Living with heart failure; exercise and cancer; too old to drive: Upstate Medical University's HealthLink on Air for Sunday, Nov. 12, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a cardiac nurse and one of her patients talk about what it's like to live with heart failure.

Ashley Greiner: ... In the chronic illness world, it's coined "your new normal." You find your new normal. You find a new path. You find the things that you are able to do within the confines of your illness. ...

Host Amber Smith: And a doctor explains how exercise can be of benefit to someone going through cancer treatment.

Kaushal Nanavati, MD: ... High-intensity exercise, in one study, actually showed that it reduced the potential for spread of cancer by nearly 72%. That's huge. ...

Host Amber Smith: All that, some advice about taking away the car keys from an aging parent, plus a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a doctor explains why exercise can be a benefit during cancer treatment. Then, a specialist in geriatrics discusses when and how to take the car keys from an aging parent. But first, we'll learn what living with heart failure is like from a cardiac nurse and one of her patients.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

The Heart Failure Society of America estimates that nearly 6 1/2 million Americans over age 20 have heart failure. Today we'll learn about this condition with nurse Natasha Zmitrowitz -- she's the heart failure program coordinator at Upstate University Hospital -- as well as Ashley Greiner, a patient who was diagnosed with heart failure seven years ago.

Welcome to "HealthLink on Air," both of you.

Natasha Zmitrowitz, RN: Thank you.

Ashley Greiner: Hi. Thank you.

Host Amber Smith: Before we get too far into this, I'd like to go over some terminology. Heart failure doesn't mean that the heart has stopped, is that right, nurse Zmitrowitz?

Natasha Zmitrowitz, RN: Yep, that's right. Basically, heart failure means that something's wrong with your pump. So, essentially your heart is a pump that pushes blood through your body to where it needs to go. And when you have heart failure, something is wrong with that pump, so you're not getting adequate blood flow to the organs that you need it to.

Host Amber Smith: So what is the difference between left heart failure, right heart failure, and I've heard of congestive heart failure.

Natasha Zmitrowitz, RN: Good question. We don't use the word congestive heart failure anymore. Now that we have more definitive criteria for guidelines and medications that help reduce admission (to a hospital) and increase length of life, we focus those medications on two main types of heart failure, not left versus right, but what we call systolic heart failure or diastolic heart failure.

So essentially that means there's either something wrong with the squeeze of your heart or something wrong with the relaxing-and-filling-up-with-blood of your heart. So when we look at those, we talk about a number called ejection fraction, which is something that heart failure patients should know.

Your ejection fraction is the percentage of blood that gets squeezed out of your heart with every heartbeat. When you have a normal ejection fraction, it is 50% to 65% or so. When we talk about a reduced ejection fraction, we're looking at an ejection fraction of about 40% or lower. And that is how we decide what type of heart failure you have. And the terms are heart failure with reduced ejection fraction or heart failure with preserved ejection fraction. And both of those types of heart failure have a little bit of a different way of treating them.

Host Amber Smith: Do we know what causes heart failure? Is this something that just happens as we age, our hearts kind of give out? Or does this develop in younger people?

Natasha Zmitrowitz, RN: Well, certainly it can develop as you age. You're more at risk, the older you are because the longer your heart works, it's like a muscle. So I tell my patients, you know, if you're working out your bicep and lifting weights, that muscle's going to get bigger. It's going to get thicker. Same thing with your heart. And when that happens, it doesn't relax as good.

So typically in our elderly population, we'll see heart failure with preserved ejection fraction, and there's other things that cause heart failure. One of the biggest things is coronary artery disease, or the junking up of the vessels inside of your heart that deliver blood. Another issue that can cause heart failure iswhat we call the silent killer. Hypertension, or high blood pressure, can also lead to heart failure.

We typically like to get a really good history on patients because certainly family history matters, genetics matter. If you've been introduced at all to chemotherapies, a lot of chemotherapies, some for breast cancer, can even cause heart failure eight, nine years down the line after stopping treatment. There's other disease processes that can cause heart failure, thyroid disorders, rheumatologic disorders.

So there's a lot of things, including addiction to cocaine, amphetamine, things like that, that basically make your heart run a marathon. So that can certainly cause heart failure as well.

Host Amber Smith: So it sounds like there are things that would increase someone's chance of developing heart failure.

Natasha Zmitrowitz, RN: Absolutely.

Host Amber Smith: How do people typically learn that they have heart failure?

Natasha Zmitrowitz, RN: Typically it's when they start to experience symptoms and they go to a doctor or come into the hospital feeling short of breath, maybe their legs are swollen, belly's swollen. They can't eat really well because their belly's so swollen. They have trouble sleeping. And when I say have trouble sleeping, when they lay down to go to sleep at night, it increases their difficulty with breathing, and they have to prop themselves up with pillows. So any of those changes, if there's a change, people will sometimes seek out medical attention. And we do what's called an echocardiogram, or an ultrasound of the heart, and that shows us the pumping ability of the heart.

Host Amber Smith: Well, let me ask Ms. Greiner to talk about how she learned that she had heart failure. This was seven years ago, right?

Ashley Greiner: Yes. I was 35 at the time. I was a practicing attorney. I was pretty busy. I didn't have any kind of overly, like, scary symptoms. I kind of had little things happening to me. And, kind of like most women do, I explained them away. I thought I was getting older, more out of shape. I was getting a little bit out of breath. I was slowly putting on weight, mostly in my abdominal area.

As time went on, there were specifically kind of two days in a row where, like Natasha said, I had a really hard time laying flat to go to sleep, and I started retaining fluid in my lower extremities. And I went to work the whole day, and it continued for two days in a row. So I actually drove myself to Upstate (University) Hospital, and I was actually diagnosed in less than an hour with a proBNP blood test and an echocardiogram.

At that time, I did not realize how sick I was. My ejection fraction was 5%, and I was told if I hadn't come in, I probably would not have made it more than a few days. I was diagnosed, at that time, they just said congestive heart failure, but it was systolic heart failure. And I was transferred to the cardiac ICU (intensive care unit), and ultimately I was transferred to an advanced heart failure clinic in New York City, where I was for an extended period of time. And I've continued to treat there, as well as locally at Upstate, for the past seven years.

Host Amber Smith: Did this diagnosis come as a complete shock to you, or did you, have you ever had heart issues, or does your family history include heart failure?

Ashley Greiner: It was a complete shock. I actually have an idiopathic diagnosis, which means no known cause that the doctors could actually attribute it to. I have never had high blood pressure. I have no coronary artery disease. Still to this day, I have no blockages. I've never had a heart attack. I have no family history of heart failure.

There are some heart issues in my family, but I have not, I don't have any cholesterol issues, never had blood pressure issues. I was diagnosed about four years, four to five years prior, with Hashimoto's thyroiditis, which is a thyroid autoimmune disease. But that was always well managed, so they did not really think that was a contributing factor. And they couldn't really give a definitive diagnosis of anything like a viral cardiomyopathy because at the time that I was diagnosed, I didn't have a virus.

So, you know, those all could have been possibilities, but there was no way for them to pinpoint exactly what caused my heart failure.

Host Amber Smith: When you were hospitalized initially, how long were you hospitalized before you were stable enough to return to your home, and you live here in Elbridge, right?

Ashley Greiner: Yes. I live locally. At the time I was living in Kirkville-Bridgeport area. And locally I was in the hospital for a couple weeks, and then I was transferred to New York City for a couple more weeks.

It's actually very hazy. I don't remember. I mean, I was in the hospital in the ICU for quite a long time, until I was stable. I was discharged from -- initially I was not going to leave the hospital without a heart transplant because my ejection fraction was so low. Luckily, because I was able to go to an advanced heart failure clinic with just more resources, I was able to leave the hospital with an external defibrillator called the Zoll LifeVest, and monitor my progress for three months on medication to see if my ejection fraction improved to over 35%, which is where they like you to be, to not get a pacemaker or defibrillator.

Unfortunately, mine only went up to 10%. So I was implanted with a pacemaker defibrillator about three months after my diagnosis, well, about four or five months after my diagnosis. And then I still continued to have a lot of problems, and I spent my whole first year basically in and out of the hospital because of fluid- and edema-related issues.

After that first year, I eventually had the CardioMEMS implant, which is an implant that sits in your pulmonary artery and measures your pulmonary arterial pressures. And it remotely monitors you so that your doctors can basically see if you're going to be retaining fluid or if you're dehydrated, and essentially keep you out of the hospital and adjust your medications remotely.

And since then, I've basically only been hospitalized two or three times over the past five years for fluid-related issues.

Host Amber Smith: So, aside from the times that you've had to be hospitalized, what kind of a daily impact does heart failure have on your life? Are you restricted in things that you can do because of it?

Ashley Greiner: Yeah, absolutely. When I was first diagnosed, after my initial time in the hospital, I did go back to work. My company at the time was amazing. I am so thankful. But for two years trying to manage this disease and go back to work -- and I have to mention, it's different for everyone -- but trying to go back to work in my field was very difficult.

And even though I had a great company and my colleagues were amazing, it was a very stressful field. And the stress, along with the time, and it wasn't fair to me or the company with the amount of time I was missing going in and out of the hospital, and with doctor's appointments and whatnot, I had to stop working as an attorney.

So that was a huge change in my life. Obviously, you go to law school for a very long time. I had to, at the age of 38, move back in with my parents, not how I envisioned my life. I had to go out on disability. I was very active. I had ran a couple half marathons. I was still doing like fun zombie 5Ks with friends and traveling a lot. And at the beginning of my diagnosis, that was absolutely nonexistent. I have now, over time, been able to resume traveling and kind of stuff like that. In the chronic illness world, it's coined "your new normal." You find your new normal. You find a new path. You find the things that you are able to do within the confines of your illness. And for me, that looks like I started becoming a patient advocate. I started an online heart failure patient and caregiver support group that has just under 3,500 members worldwide.

And I have to eat low sodium because of my heart failure, so I challenge myself with trying to make great low sodium like recipes and foods. I use this time to travel to be closer to my extended family. And as much as I don't want be a 42-year-old living with my parents, I have a great opportunity to spend so much time with them, which most people don't get. So I try to look at the positive side of everything.

Host Amber Smith: How could a listener find the online support group that you mentioned?

Ashley Greiner: It's actually through Facebook, and it's actually CHF Patient ampersand -- the & sign -- and Caregiver Support Group. And you just have to answer a few questions because we like to keep it just for patients and caregivers and their families. We don't like health care professionals. Sorry, Natasha. We like to keep it a safe space for everyone, so they feel very comfortable to be open. But yeah, that's all they've got to do.

Host Amber Smith: Well, nurse Zmitrowitz, once someone has been diagnosed with heart failure is there any way to reverse it?

Natasha Zmitrowitz, RN: So certain heart failures can be reversed. One of those is what we call a takotsubo cardiomyopathy, or what we call stress-induced cardiomyopathy.

It can also happen in body stressful situations such as severe infection. We see it a lot of times in the ICU or through surgery. So that is one that you can recover from.

I can say that there are some amazing medications out there today that can help improve your ejection fraction. When it comes to heart failure with a preserved ejection fraction, when you have that thickening of the heart muscle, that is typically something that we look more at symptom management for, because that can't be reversed. You can, however, in systolic heart failure or with a reduced ejection fraction, medications or devices such as special pacemakers that can help resync the heart back to beating correctly. Those can help recover your ejection fraction.

Host Amber Smith: Are there other things that people can do to try to improve their ejection fraction? I'm thinking about exercise.

Natasha Zmitrowitz, RN: Well, Ashley could probably tell you, as an insider, about cardiac rehab. Unfortunately it's not available, or not covered by insurance for all heart failure patients. Typically you either have to have had a heart attack, a heart surgery, like an open heart surgery, or you have to have a reduced ejection fraction. But we do see a lot of benefits to cardiac rehab.

And Ashley, I don't know, are you thinking that cardiac rehab is helping?

Ashley Greiner: Yeah. I actually, I have wanted to get in cardiac rehab numerous times over the past seven years, but like Natasha said, there's so many kind of rules. Either my ejection fraction was too low, or not low enough, because healing and your journey with heart failure is not linear. My ejection fraction has gone up. It's gone down. It's kind of been all over the place. And so, insurance won't cover it if you have, or you haven't had a hospitalization recently. So there's all these kind of parameters you have to meet.

And so I recently, finally was approved for cardiac rehab. And I can tell you my ejection fraction hasn't gone up, but my ability and my stamina have increased. I don't feel as winded doing things. My, you know, I think the scale is called the "perceived rate of exertion" that you use. I'm able to do things, and I don't feel as like I'm exerting as much energy, which is really what I'm looking for because I know in my particular case, my heart failure's not going away. I'm nearing the part of my journey where I am getting closer to needing a transplant.

I was recently just evaluated for an LVAD (left ventricular assist device), which is a mechanical heart pump. So like, I am progressing in my journey, but I'm just looking for things to kind of be the healthiest I can be, the strongest I can be, like eating low sodium, exercising as much as possible, and kind of things like that.

But, yeah. I think cardiac rehab's a great tool because it teaches you how to listen to your body and exercise within the constraints that are healthy for your body and your heart.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more about heart failure.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith. I'm talking to Natasha Zmitrowitz - she's a nurse and the heart failure program coordinator at Upstate University Hospital -- and Ashley Greiner. She's a lawyer who was diagnosed seven years ago with heart failure, and she's telling us about what life is like living with heart failure.

You mentioned the low-sodium diet, and I assume that's recommended for everyone that has heart failure, right?

Ashley Greiner: Yeah. It's different for everyone. Correct me if I'm wrong, Natasha. You know, everyone needs sodium to live.

Natasha Zmitrowitz, RN: Yeah.

Ashley Greiner: But I think most people eat too much sodium. And everyone has their own kind of baseline. I know when I started, you know, I'm a little bit of an overachiever, and so when they said "under 2,000 milligrams," I went as low as possible, and that was detrimental to me.

I was in the hospital just as much for being too low with my sodium as some people are with not being low enough. So it's a delicate balance. Same with, a lot of us are put on fluid restrictions because our hearts aren't beating properly, and so we're not getting enough oxygenated blood to our organs, including your kidneys, which help filter out fluid. So that's why we start retaining fluid.

So if we control our sodium and we control our fluid intake, we can help minimize the work that our kidneys can't do. So, it's a delicate balance. I might be able to have 2,300 milligrams of sodium, which, that's really what I need, and I don't have a fluid restriction because I kind of know where I need to be at. Whereas someone else might need to only eat 1,300 milligrams of sodium and 2 liters of fluid a day.

So it really kind of takes some working with your doctor and watching your blood tests and stuff like that. But I find that just from what I see from my lovely, wonderful group members and other people I've encountered and met on my journey, and just for myself, too, that is like the hardest, I think, one of the hardest hurdles to overcome because everything, even sweet things, are like packed full of sodium. Even your soda is full of sodium. It's just in everything. And so just trying to eat at home alone is so hard. Forget trying to go out to eat. That is its own hurdle in and of itself. So, yeah, I thinkthat is, that's a huge part of this journey.

Host Amber Smith: Nurse Zmitrowitz, how often do people with heart failure see their cardiologists, typically?

Natasha Zmitrowitz, RN: I would say it depends. Like Ashley said, this chronic illness is up and down. When you come in at first, it takes a while to get stabilized. When it comes to the medications, the grouping of medications that are recommended by the American Heart Association, the Heart Failure Society of America, American College of Cardiology, they all have these recommendations of four main medications. And those medications have shown best outcomes when they're at their highest tolerated doses.

So for Ashley, if she's on a medication, say, called lisinopril, Ashley might only be able to tolerate 5 milligrams of that, where I might be able to tolerate 20. So as long as we get to our highest spot possible, that takes some time. These medications all affect blood pressure. They all affect kidney function. They all affect potassium levels. And we can usually only play around with one medication at a time to keep patients safe.

So at first you may be seeing your cardiologist every two weeks, especially at our heart failure clinic where we focus on the titration and up-dosing of these medications. For patients who are very fluid overloaded and really struggling to keep that fluid down, we try to keep them out of the hospital at our heart failure clinic by using IV diuresis, getting the water off them through IV medications. And some of those patients will come twice a week. And then there's other patients who are doing great.

Host Amber Smith: So it sounds like there's some careful monitoring of the medication, certainly. And Ms. Greiner talked about the sodium intake. Are there other things that people with heart failure have to keep track of that might give them clues whether things are improving or deteriorating?

Natasha Zmitrowitz, RN: Sure. I think one of the biggest things is daily weights.

We want all our patients to weigh themselves in the morning after they first urinate. We don't want them counting what's in their bladder because that gives a false weight. But sometimes people will notice a weight gain before they even feel any type of symptom from overload. So weighing yourself every day is a really big thing.

And then documenting it. That way tomorrow, you don't have to worry about remembering what you weighed today. It's right there for you. We always tell our patients to look for a weight gain of 2 to 3 pounds in a day, that it would not be from food, that is definitely fluid.

But if you're writing it down and documenting it -- some patients may never gain 2 or 3 pounds in a day -- but if they're writing it down, they can catch a trend. They can see, "Hey, look, Wednesday, Thursday, Friday, I'm gaining a pound, every single day. I might be heading into trouble. I need to call my doctor."

Host Amber Smith: So it sounds like this is a disease, a chronic disease that can be managed, but it seems like it takes a lot of effort, really, on the patients and the providers to manage it.

Natasha Zmitrowitz, RN: Absolutely. And you know here at Upstate we have a very large population that has a lot of social determinants of health and barriers with access to care, access to medical transportation. So we've tried to implement some things to remove some barriers. We now enroll our patients in what we call a medication adherence packaging program, through our outpatient pharmacy. That is, if they're in hospital, they get their medicine delivered by "Meds to Beds," which means they get their meds right at the bedside before they leave. They don't have to go to the pharmacy on the way home. And then also, within five to seven days you have a pharmacist calling you saying, "Hey, how's your medication going? How are you feeling from it," working on making sure that they're getting their refills.

If they can't get to the pharmacy, they're making sure they're getting them delivered. If there's a change, and they can't get the medication, it's getting couriered to them. So that's been a really wonderful thing to help with some of the barriers.

We also have a grant that has been funded by Upstate Foundation, which has done awesome things for our patients who have trouble getting to foods that have low sodium, getting access to those foods. In the city of Syracuse, 40% is a food desert, so a lot of our patients are getting their food from corner stores and gas stations and food banks, and really all of those foods are loaded, loaded with sodium. So we have been able to develop a program with a company called Off the Muck, located in Cannastota, New York. They offer a low-cost box of fresh fruits and vegetables to our patients, and the Upstate Foundation has allowed us to purchase a box per patient. And they get those delivered post-discharge. So that's been helping.

You know, you get out of the hospital. The last thing you want to do is go to the store and go shopping. You probably want to get in your own bed. You want to relax. You know you want to sleep a little bit because you don't get a lot of sleep in the hospital. So that helps alleviate some of the stress and transition from going back to home.

Host Amber Smith: Well, I want to thank both of you for making time for this interview. I appreciate it.

Natasha Zmitrowitz, RN: Thank you.

Ashley Greiner: Thank you.

Host Amber Smith: My guests have been nurse Natasha Zmitrowitz -- she's the heart failure program coordinator at Upstate University Hospital -- and Ashley Greiner. She's a lawyer who was diagnosed seven years ago with heart failure. I'm Amber Smith for Upstate's "HealthLink on Air."

Why exercise makes sense during cancer treatment -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Maintaining an exercise routine may not be your top priority during cancer treatment, but there are benefits to being active.

We'll hear about that from my guest, Dr. Kaushal Nanavati. He's an assistant professor of family medicine at Upstate, who is also the director of integrative medicine and survivorship at the Upstate Cancer Center.

Welcome back to "HealthLink on Air," Dr. Nanavati.

Kaushal Nanavati, MD: Thank you, Amber. It's been a long time.

Host Amber Smith: Several health organizations have general exercise recommendations. Dr. Nanavati, are there authoritative recommendations about exercise while undergoing cancer treatment?

Kaushal Nanavati, MD: So there are, actually, several cancer organizations that have recommendations based on the best known current evidence. And the information and evidence change, and as they do, the recommendations do periodically change as well. So the American Cancer Society is kind of the premier organization that a lot of people look at for recommendations, but, there are recommendations from multiple societies.

Host Amber Smith: Do we have evidence that it's actually safe to exercise during cancer treatment?

Kaushal Nanavati, MD: Not only do we have evidence -- it's recommended. And for many people what they forget is that when you talk about some of the impact that cancer has on a person's life, if we just think about, so first of all, let's go back a step. When we say cancer, what that really means, it's a family of conditions. It's a whole compendium. And so one cancer does not equate to another. And someone who has cancer, during their journey through cancer, their body goes through different stages, different phases, and so even their body at different times will be able to tolerate different things.

All of that being said, as a broad stroke, general recommendation, the value of exercise, if I put it in the cancer context, three main points to really bring up. One is that it's been known, through evidence, that exercise reduces the potential for onset of certain cancers, especially when you think about breast cancer, colorectal cancer, endometrial and gastric cancer, esophageal cancer, kidney cancer, and specifically with lung cancer, for people that smoke, exercise reduces their risk of lung cancer. So that's just the risk of getting it.

And for people who have cancer, exercise reduces the rate of recurrence, especially when it comes to things like certain types of breast cancer. So now we're talking about recurrence.

Then we think about cancer therapies. Exercise, through the literature, has been shown to actually enhance the benefit of the treatment and also benefit in actually helping to reduce the cancer burden on the body, whether it be reducing the spread of cancer, what we call metastatic disease. So high-intensity exercise, in one study, actually showed that it reduced the potential for spread of cancer by nearly 72%. That's huge. Right? And high intensity activity isn't something that necessarily everybody does, but clearly there's some potential benefit for the right person in the right condition.

And then the idea of side effects of cancer chemotherapies, right? Whether it's immunotherapy or chemotherapy, or just going through the cancer journey. People experience mental fatigue, physical fatigue, emotional drain, and even the side effects of things like bone thinning, heart toxicity, cognitive decline, all of these things have been shown to benefit. When somebody has exercise, they actually experience less of the side effects and more of the benefits.

Host Amber Smith: I want to ask you a little more specifically about the types of exercise, but I'm assuming maybe the recommendations are different depending on what type of cancer a person has, or how progressed it is or where they are in their treatment.

Kaushal Nanavati, MD: So that's exactly right. And on the other hand, as a baseline, we can say that anyone at any stage of any type of cancer can benefit from being physically active.

Physical activity includes basic things like going for a walk, riding a bicycle, going up and down the stairs, that type of stuff. And then there's more intense forms of activity. We think about exercise in terms of aerobic and anaerobic activity. So aerobic is the standard cardiovascular stuff that people think about, whether it's walking, jogging, treadmill, bikes, swimming, that type of stuff. And the anaerobic stuff relates to things like weight-based training.

So the current guidelines for exercise, which are -- it used to be that 150 minutes of aerobic exercise per week and then a couple of sessions of weight-based training. The latest guidelines actually encourage up to 300 minutes of aerobic exercise per week, along with two to three sessions of weight-based training per week.

So, ultimately, you end up looking at somewhere around anywhere between three to five or three to seven hours of exercise per week, if you include the weight-based training, to give the biggest kind of value for people who have cancer and for people who don't.

Host Amber Smith: What about less vigorous things like relaxation exercises like yoga or even tai chi. Do those count as movement and exercise?

Kaushal Nanavati, MD: They count and have their own value, actually, in terms of not only helping a person with things like balance and coordination, if they've had side effects of their treatment, but relaxation therapy has an impact on the biochemistry and hormones in the body. And so things like deep breathing exercise or practice.Some people meditate. Some people just do deep breathing. Walking in nature, as a reflective exercise. Tai Chi. Yoga. Pilates. All of these things actually have an impact biochemically in boosting the immune system, which is valuable in many instances and at the same time also have a benefit for reducing inflammation in tissues and muscles and joints, improving flexibility.

And so overall well-being improves, but specifically not only the physical, but the mental, emotional, biochemical and hormonal constitution of a person's body actually gets better as well.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking to Director of Integrative Medicine Dr. Kaushal Nanavati from the Upstate Cancer Center about the value of exercise during cancer treatment.

So let's get a little more specific about exercises that would be good for someone who is maybe new to exercise, that hasn't really done a whole lot of activity in the past, and now they're in cancer treatment. What types of things would you recommend for that person?

Kaushal Nanavati, MD: Start low and go slow, right? And I'm smiling as they say that for those that really can't see us anyway. You know, the key is what you want to do is be consistent. There was a study that was done that showed that people who exercise 30 minutes three times a week versus people who did 10 minutes a day, the ones that did 10 minutes a day were more likely to make it a habit.

So the key is really to get started. This morning, my thought was to embark, right, to begin the journey. The most important thing is taking that first step. So for those people that haven't exercised regularly, make it a part of your routine. Make it a non-negotiable so that everything else works around that.

For me, before I go to work in the morning, I have my exercise time. And then if I have time later in the day, I may exercise more or go for a walk in the evening with my wife or my family, et cetera. But fundamentally, I get my self-care time in in the morning because I know that once the day gets going, sometimes we get busy, things come up, et cetera. But first thing in the morning, we can actually plan for it. So I encourage people who haven't started to even plan for five or even 10 minutes, depending on their physical ability.

And more importantly, I will put the caveat that if you haven't exercised regularly, make sure you work with your health care provider and ensure that you're healthy enough to begin exercising. And then they, or they can connect you with somebody who can guide you on how to optimally exercise. At Upstate, we actually have the advantage of having multiple specialties and specialists available. And we even have a physical therapist who is specifically now focused on physical activity in cancer patients. So we're going to have more and more resources available, which I'm really excited about because everyone has different ability. At the same time, every cancer type has a different impact on the body. And depending on how it's impacting one person versus the other, we can be more specific about the types of recommendations we make and the approach that people can take.

But there are fundamental things we all do during the day. And as long as we're more active than we are sedentary, there's value. One of the things that exercise does, actually, which I think is fascinating biochemically, is it actually has an impact on reducing cancer metabolism. So what I mean by that is, if you exercise very vigorously, what happens is your muscles need the blood flow, which kind of steals it away from those cancer cells that are starving for it and clamoring and competing for it. And so if you're exercising and the muscles are getting the blood flow, the cancer cells are getting less of it, which can eventually lead to starving them out. And, biochemically exercise actually works inside the cells to induce natural kind of cancer cell death, so that we can actually get rid of them faster. So that is amazing stuff that we don't even think about.

Host Amber Smith: What about athletes who are used to working out at a high level? Do they ever have to take it down a few notches?

Kaushal Nanavati, MD: So the best answer in medicine that we always teach our students is, "it depends."

So it depends, Amber. And what I mean by that is that it depends on the person, depending on what type of cancer they have. In many instances, they may have to take it down a notch, especially if they're experiencing fatigue, bone pain, if there's stress on their heart because of the treatment or the therapy that they're getting, if they're having impact on their cognitive function, et cetera. Or it's metastasized somewhere else, let's say, to the bone or muscle.

Definitely, I think across the spectrum, from the sedentary person to the person who's an experienced athlete or a competitive athlete, fundamentally we have to make sure that what they're doing is not increasing stress load on their body, on their heart, and on their skeletal structure as well. And then give them a green light as to the degree of intensity, frequency, duration, all those things they can do. But that doesn't mean that they can't be active and doesn't mean that they still can't compete and/or engage in activity as they're able to tolerate and as is dictated by the type of cancer they have.

Host Amber Smith: Does it matter whether the person exercises indoors or outdoors?

Kaushal Nanavati, MD: So if they're exercising, I'm smiling, right? Because they're already doing the thing. Outdoors and indoors, in terms of what the evidence suggests, as long as they're doing it, there's value.

We know that there's benefit to daylight, in terms of mood, cognition, attention and feelings of joy. At the same time, if it's February in Syracuse, then you've got to be careful as to what the weather is outside as well.

So, it is variable. At the end of the day, doing the exercise is where the greatest value is. And then the environment should be one that supports somebody's sense of joy, versus stresses them out. And that's the way they can kind of figure it out as to what works best for them.

Host Amber Smith: I've heard that oncology treatments can weaken the immune system, so do you have any concerns regarding group exercise classes, where the person would be surrounded by other people who are exercising?

Kaushal Nanavati, MD: Yeah, actually that is something to consider, and that is something to pay attention to because the potential for infections such as viral infections, et cetera, is higher, especially if you're sharing equipment or it's not cleaned properly from user to user. Then we have to be careful.

Also, oftentimes when you're in physical exercise environments with groups, not everybody is necessarily practicing optimal hygiene. And even if they are, if they have a cough or they have a cold, then the potential for risk is higher for a cancer patient, especially if they're on some type of immune suppressing treatment.

And so they do have to be careful about that. And yeah, sometimes you love that emotional support, and the support of a group can be uplifting. And at the same time, in terms of exercise itself, you still have to be careful.

Host Amber Smith: Well, on that note, are there things to watch out for so that you're not overdoing it or is there anything risky about this, just to be aware of?

Kaushal Nanavati, MD: I think the most important thing one has to gauge is, 1, their ability,and 2, pair that with their health providers' recommendations, specifically their oncology team and their primary care providers, since between the two of them, their health is assessed, not just in terms of their cancer diagnosis, but their overall health in the context of their life, in terms of their goals.

And so that becomes the important thing. You know, people will hear exercises good for you, and then just start doing it. But, you know, when you jump-start the system, sometimes there's a little bit of stress that comes with that. So, taking a gradual approach to increasing it, but being consistent.

There's a great quote by (actor) Denzel Washington that talks about dreams are just dreams, but in order to achieve those dreams -- I'm paraphrasing -- it requires discipline. It requires consistency. And I think when it comes to physical exercise, the key is consistency, just as it is with nutrition. And I do have to put a plug in that exercise and nutrition go hand in hand. So when people do better with both, it enhances their overall well-being and clearly creates an environment that gives them better opportunity to have an anti-cancer environment within their body as well.

Host Amber Smith: We talked about sort of the ideal amount of time being three to five to seven hours a week, kind of spread across the week. But what about the person who's battling fatigue and struggling just to get through the day sometimes. Do you have any advice for that person?

Kaushal Nanavati, MD: Yeah, actually it is exercise, because what happens is when it comes to cancer-related fatigue, we know that people that exercise actually have improved energy. And so, they may not start with an hour a day. But what they can do is start with two minutes or five minutes, get up to 10 minutes.

We also know from other studies that if you get 10 minutes of cardiovascular exercise, aerobic exercise that's actually good for your heart. We also know that people that tend to exercise more consistently actually have improved energy.

So, it's kind of like, if I don't do it, I'll remain tired, but if I do it, I might be tired in the moment, but over time I'll actually have better and better energy, improved stamina, and that actually helps in the long term.

Host Amber Smith: Is there a value to building in a rest day where you don't do aerobic stuff, or you don't do weight training, you just sort of let your body rest?

Kaushal Nanavati, MD: That depends on the person and depends on the intensity of what you're doing. If you're going for walks every day you can go for walks every day. If you are going to be doing a power lifting competition, or you're going to be doing something engaged competitively or training for a marathon, then you have to kind of do what's right for your body, giving moments of rest. Especially when you do longer endurance or strength-based more intense activities, then your body does need time to recover, depending on how intensely you're doing it. For people that are doing moderately intense activity and / or low intensity activity, generally speaking, they can remain consistent throughout the week.

Host Amber Smith: At the beginning of this interview, we talked about the benefits really of adopting an integrative approach that combines medical treatment with exercise, and you also brought up nutrition. Do we understand, in the body, what it is that is happening that helps reduce the spread of cancer, potentially, or reduce the risk of cancer? What is happening, like, at a cellular level?

Kaushal Nanavati, MD: A ton of stuff, I'll tell you. Everything from impact on dopamine to immunoglobulins, to actually impacting cellular structures that lead to kind of advanced cell death and slow down the progression of cancer, slow down the spread of cancer, what we call metastatic disease, what we call proliferation or growth of the cancer.

There are multiple, multiple enzymes and hormones and chemicals that are affected, including what we call cytokines and the VEGF (vascular endothelial growth factor) protein that some people have heard of, something called mTOR, (mammalian target of rapamycin) multiple, multiple enzymes that get affected.

In fact, the other thing that ends up happening is, it actually has an impact even on the blood supply to cancer cells and reducing that, as I mentioned, with higher intense activity. So, everything from regulating the metabolism of cancer, how much it gets for nourishment, to regulating the immune environment in the body to keep our immune system stronger, to reducing the cancer risks, as I mentioned, to reducing the cancer related side effects. And all of that, combined, is happening simply by staying physically active on a consistent basis.

Host Amber Smith: Well, this is really good to know and very important information. I appreciate you making time for this interview.

Kaushal Nanavati, MD: I really appreciate it because I agree that this is really the stuff that puts the power back into a person's hands to be able to navigate their living experience, even with a diagnosis of cancer, recognizing that you want to be, you want to live like you're living, and you want to have the best quality of life moving forward, regardless of the diagnosis, to the best of your ability.

Host Amber Smith: My guest has been Dr. Kaushal Nanavati, an assistant professor of family medicine at Upstate, who is also the director of integrative medicine and survivorship at the Upstate Cancer Center. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University. How do you advise adult children when it's time to take the car keys away from a parent?

Sharon Brangman, MD: Well, this is one of the toughest things that we deal with in geriatrics. There is no set age when somebody should stop driving. This is a very individual thing. We should not have a one-size-fits-all. The aging process, in and of itself, can make driving more risky. For example, someone could have arthritis in their neck, and they can't turn their head to look over their shoulder when they're changing lanes, or they may have a weakness in their legs that could keep them from pressing down hard on the brakes. There are also vision problems that occur, or hearing problems that can make it difficult to drive. And of course, if you have any kind of memory problem that impacts your ability to make decisions or have appropriate reactions when you're driving, that could be another red flag.

So what we usually tell adult children is that they have to have a plan. You can't just do this overnight. You have to look and see how you are going to supplement the driving needs of their parents, for example, when they have to stop driving. And we live in a society, and especially in our city, we don't have a very walkable city, and most of our services are out in the suburbs. So when you stop someone from driving, you can cut them off from everything from groceries to the pharmacy, to going to church and socializing. So you have to have a plan. You have to have a process so that you can figure out who's going to fill in those gaps. A lot of adult children feel ambivalent because they can't do it, but we now have lots of driving services, and there are actually people who do this now as a living, who can come and help drive. And yes, you may have to give up some of your spontaneous ability to come and go, but you can still be able to get the things you need appropriately, if you don't have a car yourself.

And we always want to stop before there's a terrible accident. And I don't have a crystal ball to predict when that might happen for any one person, but we don't want to wait for someone to get hurt before we make that decision. And that's the part that gets tricky because again, that's a very individual thing.

There are driving evaluation programs that can be helpful, where an older adult can go and get a driving test by someone objective to just see how they are behind the wheel, and if there's any adaptations that might be helpful or anything that can be done to help them stay on the road safely. We have some patients who stopped driving at night, or they don't drive during the busiest times of the day when the roads are quieter, and that's sometimes is an adaptation that works. But unfortunately, there does come a time when it is time to hang up the car keys to keep you safe and to keep others safe, as well.

Host Amber Smith: You've been listening to Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Cathy Kodra, an independent editor in Knoxville, Tennessee, is the author of a collection of poetry called "Under the Adirondack Moon." She published that in 2017. Her love of nature pulses throughout the beautiful elegiac poem she sent us, "Birdie Leaves This World":

Bees arrive and gently lift you up

to a bed of honeycomb that hangs

a wing shy of the nursing home cot

before they bear you high and higher

to weightless light where honey and jam,

sheep and yarn and song, encircle you

in benediction, where you taste snow

on your tongue again, where shocks of hay

shine in the sun like thick strands of hair,

and you soar above the world you knew

to a pure state of satiation

you hadn't believed in, hadn't seen

in the tea leaves you brewed each morning,

not noticing your soul's reflection.

Astride the humming carpet, you turn

back once, see your children crying for

how they've disappointed you, lovers

suffering for how they've done you wrong.

You urge them all, Go easy to your futures. Never underestimate the forgiveness of a soul in flight.

Below you they stoop low in sorrow,

cling to each other, seeking solace,

not remembering to gaze skyward

where the bees bear you high and higher,

where the new honeyed light encircles

your hair like a halo, where snow falls

past your smiling lips, and on you soar.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.