Lessons from Sports and Exercise Medicine

Hello and welcome to theSt Emlyns Podcast. I’m Simon Carly, and today we’re going to do something a little bit different, but very much related to the current COVID-19 stroke, coronavirus, stroke, SARS, COVID-2 outbreak. We’re getting together with a couple of experts in their fields to talk about aspects of well-being, support, immunology, nutrition, exercise, sleep, and a whole range of things which we think are really important as we think about how we are going to get ourselves and our colleagues through the next few months.

I’m going to start by getting them to introduce themselves. I’ve got two people on the podcast with us today, which is a bit unusual for us, so bear with us on the editing. Guys, do you want to introduce yourself? John, you go first.

Hi, Simon. I’m John Rogers. I’m a consultant in Sport and Exercise Medicine in Manchester. Over the last 12 to 14 years of my career, I’ve worked a lot with endurance athletes in British athletics and at British Triathlon. We see a lot of respiratory tract infections in the athletic population that we look after. It’s probably the biggest time loss factor, medical factor that we see. As a result of that, there’s been a lot of scientific intelligence and resources put into the prevention of respiratory tract infections during my career. I’ve worked with my colleague, Nathan Lewis, over the last 12 years, and we’ve seen a lot of athletes who have had problems with fatigue and overreaching because of the significant volumes and intensities of training and the stress, both physical and psychological, that comes with competing at major games and in very high-pressure situations.

Nathan?

Hi, Simon. Yes, I started out clinically and initially trained as a dietitian. When I left the NHS, I was working in intensive care, supporting athletes and prescribing nutrition to patients in that setting. I subsequently went on to do a PhD in Exploring Fatigue and Oxidative Stress in elite endurance athletes. I’ve worked for the English Institute of Sport as a nutrition scientist and as a nutritionist for the last 15 years across four Olympic cycles. I also work for a company called Orreco, which specializes in recovery solutions and biomarkers for elite athletes around the world. My day job now is very much focused on the elite athlete.

You guys are both experts in your fields. There’s no danger in us ever doubting the credibility here, and it’s fantastic to have people like you just so local. One of the things I’ve learned a little bit over the past few weeks with the COVID-19 outbreak is we’re breaking down walls, speaking to different people that we didn’t speak to before, and we’re learning huge amounts from each other. That’s kind of what I want to get out of today.

As we sit at the moment here in Manchester, we’re on the upswing of the curve of cases that are coming through, and we’re seeing some really quite terrifying stuff coming through the doors. We also have a workforce who are potentially facing one of the toughest times of their careers over the next few months. They’re stressed, anxious, and worried, but they’re also up for it. They’re ready, prepared, and they want to be as good as they possibly can be. We also need to flatten the two curves. I talked about this on one of the other podcasts. There’s a curve of general population infections. We need to flatten that to keep under NHS resources, but we also need to flatten the curve of healthcare worker infections. If we all go off sick at the same time, we’ve got a major problem because there will be nobody to look after the patients, who will be us. Anything that we can do to support our staff to stay healthy and recover quickly is really important. That’s why I’m really delighted that you guys have come along today.

We always take an evidence-based approach at St. Emlyn’s, and I know that you’ve got some ideas, thoughts, papers, and evidence to talk to us about today. Do you want us to kick off? Where do you want to start with how we can keep ourselves in tip-top condition during these difficult few months?

If I start, Nathan, with some of the background on lifestyle factors and then maybe you pick up on the nutritional side of things, is that okay?

Thanks, John. Yeah, great. I think the three big areas, Simon, for me were sleep, stress, and exercise. There’s been a lot of research in the sporting population around these areas. On a conference call on Friday with Nathan and various sports science people in North America and the UK, one of the presenters was Ricky Simpson, an exercise immunology researcher in Houston. Ricky’s research has focused a lot on exercise and the pros and cons of exercise on the immune system. He works with NASA and astronauts to optimize their immune health, and also with cancer patients and athletes. Some key papers on reducing respiratory tract infections and optimizing our innate and acquired immune response highlight the benefits of sleep. Professional sports have invested heavily in this area over the last three to five years, aiming for at least seven hours of sleep a night. The general advice is to look at sleep hygiene, minimize caffeine in the afternoon or evening due to its long half-life, reduce screen time in the evening as it can adversely affect sleep, and ensure your bedroom is dark, warm, and comfortable. Good quality sleep can have a really beneficial effect on your immune system.

In the months ahead for our frontline staff, the first rule is don’t become a casualty yourself. You’ve got to look after yourself. We don’t want people burning out. It’s a marathon, not a sprint. Try to look after yourself as well as you can and make sure you’re recovering and have downtime to avoid excessive stress.

Stress is another big area. We know stress is closely related to the immune system, affecting the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Managing stress appropriately can enhance immune health, but high stress levels, which are inevitable over the coming months, can increase your risk of infection. Think about strategies to minimize stress, like exercise or meditation. There are many good resources out there around mindfulness and different apps. I use an app called Calm, which I find very helpful for meditation.

Exercise has many beneficial effects on physical and psychological health. The general CMO guidelines for health and well-being recommend 150 minutes per week of moderate-intensity exercise or 75 minutes of higher-intensity exercise, along with strength training twice a week. While excessive exercise can stress the immune system, 30 to 60 minutes of exercise a day, five days a week, keeps you fit and healthy, helps you sleep better, and manages stress.

So, a couple of things I want to ask you about there, if that’s okay. There’s a great book called “Why We Sleep” by Matthew Walker, which we reviewed on the blog. It offers amazing advice about sleep, touching on many of the things you’ve mentioned. Of course, many of our workers work shifts, which disrupts sleep patterns, but there are ways to mitigate that.

Hospitals seem to run on caffeine, but there is good evidence that having caffeine in the hours before you sleep, particularly after lunchtime, can disrupt sleep patterns. Alcohol, another common crutch during stressful times, also disrupts sleep patterns. These are stresses that affect people due to the nature of our work, but they are changeable and adjustable.

Absolutely, Simon. I’ve read Matthew Walker’s book as well—a fantastic piece of work. He advises professional sports on sleep strategies. Caffeine has a long half-life of around 12 hours, and even decaffeinated coffee can contain about 30% caffeine, impacting sleep quality and quantity. Alcohol can help you get to sleep quickly but adversely affects sleep quality. Sleep is crucial for optimizing immune health, so it’s important to practice good sleep hygiene, especially given the challenges with shift work and trying to sleep during the day.

Couldn’t agree more. Quick solutions include sleep masks as alternatives to blackout curtains, ear defenders or ear plugs if you can tolerate them, and having a regular routine when you come home from a shift to help your body adjust. Reducing screen time before bed is crucial, although there’s some debate about the efficacy of removing blue light from screens.

These are all marginal gains that can significantly improve sleep and overall health. There’s a lot of focus on avoiding exposure to COVID-19 through PPE, isolation, and hand hygiene, which are all crucial. But we also need to support our own immune defense to cope with inevitable exposure.

Regarding mindfulness and yoga, there’s a free offer from 10% Happier for NHS workers, available for six months. Other apps like Headspace are also beneficial. My yoga teacher offers online classes now, which is a great way to stay engaged. Some might think of mindfulness and yoga as unconventional, but they are incredibly useful relaxation techniques.

Absolutely, Simon. In recent years, we’ve seen a lot of engagement in mindfulness and meditation within the athletic population. Headspace is a key app we use with athletes, and there’s been a growing focus on mental health due to competition stress and long-haul travel effects on sleep. We promote these tools among our athletes.

We’re not endorsing any specific app here, but these are examples of what’s available. There are free and paid versions of these resources, so find something that suits you.

Another important area is hydration and oral health, which are crucial for optimizing immune health. Athletes on long-haul flights are advised to stay well-hydrated and chew gum to increase saliva flow rates, improving mucosal health. Salivary IgA is a key part of oral immune health and can be relevant to initial exposure and defense.

Excellent tips, John. These are all achievable steps. Think about your routines and lifestyle, and see how you can make adjustments to improve your health and well-being.

Nathan, you’ve got a lot of expertise in nutrition. This is often a controversial area, but there is substantial evidence supporting the impact of nutrition on immune function. You sent me several papers, including Cochrane

reviews. Let’s delve into the nutritional side of things.

Absolutely, Simon. Sports nutrition and sports science have produced a wealth of evidence-based research. Looking at high-level evidence, such as meta-analyses and Cochrane reviews, we see significant findings related to nutrition and immune health.

Vitamin C, for example, has been well-researched. Linus Pauling’s work in the 1970s highlighted its benefits, and subsequent studies have supported this. A Cochrane review of five studies in heavy exercisers showed a 50% decrease in upper respiratory tract infections with vitamin C supplementation, typically around 250 milligrams to one gram per day. Achieving one gram a day through diet is challenging, but 200-250 milligrams is possible with a diet rich in fruits and vegetables.

Polyphenols, particularly flavonoids found in fruits, vegetables, tea, and coffee, also play a role in reducing upper respiratory tract infections. Meta-analyses show a 30% reduction in URTI incidence with flavonoid intake.

Research in athletes experiencing fatigue has shown lower levels of carotenoids in their blood, which are biomarkers for fruit and vegetable intake. Ensuring a diet rich in these nutrients is crucial. Aim for seven to ten servings of fruits and vegetables a day. If that’s difficult due to long shifts, consider soups, smoothies, or green powders to boost intake.

That’s fascinating, Nathan. The idea of testing blood for dietary intake is mind-blowing. Seven to ten servings of fruits and vegetables are higher than typical recommendations. What are your thoughts on supplements to achieve these levels?

Supplements can be helpful. Research in military personnel and stressed law students has shown benefits from green supplements, which contain dehydrated vegetables, herbs, and fruits. These can be added to recovery drinks or smoothies to boost intake of phytonutrients, which you won’t get from a multivitamin.

It’s important to mention vitamin C in the context of sepsis. Recent studies in critical care have shown it doesn’t have the expected effect on septic shock patients. However, in the context of prevention and reducing infection severity, vitamin C remains relevant.

Vitamin C deficiency increases the risk of respiratory infections and affects their severity and duration. Avoiding nutritional deficiencies is crucial for immune function. Ensuring adequate vitamin intake supports both innate and acquired immune systems.

Probiotics are another area with strong evidence. A Cochrane review of 12 studies showed a 50% decrease in upper respiratory illness incidence with probiotics. Probiotics can be consumed through drinks like Actimel and Yakult, which have shown favorable antibody responses to vaccinations.

Vitamin D is also vital. Many people in Northern climates are deficient, especially without supplementation or sun exposure during winter. Vitamin D supports immune function, influencing antimicrobial peptides in respiratory secretions. Supplementing with 2,000-4,000 IU of vitamin D3 daily is advisable if you haven’t been taking it during winter.

Omega-3 fatty acids, particularly EPA and DHA found in fish, play a crucial role in the inflammatory response and resolving inflammation. If you don’t eat fish, consider supplements to ensure adequate intake.

To summarize, we’re trying to apply evidence from one group (athletes) to another (healthcare workers) to optimize health during this pandemic. This is a reasonable approach given the physiological similarities and the current lack of specific research on COVID-19.

Thank you both for your insights. We’ll put notes on the blog, including links and references to the papers you mentioned. This information can help flatten the curve of healthcare worker infections and ensure we have enough people to treat patients. Thank you, John and Nathan.