me this. I have no idea.

EDWIN DAVILA, DO
A hundred percent. I myself have lived in gyms since I was knee-high, so they're common to me. But if I'm just getting into it and I walk into this gargantuan facility with noises and clanking and machines and talking, I don't know where to even start. If my perception of exercise is just that, I've already created a barrier. And a very large one, in fact.

GINA GALAVIZ EISENBERG
How do you break it down to make it simple? Tell us some success stories of some of your patients.

EDWIN DAVILA, DO
Absolutely. The first thing I ask is give me the day in the life of you in terms of the patient. I want to know what their day consists of. I want to know if they're a grandparent, do they watch their grandkids a lot? Do they have a social environment they enjoy? Are there activities that they have been doing since they were younger that are just not being as effective anymore? I narrow that down to understand what their driving forces and their functional goals. And when I say functional goals, it can be something as simple as we always have this large gathering every couple of months with my family, and it's a lot of moving and a lot of picking up and a lot of doing things, preparations, and I just don't want to lose that. Or it could be somebody who's just retired and they want to travel more. Well, traveling involves a lot of walking through airports and picking things up and loading things and all this motion. So, you identify what it is that drives that individual. If you find that, it increases the likelihood of compliance when you develop a protocol, if you will, that is in line with getting more and more closer to achieving those goals of that individual.
You asked of some success stories that I have. I had a patient who came in, had been hospitalized for about two weeks and felt severely deconditioned. They walked in with their family, and I noticed that they were using a walker. They did not use a walker the last time I saw them. That's where I started the conversation. I noticed you're using a walker today, what's going on? And they told me what was going on and well, and the family was like, don't worry doctor, we have made sure she does not do a lot around the house. We don't want her picking things up, we don't want her moving. I looked at them and I was like, that is a wonderful way to show you truly care about your loved one, but I'm going to be the bad guy here. We're going to switch that up today. I want you to tell me everything you were doing before you went to the hospital. Well, I cooked, I cleaned, I lifted. I was like, okay, this is what we're going to do. For one, you're going right back to that, but we're going to go slow. I want you to do some form of your usual activity at home. I wrote it down, cleaning, cooking, gardening. We're going to do three days of gardening this week. We're going to do it for 15 minutes, at least. If you need a break, we're going to take a break. Then I want you to do two sessions of laundry this week. Along with that, we're going to add that to this. I'm writing this all down, and I put the amount, I put the length, I put what you're doing and I gave it to them. This is going to be your plan for this week. I'm going to see you in two weeks. I want to know how well you did. And sure enough, two weeks later. She struggled, but she was able to do it. And as time progressed, she could do more. I was like, very good, did you use the walker? A little bit. Okay, we're going to increase a little bit of your prescription now, we're going to change it a little bit. But by me quantifying these metrics, these variables, it became not just a, well, the doctor said I should probably do this. No, he said three of these, two of these, with this much time with the intention of increasing if I'm able to do it. It really made a difference, I think.

GINA GALAVIZ EISENBERG
Well, yeah, because you're moving, you're walking, you're twisting and turning. I guess eventually she can start walking again without a walker.

EDWIN DAVILA, DO
100%. There are pillars to developing exercise prescription. We refer to it collectively as the FITVP protocol, or algorithm or whatever you want to refer to it. It's frequency, intensity, time, type, volume and progression. So, each of these things you are trying to answer based upon the protocol you're doing. Frequency, how many times do you want me to do something? Intensity, to what degree of intensity should I be doing this activity? Time, how much time am I supposed to do it? What is the type of activity? The collective amount of that activity and then the plan for progressing over a period of time and the expected goals, and that really solidifies it with more of an objective thing. Just like we do with, let's say, blood pressure. I'm going to start you on this medication. I'm going to use this dosage. We're going to be shooting for this blood pressure. If it's great, we're not changing it. If it needs to, we're going to change and we're going to change it on this day. It's no different.

GINA GALAVIZ EISENBERG
Well, it makes total sense, though. It's nothing that's going to make me feel overwhelmed because I can continue to do that. Maybe I don't park as close to the front door of the grocery store so I can walk a little further. Just small little goals like that. Olivia, what do you think?

OLIVIA RAHMA, NP
I think that's fantastic. It's much more achievable to have specific small goals than just to say, well, the guidelines say you should have 150 minutes a week, and you could break that into 30 minutes, and they're like, oh my gosh, when am I going to find the time for that? Immediately they check out so I think that sounds fantastic. I'm going to start doing some prescriptions, I think.

GINA GALAVIZ EISENBERG
Yeah, you need to send Olivia some of your prescriptions.

EDWIN DAVILA, DO
Absolutely. And just as a plug for anybody out there who wants to kind of start getting into this, there is a wonderful resource about, I think it was 2010, if I'm not mistaken, the AMA, the American Medical Association partnered with the American College of Sports Medicine to create an initiative referred to as exercises medicine. It is an initiative that was designed specifically for this, to create resources for any kind of practitioner, clinician to be able to have resources. Let us face it, some of our patients can be quite multifactorial in their conditions. So, how do you deal with a patient who has heart failure versus COPD versus neuropathy versus something like cystic fibrosis? Well, this resource, and you just Google it, exercise is medicine AMA, ACSM, and they have a kaleidoscope of actual printouts that can help you. Patient with this, here are the good recommendations based upon the guidelines. Wonderful way to start, wonderful way to print something out and just give something where it feels like, this is my patient and I can start them here.

GINA GALAVIZ EISENBERG
I'm going to check that out. I mean, I'm not on any medications. 60 years old, so I can't wait till I hit that number 65, but still a lot can change in 5 years. I tell my husband; I need to start preparing for 65 if that makes any sense. I'm watching what I eat and eating the right kind of food. So, you get your patients exercising and they want to do more walking or start running. What do you tell them to eat? They haven't been eating what they're supposed to. Before we do that, I need to take a quick break. I've just been getting so involved, Olivia, I missed it there. We're going to continue our discussion in just a moment. I'm Gina Galaviz Eisenberg, along with our co-host nurse practitioner, Olivia Rahma, and our special guest, Dr. Edwin Davila. You got me talking. You're listening to the award-winning Docs in a Pod.

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GINA GALAVIZ EISENBERG
Thanks so much for staying with us on the award-winning Docs in a Pod. I'm Gina Galaviz Eisenberg, along with our co-host nurse practitioner, Olivia Rahma, and our guest is Dr. Edwin Davila. Let's talk more about prescriptions for exercise. So, I'm going to start walking. I'm your patient, but I haven't really walked more before. What should I be eating? Maybe I eat more vegetables or salads. Talk about this whole protein thing. What is it? What's a protein?

EDWIN DAVILA, DO
Wonderful. Well, protein in the nerd talk is a collection of amino acids creating a polypeptide chain, which can be in multiple different forms and structures ranging from just a simple polypeptide to quaternary structures. That's the nerd talk. What it really is, is it's the building blocks of so many different tissues throughout the whole body. But in this particular situation, we're talking about two mainly. One, you can have many hormones that are derived from proteins or protein structures. But specifically, we're talking about skeletal muscle. When we think about muscle, I talk about building muscle. Sometimes my patients are like, I don't really want to build muscle. I'm not trying to be bulky or be some kind of body builder. Full disclosure, I'm a body builder so my brain goes there. I reference a lot of the more important things and you talked about a huge, important thing previously is as we get older, you plan for the future. And we know that one of the biggest issues we're dealing with, again, a little biased, is the effects of sarcopenia. Now, sarcopenia is the effect of not just muscle loss, but loss of strength, loss of actual muscle tissue and loss of function. Function kind of goes back to my patient where once they were able to walk without a walk without assistance, then all of a sudden, they need a walker. Or they're used to picking up item X all the time but as they get older, it's just heavier. They didn't become heavier, their ability to lift this became impacted. And what we're seeing is that over time individuals who do not have a lot of activity, specifically in the realm of resistance training or malnourished or not adequate amounts of protein are more susceptible. And protein, where do we get it from? Well, we get it from a lot of places. Anything that was a living animal source at any given time is a protein source, a very good protein source. We can also get them from vegetables, things like rice and from soy, things like peas, grains, quinoa is a good one. When it comes to volume, that's one thing, but getting proteins that are very much in line with the amino acid ratios of our own physiology are sometimes even more important. I'm a big believer in anybody who has any kind of dietary choices they prefer, but sometimes, as an example, let's say a vegetarian, the ability to obtain the amino acid balance which our bodies need, sometimes it's a little harder versus eating it from animal sources. Which the ratio to ratio very similar in structure as ours, especially the three most important ones. I shouldn't say most important, but very important the essentials. And as we get older, we notice that our protein intake declines. It just does. We've all heard that. What did you eat today? I had some toast. Oh, I had a soup. Oh, I had this. Well, did you have any meat? Did you have any eggs? Did you have any fish? Tell me a little bit about the grains you were eating. No, not really. And over time, this leads to a loss of skeletal muscle. So that is another important element that I speak to my patients about is to make sure that not only are we getting the activity we need but are we adequately getting the amino acids and the protein necessary to maintain that muscle for the long term.

GINA GALAVIZ EISENBERG
Do you suggest we go to the grocery store and get ground meat? Because that's easy. Or a steak or sirloin, that type.

EDWIN DAVILA, DO
It really depends. Every patient's a little different. We also look into the other things, what is their cholesterol like? What are the other different elements of these things? Some protein sources are better than others. Lean protein sources, as we like to call it, are, because we're talking about beef, lean cuts. Something like, let's say a flank or sirloin is better than a 20% ground chuck. But at the same time, there's things like fish, which I'm a big fan of poultry. Eggs are easily digestible and something we eat. While I don't particularly want my patients to go off and purchase things, I'm also a big fan of protein supplements. Most of them are derived from whey. Whey is a protein derived from the production and manufacturing of milk. It's very easily digestible and is very well tolerated in the GI tract and in a small volume, you can get a large quantity of quality protein. So, I do recommend that to patients. And as a little bit of a stinger, people are always like, whoa, what are you doing? I also actually prescribe and recommend the utilization of creatine to my patients, which people think, whoa, creatine? That's for the athlete. Well, in reality, creatine is something our body makes daily, but we make it from protein. So, as we decrease our protein intake, we sometimes decrease our creatine production, and creatine is a driving force of muscle function, so all of these things are all tied together.

GINA GALAVIZ EISENBERG
What resource should folks go to learn more about this? Besides asking their doctor and of course, obviously, if you're in San Antonio, Dr. Davila, he'll take some new patients, right?

EDWIN DAVILA, DO
Absolutely. If you're looking to learn more, I'm a huge fan of looking at journals. Everything that we should ever do has to meet the scrutiny of evidence-based medicine. I didn't mention this, but this is very important. There's a lot of information out there when it comes to this realm that falls in line with what I would call colloquially bro science or gym science, individuals who say a lot of things and they sound good, and the person looks like they know what they're talking about, but when pushed against evidence-based medicine, it loses its luster. It doesn't actually hold the candlestick. Going to resources from governing bodies that have peer-reviewed evidence. Again, I'm a big fan of the ACSM, the American Society American College of Sports Medicine, NASA, the National Academy of Sports Medicine, the ADA American Diabetes Association the ACCAHA, American College of Cardiology and American Heart Association. All of these resources actually have on their website dietary recommendation. If somebody was curious, well, how much protein should I take? If we're putting pen to paper, put somewhere about 0.82 grams per pound per day. People sometimes say one gram per pound, but there's a lot of variables that go into that as well. But, that's a good place to start.

GINA GALAVIZ EISENBERG
Okay, very good. And of course, if patients have questions, and if you don't have the answers, but I'm sure you guys do, but still, WellMed has other docs within their system to help your patients. Olivia, do you send folks to dieticians as well?

OLIVIA RAHMA, NP
Yeah, I actually have a program through our WellMed Abbott Nutrition where my patients can call to speak specifically to a nutritionist. Normally, I'll give them a form before they do that that kind of checks off whatever their goals are, whether they're a diabetic and they want healthy snacking tips or they want to gain weight and they want to do that without eating bags of Cheetos, that's a really good resource for them as well. I give that out pretty often, actually.

EDWIN DAVILA, DO
One plug for WellMed is also highly underutilized in some areas I've seen are the senior centers. The senior centers, a lot of individuals might not know, have trained exercise physiologists at times in which a practitioner can say, my patient just came from the hospital, severe deconditioning. Needs increasing of lower extremity strength or functional capacity, and they don't even need to do anything more than that. Just write that down. That could be taken to some of these facilities. The individuals there will see it. They'll help the patient establish and learn to use the facility to maximize that and then other things that they see. Huge resource, I want to make sure that's not missed.

GINA GALAVIZ EISENBERG
That's a great way to end our segment. Thank you so much, Dr. Edwin Davila, for joining us today on the award-winning Docs in a Pod. He's here in San Antonio, Texas so look him up, and thank you to our co-host nurse practitioner, Olivia Rahma in St. Petersburg, Florida, look her up. In the words of the late Charles Osgood, I'll see you on the radio. I'm your host, Gina Galaviz Eisenberg.

OUTRO
Executive Producers for Docs in a Pod are Dan Calderon and Lia Medrano. Associate Producers, Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed.
We welcome your emails with suggestions and comments on this program at radio@wellmed.net. Be sure to listen next week to Docs in a Pod presented by WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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