Patients worry about cancer but struggle to make lifestyle changes. Here’s how to discuss factors they can control and realistic steps they can take. Includes an explanation of the complex relationship between body composition and cancer risk (spoiler: muscle matters as much as fat!) and offers helpful websites and apps for both doctors and patients.
Mm. They're quick housekeeping disclosures. There we go. Um, So my objectives today are to talk about alcohol and diet in relation to cancer risk, um, to review the importance of body composition to cancer. I'm so often we use BMI as a surrogate for obesity, but we really need to be thinking about body composition to learn about the complex relationship of obesity and cancer. Um, and then examine the effect of exercise on cancer prevention. And I'd like, you know, to have you think about how you can make an exercise prescription for your patience because sometimes if you give them something to do, that's like something that they can really take to heart, and sometimes it can motivate them to exercise. And then I also want to discuss the role of sleep and stress reduction. So just a brief mention of epi genetics, which is its expression of genes due to environmental factors. And I actually don't know who had this quote that says jeans, load the gun, but environment pulls the trigger. But I just love that because it really describes, um, how, even if we have some genetic predisposition, we're not destined to be sick. um, food and exercise sleep, stressed trauma or lack of trauma supplements? Um, mental health, toxic exposure. They all influence. The disease is manifested, and you as primary care doctors are in an amazing position, like a great position to help with the prevention of chronic disease and cancer. Sometimes the way you talk with the patient about something, or if you can give them information that can help them, it can motivate them to change. And I find that the role of these environmental effects on their risk of cancer is a much more motivating, uh, factor for patients. So I'll give you an example. So a patient who is not exercising if I let them know that it doesn't matter if they lose weight, and it doesn't matter if they look good in their genes or that they look good in their clothes. But if they exercise, even if they don't change their body weight, they actually lower their risk of recurrence of their breast cancer. For instance, Um, that's a really powerful reason for a patient to exercise, and it doesn't have to do with how they move the needle on the scale, and I find that there are much more motivated to actually exercise in that situation. So I'll point you to these, um, these guidelines because a lot of the information I'm going to talk about, especially in in relationship to diet and some lifestyle issues are summed up in these World Cancer Research Fund and American Institute for Cancer Research Guidelines. This is available for free online. You can download the 2000 and 18 recommendations, and I find it to be a really helpful resource for primary care doctors or for anybody who's interested in cancer. So lifestyle factors that increase cancer risk are poor diet, excess body weight. So excess body wake causes a 7.8% of cancers and 6.8% of cancer deaths for these cancers here, breast, uterus, colon, kidney and gallbladder infections are also associated with cancer such as hepatitis C, virus, hepatitis B, virus and HPV, um, liver, cancer, head and neck, anal and genital cancers in both men and women, um, smoking causes 20% of all cancers and 30% of all cancer deaths. That's a statistic you're familiar with, and then the other one that I really want to stress today, is how alcohol causes cancer, too. It's been classified. Now is a carcinogen by the American Cancer Society. About 50% of head and neck cancers are caused by alcohol, and the last one that I was going to stress a lot is sedentary behavior and lack of physical activity and how that increases the risk of cancer. So nearly 50% of the most common cancers can be prevented. So just that is an amazing statistic. And the lifestyle behaviors to decrease risk include eating well weight control like not gaining weight, exercising independent of weight, not smoking, wearing sunscreen, getting vaccinated for HPV or HPV, and limiting alcohol. So these are things that we can talk with our patients about and give them agency over to decrease their risk of cancer. So this is a, um this is a slide about the burden of disease injuries and risk factors among among the U. S. States, and this is from JAMA 2018, and it's kind of a busy slide. But what I really want you to focus on is the light blue, which is here, here, here, here, here, here, here. This is neo plas ums and this is risk factors and related deaths. So diet this is the increased risk of cancer related to diet tobacco, high body mass index, high fasting, plasma glucose. So, as primary care doctors are taking care of patients with diabetes, um, diabetes is actually a risk factor for cancer. I'm alcohol. Air pollution, an occupational risk, and the occupational risks can include chemical exposure. But it can also include night shift workers. So patients that work the night shift have an increased risk of multiple kinds of cancer. The strongest correlation being with breast cancer. So we live in Northern California, and it's unfortunate for Northern Californians that alcoholism modifiable risk factor for cancer I'm ASCO has formally stated that alcohol is a risk factor for multiple malignancies, and modest use of alcohol can increase the risk of cancer. But the greatest risk are observed in heavy long term users. About 70% of people in the United States do not recognize alcohol as a risk factor for cancer. So if you ask your patient, if you gave them a test question and you ask them what causes cancer, you know you could say tobacco, not exercising, being overweight, alcohol 70% of people wouldn't pick alcohol as a risk factor. Um, the guidelines set that two a day for men is recommended or less or one a day for women or less. And I would I would really focus on the or last. So alcohol use and burden of disease globally is that globally alcohol use was the seventh leading risk factor for death. And for a judge greater than 50. Cancer accounted for the largest proportion of alcohol attributed deaths, 27% in women and 18.9% in men. This was in the Lancet in 2000 and 18. So, um, there is convincing evidence that alcohol increases the risk for head and neck cancer, esophagus, liver, colon, rectum and postmenopausal breast cancer. There's a probable increased risk with stomach and premenopausal breast cancer and a suggestive increased risk, which is not a strong for lung and pancreas cancer, and it also looks that looks like that if you drink, you have a decreased risk of kidney cancer. So I'm not sure that's the best reason to drink, and this is breast cancer is one of my interest. I mainly see breast cancer patients in This is from cancer research in 2000 and eight, and it showed the relative risk of developing an ER pr positive, postmenopausal breast cancer based on alcohol consumption. So when my patient from Marin County comes in and says I do everything right, I exercise. I eat well, like I'm a normal weight. There's I don't have cancer in my family, but they drink two or three glasses of wine per night. This is probably the reason that they have breast cancer. Um, and as you can see, if you have less than one per day, it's about 7% risk. 1 to 2 per day, 32% risk and greater than three a day is about 51% risk. So, you know, I think trying to talk with patients about drinking less than one drink per day for women is a very prudent measure that primary care doctor could advise. So these are the guidelines I was talking about earlier the World Cancer Research Fund and you can you can get a a paper copy of these if you send off for it, or you can download it on the Web. This is a very helpful guide, and they update this periodically. The most recent update is 2018, So let's shift to diet. So Hippocrates said, Let your food be your medicine and your medicine Be your food. And I think that we have come to the conclusion, I think in mainstream medicine as well as an alternative and integrative medicine that that food can be a powerful weapon and diet can be a powerful medicine for patients to help them be well. So I recommend the anti inflammatory diet, and I want to go through what that means and why. I recommend that Um, an anti inflammatory diet is a diet that lowers inflammation in the body because it because of the types of foods that are eaten but also because of the fiber that it is involved in this kind of diet. So I feel like there's been a lot of talk about plant based diets, and we have I'm following just a plant based diet, and I tell my patients that they don't have to be vegetarian. They don't have to only eat plants, but you want to try to increase your plant based foods in your diet so increasing whole grains, fruits and vegetables of all the different colors. Decreasing animal facts. Limiting red meat to 2 to 3 servings a week, so animal fats can be inflammatory and they're saturate effects that can cause a vascular disease. But the real one of the real problems with red meat is actually the iron so iron can can be in the colon can change. The microbiome can change the biofilms that's that are on the colon surface. And iron itself is a personage in, um in in the in the gut. So it's it's very complicated, and I but I don't tell my patients they can't have any red meat. I just say that it's better to eat less red meat or or you don't actually need to eat red meat unless you really want to, um, increase in a Marine Omega threes, um, and decreasing of processed foods. Sugar, white flour, white rice. Um, I recommend seasoning people, um, the food with anti inflammatory spices, garlic and onions, ginger and turmeric. And if you're going to drink, drink red wine because it has some phyto nutrients. Um, and green tea also is very healthy. People ask me if coffee is healthy, and coffee is completely fine to drink, especially if you're not loading it with sugar and saturated fat. So a lot of my patients, when they get diagnosed with cancer, they'll say, Oh, I'm juicing, Dr Marshall. And, um, one of the things is that juicing is not. I really don't feel like juicing is the best way to get nutrients, because when you juice, you get a high sugar content, especially if you're using mainly fruits and the fiber is removed. So, um, I feel like when you're eating fruit, if you're eating the whole fruit and you're eating the fiber, that's going to lower the glycemic load because of the fiber. And, um, it's better to eat the whole food than it is to to just take the different parts of the food. One of the things one of the examples I get for reducing, is also that we were probably not meant to eat 50 carats, and when you're juicing, you could eat the equivalent of 50 carats. You were probably meant to eat one or two real carrots with the fiber, and that way we don't get out of balance on those different video nutrients. which can affect different parts of the body, sometimes in a negative way. We'll go through that in a moment. We need fiber for our microbiome. We need fiber to eliminate toxins and hormones through the colon. Um, weight control and satiety are increased with fiber, and that helps with control of obesity recommending 25 to 35 g of fiber a day. Um, I recommend 5 to 10 servings of fruits and vegetables today. Um, and in America, that's a lot because a lot of people the average is about 1 to 2 servings of fruits and vegetables. Today, there's only 12% of the population that eat 5 to 10 servings of vegetables and fruit. Today, probably we have a higher level of people that do that in California compared to the rest of the country. But it's actually really low. Um, so one of the things to encourage patients to eat more fruits and vegetables is just to really let them know what a serving is. Because a half a cup of cooked vegetables as a serving, a whole cup of raw vegetables, um, is a serving, so it's it's not as much as they think But it's, I think it's important to help them try to get to at least that five servings so that they'll be getting more fiber in their diet as well. Yeah, so many of you may have known about this already. Um, the Environmental Working Group, and you can look this up online, the Environmental Working Group dot dot org or www dot org. And it has this thing called the Dirty Dozen in the clean 15, which I like to give out to patients. Um, I give them this Web address, um, in my dot phrase, and I tell them about this because some of them say, Do I have to eat all organic or can I eat non organic? It's so expensive to eat organic. And so this is a way for them to decide what would be safe to buy conventionally, because there really aren't very many pesticides on it and which things are, which are. Things are better to buy organic because the pesticides that are used in growing these different crops are dangerous. Um, and so this is a nice website. This also has. There's also something called the healthy living app that you can download on your phone, and it will. It will actually give you information about food, and you can even scan labels where it'll tell you whether it's something that's safer or or not. They rate things 1 to 10 as far as safety. So next let's go to sugary drinks and cancer risk. So there's a positive association between sugary drink consumption and overall cancer risk. The hazard ratio of 1.18 breast cancer has a hazard ratio of 1.22 so increased by 22%. Um, if if the person is drinking sugary drinks and there's a positive association also with just fruit juice so it doesn't have to be Coke, but 100% fruit juice as a hazard ratio of 1.12 artificially sweetened beverages, though they have some downsides. Do not increase the risk. However. It is thought that artificially sweetened beverages, the artificial sweeteners can change the microbiome and cause inflammation in the GI tract. So the 14 components of dietary risk This is a summary slide from Lance at 2012, so diets low in fruits, vegetables, whole grains and I don't mean holy bread. I mean whole grains like King Wah brown rice borrow? I mean, actually the whole grain nuts and seeds, milk, fiber, calcium, seafood and polyunsaturated fatty acids. That's low in these things and diets high in red meat, processed meats, sugar sweetened beverages, trans fatty acids in sodium, probably as primary care doctors. You guys know this better than anyone, and your patients are. You know you're trying, especially if you're working with diabetics. You're trying to change their diet to be more healthy. But these are the dietary components that are associated with cancer, diets that are low and these ones on the left and diets high in the ones on the right. So let's talk about vegetarians and colon cancer. So this is a large study of 77,000 people plus the Advent Health Study, and they looked at colon cancer and rectal cancer, and they had. They're a very small number of colon and rectal cancers compared to the general population, um, at 7.5 years, and they looked at the adjusted hazard ratio and vegetarians versus non vegetarians for colorectal cancer, and they looked at all the different types of vegetarians or semi vegetarian diets, and what they found kind of across the board is that people that follow a heavily plant based diet or vegetarian diet, even if they included some animal proteins. So the lacto ovo um, included milk and egg Pesko included fish, milk and egg and then semi vegetarian, where they actually even ate some chicken. But these people were not eating red meat. They had a high fiber diet, lots of phyto nutrients, lots of fruits and vegetables and whole grains, and there was a reduced risk of colorectal cancer across all of them. Now, interestingly, the pesky Terrians actually did the best. And those those patients are thought to have had a lower risk because they also have the anti inflammatory effect of omega threes in fish, which are highly anti inflammatory compared to omega six fats and that are often seen in red meat and meat. So for colon and rectal cancer, there was a decreased risk, and for all colorectal cancers, it was a decreased risk. So the who has classified red meat as a carcinogen, and I am sorry the slide is a little blurry, Um, but sausages and hot dogs, bacon and salami are classified as, UH, cancer causing, causing cancer carcinogens. For sure, they feel that red meats, including pork, beef and lamb, probably caused cancer, and it's probably related to dose, and it can also be related to how the food is cooked. So it cooked on a grill, um, and burnt like burnt animal fat and burn animal flesh. Um, seems to be more carcinogenic than, uh, something that's braised or cooked on the stovetop and not not fried or ground. Yeah, so I'm borrowing this slide from Dr Donald Abrams, who's an integrative oncologist, and I just I just kind of like that. We'll have the half pound double dialects cheese steer burger, please. Do you want chemotherapy with that? If you want a side of chemotherapy, so next, going to move on to supplements. So a lot of patients want to take supplements to prevent cancer or if they get cancer, they want to take a bunch of supplements to prevent side effects or decrease their chances of cancer. And this is the American Cancer Society statement on supplements. Um, there's really strong evidence that eating a good diet reduces the risk of cancer, but there's absolutely no evidence that supplements reduce the risk of cancer, and some high dose supplements can actually increase cancer risk. I'm going to go through a few things. A few studies that have been done and and if you want the if you want the references for any of these studies, I'm happy to send them to you. But in the interest of time, I didn't list all of the references, but they have been studied. These are the studies that have shown an increased risk of cancer with supplementation. Men with a high risk of lung cancer on high dose beta carotene versus placebo. The men on beta carotene at a higher incidence of lung cancer. Men on vitamin E versus selenium versus placebo. The men on vitamin E had a higher prostate cancer incidents, and the men on selenium had a higher incidence of diabetes. In Norway, they did a study of B vitamins, and they found that that those that took folic acid and vitamin B 12 had a higher death rate from cancer. Now I would I would say that if you have a patient that has fully deficiency or B 12 deficiency, that would not apply to that patient. This was really looking at normal people who were just supplementing with the vitamins who did not have a deficiency of any type. There's a higher risk of prostate cancer with fully supplementation, and this is like a funny one because, you know, talked about alcohol and breast cancer risk. But women who drink a lot can lower the risk of breast cancer by taking folic acid. And I don't think that should be a reason to. I don't think we should tell our patients. Take folic acid and then you can drink all you want. I don't think we should do that. But, um, it's just an interesting observation, a little study that they saw so supplements that are safe and possibly helpful. Our vitamin D vitamin D deficiency. It's been shown to be associated with multiple types of cancer breast and colon being two of them. Omega three supplementation, um, is we feel as safe to take if you're a cancer patient or for prevention? Um, tumeric, um is an anti inflammatory, a very powerful anti inflammatory, and that is not has not been associated with cancer. Increased cancer risk patients taking code Q 10 if their own statins and probiotics. Um, so antioxidants should come from your food as far as I'm concerned, and you shouldn't be taking supplements of antioxidants. If you're a cancer patient and you take antioxidants, it can actually protect the cancer from radiation and chemotherapy. And patients have higher, um, recurrence risk if they take antioxidants while they're getting radiation and chemotherapy. Um, so in the metastatic setting or the setting where there being treated for a pal? E ation antioxidants do decrease side effects from cancer treatment, but you can also, uh, do the same thing by having them eat a diet that's rich in antioxidants, and then you're not taking that risk of it protecting the cancer. So I'm going to just shift now to kind of obesity and exercise and movement physical activity. And this is just a slide about the obesity problem in America. So it is predicted in 2030 that severe obesity will be the most common BMI category nationwide among women, black, non Hispanic adults and low income adults. Um, and then some of the statistics, um, that are coming from this paper are that from 1990 to 2020 b. M. I greater than 30 went from 10 to 20 to 40 to 50% from 1990 to 2020 b. M I. Greater than 35 went from 10 to 20%. So this is, as you know, as a primary care doctor, a growing problem in America and with it coming all types of chronic diseases, including cardiovascular disease, diabetes and cancer. Obesity associated malignancies. Um, this is from 2000 and nine. Um, but this this report estimated that obesity related excesses of these seven cancers accounted for 115,000 preventable deaths per year in the US obesity associated malignancies. The CDC estimates this is from 2000 and 18 that overweight and obesity now associate are now associated with 40% of all cancers in the U. S. Accounting for 55% of all cancer in women, 24% in men and two thirds of all cancer in adults 50 to 75 years old. That's a kind of staggering statistic. So I want to just take a moment to look at the complex biology of obesity and cancer and this this biology, um, is striking in that it also, um, it also has to do with the path of physiology of diabetes and inflammatory diseases of the body, including cardiovascular disease. Um, the the fact, or I feel like the adipose tissue or or the adipose endocrine organ. Think of it. Think of it as an endocrine organ. Um, it does a lot of very complex communication with the body. Um, there's, um, insulin and insulin resistance elevated glucose free fatty acids. There's leapt in and out of connecting changes. There's peripheral estrogen that can be made by the fat cell and increased inflammatory markers. These different cytokines and different chemicals that are made. They basically can communicate with the cancer cell. They can communicate with the tumor, micro environment and this. This can either help a cancer cell grow. Or it can inhibit cancer cell from growing, depending on which chemicals are elevated or decreased. Now, interestingly, muscle also makes chemicals and muscle mass can interfere with the cross talk of the fat cells to the micro environment into the cancer cell. So that's that's why I want to talk about body composition in a minute. It's it's not just whether or not you're heavy. It's whether you're heavy and you have low muscle mass, or it's whether you're normal weight and have low muscle mass and increase at a possibility in relationship to your muscle mass. So that balance of muscle to fat and how it talks to the cells of the body is really the key in and how a person's body will either help them make a cancer or help prevent a cancer. So let's talk about just, uh, sedentary behavior, so sedentary behavior is associated with an increased risk of breast, colon and endometrial cancer. And if you look at this graph, this is from the physical guidelines for Americans Physical Activity Guidelines for Americans, which is also available for free online and has really has some really great information in it and also things that you can give patients. But this is the relationship among moderate to sorry to is basically from sedentary behavior to all cause mortality. Um, and as your daily sitting time goes up, your risk of mortality goes up, and as your exercise increases as seen here from left to right, you're you're basically will lower your all cause mortality, the more active that you are. So let's say you have a job where you have to sit for eight hours today. If you exercise, you can actually counteract the bad effect of city of being sedentary by exercise. Um, this physical activity guidelines for American has they kind of prescription? This is what's recommended for all Americans, um, whether their Children adolescents, um older adults, younger adults. It's the goal of at least 150 minutes a week of moderate intensity aerobic activity than to two sessions a week of muscle strengthening activity. I'm going to go into this more in a minute, but this is actually should be the goal for our patients, whether they're cancer patients or whether they're regular patients who haven't been affected by cancer. This is what is recommended for the best health results. So let's talk about Sarko Pina, which is low muscle mass. So low muscle mass is common in cancer patients in early and late disease. It's common with age, and cancer is a disease seen with increasing age. It's an independent predictor of overall mortality in cancer patients, but also in regular patients. Um, it's present in early stage colon cancer and breast cancer patients that when they first present. Um Sarka Pina is common, and its associated with the worst overall mortality risk. Independent of body mass index. Um, low muscle mass is consistently associated with greater treatment related toxicities and the higher overall mortality in a variety of cancers. So circa Pena is a real problem, and body mass index is an imperfect surrogate for body composition. So I'll have you look at these two cats can slices. They're both patients with a body mass index of 29. But as you can see with the yellow, um, the yellow is the visceral adipose tissue, and the person on the left has markedly more visceral adipose tissue than the person on the right. Um, the person on the right has significantly more red. You can see which is muscle and and the person on the left has less muscle. And if you look at the type of muscle the patient has on the left, there's intra muscular adipose tissue, so there's fat actually infiltrating the muscle, whereas you don't really see that too much on the right. So even though both of these patients have a BMI of 29 the person on the right is actually a healthier person and has doesn't have Sarko Pini A whereas the person on the left actually does. If you look at the right hand slide, what it shows you is that your B n y, um, can cannot always predict whether you have Sarko pina and you can have high a deposit e even if you have a low BMI and you're and and it actually makes you metabolically unhealthy, you look at the very top right here. These are people with low muscle mass and high a deposit E, and you can see that it ranges across the BMI even into the normal range. So this is a study that was done at Kaiser by Betty Con, and she showed that at presentation, breast cancer patients had CAT scans and they looked at their muscle mass versus at a paucity. And a third were Sarka Penick and had a worse survival independent of me. So you can see that in this graph right here. The patients who are not Sarko Pena Sarka Penick had a better survival from breast cancer than patients who are Sarko peanut. This was also replicated in colon cancer patients, non metastatic colon patients at presentation. The ones that were Sarko peanut Worse overall survival and cancer specific overall survival. Um, if they had had circle opinion versus not and these this was independent of the BMI. So this is normal patients on the top line on the bottom graph Patients with high a deposit e This is a low muscle mass, but they weren't excessively Have they didn't have excessive adipose tissue or high animosity and low muscle mass? So really, it's important to try to help patients exercise and build muscle mass to help protect them. So I know I don't have, like a little polling thing for you to do, but you can write your own answer down here in the preventive setting. Exercise lowers the risk of all of the following cancers, except I'll give you a minute to decide your answer. Mhm. Okay, And the answer is actually melon melanoma. Um, and they think actually that melanoma, because people who have melanoma often spend more time outside in the sun and they're exercising actually having a son, Um, there's actually an increased risk of melanoma if you exercise, but it's probably due to sun exposure. So the strongest evidence for for exercise is in these cancers, um colon, stomach, esophagus, bladder, kidney, endometrial and breast exercise. Especially those guidelines that we talked about three hours a week of moderate exercise and 22 episodes a week of strength training that has been shown to decrease the risk of these cancers. There's very strong evidence for it, and this is a a observational study done by more. And, um, the references there for you. Um, this is a study that looked at 1.4 million people, and it looked at the multi variable hazard ratios for the highest versus the lowest level of leisure time physical activity by cancer type. And they were following these guidelines for Americans that I just talked about. And what they found is that the hazard ratio was less than one for 13 different types of cancer. So 13 out of the 26 cancers that they looked at had a lower risk of cancer if they exercised at the level recommended in the guidelines. And what's interesting about this is that this relationship of moderate to vigorous activity is if you do more, you don't necessarily get much more of a benefit. Um and the patient that does nothing. So let's say you're over here on on the far left, and you do any exercise at all. You will decrease your risk. You will decrease your risk. And there's an early, steep slope to helping patients improve their risk. If you if you can get up to the 1 50 to 300 minutes of moderate exercise, that's where you get the best benefit. And going past that, you don't actually get much of an increased benefit as far as all cause mortality. So how does exercise prevent and decrease recurrence by lowering insulin, changing sex hormones, decreasing harmful side of kinds of the fat cells make and raising the good cytokines that the muscles make the my Akins. It also causes chemical changes within the tumor, micro environment and immune system stimulation. So they've done studies on exercising in cancer patients and at diagnosis. And if they exercise even for 2 to 3 weeks before their surgery, a lot of their genes that stimulate their immune system were turned on. Um, there's it's act. There's active research, looking at the inflammation, oxidative stress and hormone levels with exercise and the epigenetic expression within the tumor cells. Um, that's those are active areas of research, but it's it's very, um, it's a very powerful weapon that we have against cancer, And it doesn't matter if the patient loses weight. And it doesn't matter if the patient, um, you know, changes their BMI. Um so exercise is also good for preventing and controlling chronic disease. So in the case of diabetes, um, it can control diabetes, and that lowers the risk of getting a recording from certain types of cancer. Um, we know that actually having diabetes is a risk factor, especially for the cancers that are driven by insulin like uterine cancer, breast cancer, colon cancer, prostate cancer and like following a diabetes specific diet and exercising and lowering insulin definitely lowers the risk of recurrence. I'll just show you this thing for breast cancer. Sorry, I'll go back that the increasing insulin levels increases the risk of death and distant recurrence. It's specific, um, to insulin and all other. There's a lot of other chemicals that go along with that, and strength training actually lowers insulin, the most of any type of exercise. So in the interest of time, I'm going to skip ahead. So I think that in trying to prevent Sarko Pina strength training is a really important way that we can prevent Sarko Pina. It lowers insulin, the most of any type of exercise. It increases muscle mass decreases lymphedema as risk, as well as the severity of lymphedema and people that have breast cancer. It increases strength and mobility of the joints and improves quality of life, lowers the risk of falls and fractures and actually lowers the risk of getting put in a nursing home. If you if you do strength training my big philosophy about exercises to never do nothing. The great news with exercise is a little bit goes a long way. Being less sedentary is beneficial and the highest benefit of exercises in people who go from doing nothing to doing something. There's no minimum amount, minimum amount of exercise. It can be additive during the day, so you can tell your patients if you can go and walk 30 minutes, you can do 3 10 minute walks or 2 15 minute walks. I tell them to do do exercise snacks so like to do tin wall push ups or 10 squats, even if they're squatting up and down from a chair, a five minute walk just adding up in order to help them gain confidence and strength. Um, and small amounts of strength training can help them build strength to do more aerobic activity. The five Components of fitness. As I see it, our cardio balanced strength, training, stretching and rest and mind body movement combines multiple components. So people that do yoga, tai chi and qigong are combining strength training stretching sometimes like a meditative effect, which can lower stress hormones, um, and also are working on balance. So some helpful equipment that you can have talk to patients about at home if they don't want to go to a gym or if they can't afford a gym. There's these adjustable dumbbells. You can use resistance bands or yoga mats, and though this isn't specific to primary care, I think this this is a nice website to go, too. It's called moving through cancer, and it has a lot of things that you could adopt for your for your patients, even if they're not cancer patients about how to help people increase strength training, increase aerobic activity, giving them a prescription, they can use it could be modified for one medical and to be used to help motivate patients. Um, and it's like a prescription you can actually give them. I'll give you this reference. Um, it's a It's a really good reference. It has. All of the has a lot of references to studies that have shown how exercise can decrease risk in cancer, either in the preventive setting or in the, um, setting, where you've already gotten cancer. So I want to just talk about my body movement practices because these my body movement practices can substitute for strength training. For a patient who doesn't want to lift weights or maybe doesn't is feeling intimidated by that, um, it's a good choice to add for the strength training portion. Um, so there's multiple ways to connect patients to exercise. Never do nothing. It benefits patients irrespective of weight loss or be me. And you should tell your patients that so they don't feel like they have to lose weight to get the benefit. And it's important to help them increase muscle mass and increase relative strength so that they can do more aerobic activity and strength. Training could be resistance training with weights, bodyweight, yoga, tai chi or qigong