JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 16, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.08.026
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
Diet and Exercise During Cardiology Fellowship Training Practicing What We Preach Jackson J. Liang, DO
C
ardiologists and cardiology fellows routinely
Scheduling difficulties, frequent overnight calls,
recommend lifestyle modifications for pa-
and moonlighting shifts often make it difficult for
tients with chronic cardiovascular condi-
cardiology fellows to eat meals at regular times.
tions, such as coronary heart disease and congestive
Skipped meals and late-night eating are extremely
heart failure. In particular, exercise and eating
commonly seen practices during training. The prac-
a healthy diet comprise the backbone of recom-
tice of meal-skipping has been associated with
mendations provided to patients. Ironically, how-
obesity, hypertension, insulin resistance, diabetes,
ever, providers often do not adhere to their own
and dyslipidemia (2–6). Cahill et al. (7) recently
recommendations.
analyzed more than 25,000 men age >45 years and
It is well known and accepted that cardiology is
found that skipping breakfast was associated with a
one of the busiest, most demanding fellowships
27% increased risk of coronary heart disease, whereas
among the internal medicine subspecialties, and the
late-night eating was associated with a 55% increased
additional 3-plus years of training to be a cardio-
risk (7).
logist can be stressful. Many have other personal
The nutritional quality of food served at meetings
responsibilities related to their families (spouses or
and conferences has been previously commented
children), as well as financial stressors. Exorbitant
on and changes have been proposed (8). Cardiology
debts resulting from a decade’s worth of tuition fees
fellows frequently have didactic lectures and con-
may drive already-overworked fellows to take up
ferences that provide breakfast and lunch. On
additional clinical duties in their “free time,” such as
many occasions, those lunches consist of high-calorie
moonlighting, to make ends meet.
(high-fat, high-sugar), high-sodium, low-nutritional
Given the demanding schedules and rigorous
value foods which cardiologists ironically routinely
clinical and research responsibilities of cardiovascu-
recommend that their patients avoid (e.g., pizza,
lar fellowship, it is understandable why fellows often
desserts,
find it difficult to eat healthily and make time to
morning and noon conferences in many programs
exercise. Despite this, it is imperative that trainees
generally exhibit a paucity of lean meats, whole
develop good lifestyle habits early on during train-
grains, fresh fruits, or vegetables. Although avail-
ing such that optimal health can be maintained
ability of these unhealthy foods at conferences may
throughout their careers.
be better than the alternative (skipping breakfast
DIET. The obesity epidemic in America is growing at
an exponential pace, and physicians are not immune. The Physician’s Health Study reported that 44% of male physicians age >40 years were overweight or obese, and that body mass index directly correlated with all-cause and cardiovascular mortality (1).
sugary
beverages).
Meals
provided
at
and lunch altogether due to time constraints), physicians must make an extra effort to limit portion sizes and choose healthier options, when available. Bringing healthy meals from home is another alternate option. During procedural rotations, such as interventional cardiology or electrophysiology, much of the day is spent performing procedures in the laboratories.
From the Division of Cardiology, Hospital of the University of Pennsyl-
Due to emergent add-on cases or other clinical re-
vania, Philadelphia, Pennsylvania.
sponsibilities, fellows often will have inadequate
1756
Liang
JACC VOL. 64, NO. 16, 2014 OCTOBER 21, 2014:1755–7
Fellows-in-Training & Early Career Page
time to eat a full meal between cases. As such, there
has been shown to improve physical activity and
may be a temptation to snack on unhealthy options in
quality of life, and possibly reduce burnout among
the break rooms between cases. Simple measures,
trainees (14). If programs do not make the additional
such as bringing in fruits or healthier snacks (e.g.,
effort to promote physical fitness, cardiology fellows
nuts or low-fat yogurt), could be considered to avoid
need to take it upon themselves to maintain their
this pitfall.
own health.
EXERCISE. Due to the work hours during fellowship
SOLUTIONS. In an effort to promote health, many
training, cardiology fellows may find it difficult to set
training programs have been proactive in recent
aside time for dedicated exercise outside of work.
years. For example, some steps taken by programs
Only 5 to 10 min of slow running per day has been
have included offering free or discounted gym
associated with markedly reduced all-cause and car-
memberships, supplying healthier in-hospital meal
diovascular mortality (9). Although cardiology fel-
options, and posting nutritional facts for food
lows may believe that their routine job requirements
offered at conferences and in the cafeteria. Fur-
are relatively physically demanding, the true physical
thermore, some institutions have offered incen-
demands of the job remain unknown. One study of
tives such as discounted medical insurance for
obstetricians demonstrated the actual amount of
employees
physical activity associated with work was less than
milestones, such as eating a certain number of
perceived (10). In addition to affecting personal
servings of fruits and vegetables per week, avoiding
health, the physical activity level of physicians may
fast foods, exercising a certain number of days per
also correlate with patient counseling practices about
week, or participating in sponsored walks or 5K
exercise (11).
runs. Ultimately, the responsibility to maintain
who
report
meeting
certain
health
Stanford et al. (12) recently surveyed 1,949 medical
fitness and a healthy diet falls on the shoulders of
students and physicians (residents, fellows, and
the individual, but encouragement from cofellows
attending physicians) to determine how many of
and program faculty to exercise and eat healthy goes
them met the physical activity recommendations set
a long way.
forth by the U.S. Department of Health and Human
CONCLUSIONS. Cardiology fellowship is a rigorous
Services (HHS) (12). The 2008 guidelines state that to
but rewarding experience, which is necessary to
attain substantial health benefits, including lowering
adequately prepare trainees to become competent
risk for premature death, coronary heart disease,
cardiologists. However, it is also a physically and
stroke,
emotionally stressful period with long work hours
hypertension,
diabetes,
and
depression,
adults should participate in at least 150 min/week of
that make self-care habits difficult to maintain.
moderate-intensity aerobic activity to obtain sub-
Despite this, trainees must make the extra effort
stantial health benefits and more than 300 min/
to
week to obtain more extensive health benefits (13).
the groundwork is set for these habits to be main-
They found that fellows were less likely to meet
tained throughout their careers. Increased aware-
the HHS guidelines (68%) than attending physicians
ness of this issue by many fellowship programs has
(85%), medical students (84%), or residents (73%)
prompted efforts to motivate fellows to incorporate
(12). The odds ratios (ORs) for meeting the guideline
healthy diet and regular exercise into their daily
recommendations were significantly lower for fel-
routine. Personal exercise and eating habits corre-
lows (0.5; 95% confidence interval [CI]: 0.31 to
late with how physicians counsel their patients.
0.80; p ¼ 0.04) compared with the other groups.
Regular recommendation of lifestyle modifications
Additional predictors for lower activity compliance
to our patients should serve as a routine reminder
included female sex (OR for male sex: 1.39, 95% CI:
to ourselves to follow our own recommendations
1.10 to 1.76; p ¼ 0.007) and age 30 to 39 years (OR:
and “practice what we preach.” This will ultimately
0.69; 95% CI: 0.52 to 0.93; p ¼ 0.001). The number
allow
of hours worked per week was inversely associated
cardiologists.
practice
us
to
healthy
lifestyle
become
habits,
healthier,
more
such
that
effective
with physical activity level and was a likely contributor to suboptimal physical activity in residents and fellows.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Personal fitness often is overlooked by fellowship
Jackson J. Liang, Hospital of the University of
programs, but formal prompting of trainees may
Pennsylvania, 3400 Spruce Street, 9 Gates Building,
improve exercise adherence. Participation in an
Philadelphia, Pennsylvania 19104. E-mail: jackson.
elective, team-based, incentivized exercise program
[email protected].
Liang
JACC VOL. 64, NO. 16, 2014 OCTOBER 21, 2014:1755–7
Fellows-in-Training & Early Career Page
REFERENCES 1. Ajani UA, Lotufo PA, Gaziano JM, et al. Body mass index and mortality among US male physicians. Ann Epidemiol 2004;14:731–9. 2. Farshchi HR, Taylor MA, Macdonald IA. Deleterious effects of omitting breakfast on insulin sensitivity and fasting lipid profiles in healthy lean women. Am J Clin Nutr 2005;81:388–96. 3. Song WO, Chun OK, Obayashi S, Cho S,
6. Mekary RA, Giovannucci E, Willett WC, et al. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95:1182–9.
11. Rogers LQ, Gutin B, Humphries MC, et al. A physician fitness program: enhancing the physician as an “exercise” role model for patients. Teach Learn Med 2005;17:27–35.
7. Cahill LE, Chiuve SE, Mekary RA, et al. Prospective study of breakfast eating and incident coronary heart disease in a cohort of male US health professionals. Circulation 2013;128:337–43.
12. Stanford FC, Durkin MW, Blair SN, et al. Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA. Br J Sports Med 2012;46:360–4.
Chung CE. Is consumption of breakfast associated with body mass index in US adults? J Am Diet Assoc 2005;105:1373–82.
8. Lesser LI, Cohen DA, Brook RH. Changing eating habits for the medical profession. JAMA 2012;308: 983–4.
4. van der Heijden AA, Hu FB, Rimm EB, van
9. Lee DC, Pate RR, Lavie CJ, et al. Leisure-time
Dam RM. A prospective study of breakfast consumption and weight gain among U.S. men. Obesity (Silver Spring) 2007;15:2463–9.
running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014;64:472–81.
13. Carlson SA, Fulton JE, Schoenborn CA, Loustalot F. Trend and prevalence estimates based on the 2008 Physical Activity Guidelines for Americans. Am J Prev Med 2010;39: 305–13.
5. Stote KS, Baer DJ, Spears K, et al. A controlled
10. Martinez de Tejada B, Jastrow N, Poncet A, Le Scouezec I, Irion O, Kayser B. Perceived and
14. Weight CJ, Sellon JL, Lessard-Anderson CR, et al. Physical activity, quality of life, and burnout
trial of reduced meal frequency without caloric restriction in healthy, normal-weight, middle-aged adults. Am J Clin Nutr 2007;85:981–8.
measured physical activity and mental stress levels in obstetricians. Eur J Obstet Gynecol Reprod Biol 2013;171:44–8.
among physician trainees: the effect of a teambased, incentivized exercise program. Mayo Clin Proc 2013;88:1435–42.
1757
VOL. 64, NO. 16, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.08.026
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
Diet and Exercise During Cardiology Fellowship Training Practicing What We Preach Jackson J. Liang, DO
C
ardiologists and cardiology fellows routinely
Scheduling difficulties, frequent overnight calls,
recommend lifestyle modifications for pa-
and moonlighting shifts often make it difficult for
tients with chronic cardiovascular condi-
cardiology fellows to eat meals at regular times.
tions, such as coronary heart disease and congestive
Skipped meals and late-night eating are extremely
heart failure. In particular, exercise and eating
commonly seen practices during training. The prac-
a healthy diet comprise the backbone of recom-
tice of meal-skipping has been associated with
mendations provided to patients. Ironically, how-
obesity, hypertension, insulin resistance, diabetes,
ever, providers often do not adhere to their own
and dyslipidemia (2–6). Cahill et al. (7) recently
recommendations.
analyzed more than 25,000 men age >45 years and
It is well known and accepted that cardiology is
found that skipping breakfast was associated with a
one of the busiest, most demanding fellowships
27% increased risk of coronary heart disease, whereas
among the internal medicine subspecialties, and the
late-night eating was associated with a 55% increased
additional 3-plus years of training to be a cardio-
risk (7).
logist can be stressful. Many have other personal
The nutritional quality of food served at meetings
responsibilities related to their families (spouses or
and conferences has been previously commented
children), as well as financial stressors. Exorbitant
on and changes have been proposed (8). Cardiology
debts resulting from a decade’s worth of tuition fees
fellows frequently have didactic lectures and con-
may drive already-overworked fellows to take up
ferences that provide breakfast and lunch. On
additional clinical duties in their “free time,” such as
many occasions, those lunches consist of high-calorie
moonlighting, to make ends meet.
(high-fat, high-sugar), high-sodium, low-nutritional
Given the demanding schedules and rigorous
value foods which cardiologists ironically routinely
clinical and research responsibilities of cardiovascu-
recommend that their patients avoid (e.g., pizza,
lar fellowship, it is understandable why fellows often
desserts,
find it difficult to eat healthily and make time to
morning and noon conferences in many programs
exercise. Despite this, it is imperative that trainees
generally exhibit a paucity of lean meats, whole
develop good lifestyle habits early on during train-
grains, fresh fruits, or vegetables. Although avail-
ing such that optimal health can be maintained
ability of these unhealthy foods at conferences may
throughout their careers.
be better than the alternative (skipping breakfast
DIET. The obesity epidemic in America is growing at
an exponential pace, and physicians are not immune. The Physician’s Health Study reported that 44% of male physicians age >40 years were overweight or obese, and that body mass index directly correlated with all-cause and cardiovascular mortality (1).
sugary
beverages).
Meals
provided
at
and lunch altogether due to time constraints), physicians must make an extra effort to limit portion sizes and choose healthier options, when available. Bringing healthy meals from home is another alternate option. During procedural rotations, such as interventional cardiology or electrophysiology, much of the day is spent performing procedures in the laboratories.
From the Division of Cardiology, Hospital of the University of Pennsyl-
Due to emergent add-on cases or other clinical re-
vania, Philadelphia, Pennsylvania.
sponsibilities, fellows often will have inadequate
1756
Liang
JACC VOL. 64, NO. 16, 2014 OCTOBER 21, 2014:1755–7
Fellows-in-Training & Early Career Page
time to eat a full meal between cases. As such, there
has been shown to improve physical activity and
may be a temptation to snack on unhealthy options in
quality of life, and possibly reduce burnout among
the break rooms between cases. Simple measures,
trainees (14). If programs do not make the additional
such as bringing in fruits or healthier snacks (e.g.,
effort to promote physical fitness, cardiology fellows
nuts or low-fat yogurt), could be considered to avoid
need to take it upon themselves to maintain their
this pitfall.
own health.
EXERCISE. Due to the work hours during fellowship
SOLUTIONS. In an effort to promote health, many
training, cardiology fellows may find it difficult to set
training programs have been proactive in recent
aside time for dedicated exercise outside of work.
years. For example, some steps taken by programs
Only 5 to 10 min of slow running per day has been
have included offering free or discounted gym
associated with markedly reduced all-cause and car-
memberships, supplying healthier in-hospital meal
diovascular mortality (9). Although cardiology fel-
options, and posting nutritional facts for food
lows may believe that their routine job requirements
offered at conferences and in the cafeteria. Fur-
are relatively physically demanding, the true physical
thermore, some institutions have offered incen-
demands of the job remain unknown. One study of
tives such as discounted medical insurance for
obstetricians demonstrated the actual amount of
employees
physical activity associated with work was less than
milestones, such as eating a certain number of
perceived (10). In addition to affecting personal
servings of fruits and vegetables per week, avoiding
health, the physical activity level of physicians may
fast foods, exercising a certain number of days per
also correlate with patient counseling practices about
week, or participating in sponsored walks or 5K
exercise (11).
runs. Ultimately, the responsibility to maintain
who
report
meeting
certain
health
Stanford et al. (12) recently surveyed 1,949 medical
fitness and a healthy diet falls on the shoulders of
students and physicians (residents, fellows, and
the individual, but encouragement from cofellows
attending physicians) to determine how many of
and program faculty to exercise and eat healthy goes
them met the physical activity recommendations set
a long way.
forth by the U.S. Department of Health and Human
CONCLUSIONS. Cardiology fellowship is a rigorous
Services (HHS) (12). The 2008 guidelines state that to
but rewarding experience, which is necessary to
attain substantial health benefits, including lowering
adequately prepare trainees to become competent
risk for premature death, coronary heart disease,
cardiologists. However, it is also a physically and
stroke,
emotionally stressful period with long work hours
hypertension,
diabetes,
and
depression,
adults should participate in at least 150 min/week of
that make self-care habits difficult to maintain.
moderate-intensity aerobic activity to obtain sub-
Despite this, trainees must make the extra effort
stantial health benefits and more than 300 min/
to
week to obtain more extensive health benefits (13).
the groundwork is set for these habits to be main-
They found that fellows were less likely to meet
tained throughout their careers. Increased aware-
the HHS guidelines (68%) than attending physicians
ness of this issue by many fellowship programs has
(85%), medical students (84%), or residents (73%)
prompted efforts to motivate fellows to incorporate
(12). The odds ratios (ORs) for meeting the guideline
healthy diet and regular exercise into their daily
recommendations were significantly lower for fel-
routine. Personal exercise and eating habits corre-
lows (0.5; 95% confidence interval [CI]: 0.31 to
late with how physicians counsel their patients.
0.80; p ¼ 0.04) compared with the other groups.
Regular recommendation of lifestyle modifications
Additional predictors for lower activity compliance
to our patients should serve as a routine reminder
included female sex (OR for male sex: 1.39, 95% CI:
to ourselves to follow our own recommendations
1.10 to 1.76; p ¼ 0.007) and age 30 to 39 years (OR:
and “practice what we preach.” This will ultimately
0.69; 95% CI: 0.52 to 0.93; p ¼ 0.001). The number
allow
of hours worked per week was inversely associated
cardiologists.
practice
us
to
healthy
lifestyle
become
habits,
healthier,
more
such
that
effective
with physical activity level and was a likely contributor to suboptimal physical activity in residents and fellows.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Personal fitness often is overlooked by fellowship
Jackson J. Liang, Hospital of the University of
programs, but formal prompting of trainees may
Pennsylvania, 3400 Spruce Street, 9 Gates Building,
improve exercise adherence. Participation in an
Philadelphia, Pennsylvania 19104. E-mail: jackson.
elective, team-based, incentivized exercise program
[email protected].
Liang
JACC VOL. 64, NO. 16, 2014 OCTOBER 21, 2014:1755–7
Fellows-in-Training & Early Career Page
REFERENCES 1. Ajani UA, Lotufo PA, Gaziano JM, et al. Body mass index and mortality among US male physicians. Ann Epidemiol 2004;14:731–9. 2. Farshchi HR, Taylor MA, Macdonald IA. Deleterious effects of omitting breakfast on insulin sensitivity and fasting lipid profiles in healthy lean women. Am J Clin Nutr 2005;81:388–96. 3. Song WO, Chun OK, Obayashi S, Cho S,
6. Mekary RA, Giovannucci E, Willett WC, et al. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95:1182–9.
11. Rogers LQ, Gutin B, Humphries MC, et al. A physician fitness program: enhancing the physician as an “exercise” role model for patients. Teach Learn Med 2005;17:27–35.
7. Cahill LE, Chiuve SE, Mekary RA, et al. Prospective study of breakfast eating and incident coronary heart disease in a cohort of male US health professionals. Circulation 2013;128:337–43.
12. Stanford FC, Durkin MW, Blair SN, et al. Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA. Br J Sports Med 2012;46:360–4.
Chung CE. Is consumption of breakfast associated with body mass index in US adults? J Am Diet Assoc 2005;105:1373–82.
8. Lesser LI, Cohen DA, Brook RH. Changing eating habits for the medical profession. JAMA 2012;308: 983–4.
4. van der Heijden AA, Hu FB, Rimm EB, van
9. Lee DC, Pate RR, Lavie CJ, et al. Leisure-time
Dam RM. A prospective study of breakfast consumption and weight gain among U.S. men. Obesity (Silver Spring) 2007;15:2463–9.
running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014;64:472–81.
13. Carlson SA, Fulton JE, Schoenborn CA, Loustalot F. Trend and prevalence estimates based on the 2008 Physical Activity Guidelines for Americans. Am J Prev Med 2010;39: 305–13.
5. Stote KS, Baer DJ, Spears K, et al. A controlled
10. Martinez de Tejada B, Jastrow N, Poncet A, Le Scouezec I, Irion O, Kayser B. Perceived and
14. Weight CJ, Sellon JL, Lessard-Anderson CR, et al. Physical activity, quality of life, and burnout
trial of reduced meal frequency without caloric restriction in healthy, normal-weight, middle-aged adults. Am J Clin Nutr 2007;85:981–8.
measured physical activity and mental stress levels in obstetricians. Eur J Obstet Gynecol Reprod Biol 2013;171:44–8.
among physician trainees: the effect of a teambased, incentivized exercise program. Mayo Clin Proc 2013;88:1435–42.
1757
