Why Exercise is the Best Medicine Ever!
Stan Reents, PharmD
10/19/2012 09:41 AM
Last Revision: 11/20/2019 01:58 PM
"Lifestyle"-related illnesses now represent the largest percentage of health care expenses in the US. Yet, despite all the new and impressive drugs and procedures that our health care system and the Affordable Care Act (ACA) currently offer, exercise is still the best option. Here's why I think so:
HEALTH CARE EXPENSES
The December 1, 2008 issue of TIME magazine contained an evaluation of health care in various countries: They reported that the US spends $7,026 per capita per year on health care....far more than any other country:
|ANNUAL HEALTH CARE COSTS
Yet, we aren't getting the best results. (That explains the title of their article: "The Sorry State of American Health.")
Additional research supports the TIME report:
• Obesity: World Health Organization data from 2005 revealed that the US represents only 4.6% of the world's population, but 23% of the world's obese! A 2012 report from the Robert Wood Johnson Foundation ("F as in Fat: How Obesity Threatens America's Future 2012") projects that by 2030, obesity rates will exceed 44% in all 50 states and will add another $48-66 billion to the cost of treating obesity-related disease (Voelker R. 2012).
• Cardiovascular Disease: A separate analysis of the management of cardiovascular disease in 661 medical centers in 15 countries revealed that the country with the worst blood pressure control, medication compliance, and follow-up rate was.....the US! (Black HR, et al. 2005.)
Why haven't we had better success in managing cardiovascular disease in the US? For example, cigarette smoking has been declining steadily and is now down to 19%, its lowest level in decades. LDL-cholesterol levels and the death rate due to cardiovascular disease (CVD) have both declined steadily during the past 2 decades in the US. But, CVD is still the #1 cause of death of adults.
Many patients who have a myocardial infarction (heart attack) or have very poor coronary perfusion undergo a procedure where a stent (tube) is placed inside the coronary artery to keep it open. Medical terms for this include "intracoronary stent implantation" or "percutaneous coronary intervention" (PCI). Some research shows that performing a PCI procedure isn't very effective:
• The January 23, 2012 issue of the Archives of Internal Medicine included a study showing that nearly 1 in 10 cardiac patients who undergo a PCI required readmission to the hospital within 30 days (Khawaja FJ, et al. 2012).
• In 2007, the prestigious New England Journal of Medicine published a report stating "...PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy." (Boden WE, et al. 2007).
Obviously, those aren't glowing endorsements of this procedure!
PATIENTS DON'T TAKE THEIR DRUGS PROPERLY!
Regardless of the effectiveness of the drugs listed below, patient compliance is poor:
• Antidiabetic Drugs: A study of 6090 newly-diagnosed diabetics revealed that 37% had stopped taking their diabetes medication 12 months later (Hertz RP, et al. 2005.)
• Antihypertensive Drugs: An analysis of 4783 patients revealed that almost half had discontinued their blood pressure medication at the end of the first year (Vrijens B, et al. 2008.)
• Cholesterol-Lowering Drugs: Numerous studies have documented poor long-term compliance with statin-type cholesterol drugs. In one, only 25-40% of patients took their drugs as prescribed during the 2 years they were monitored (Jackevicius CA, et al. 2002.)
• Post-MI Drugs: 12% of patients who suffered a myocardial infarction (heart attack) and who were discharged on aspirin, a beta-blocker, and a statin-type cholesterol drug had stopped taking all 3 drugs within the first month! (Ho PM, et al. 2006.)
People with diabetes, hypertension, or elevated cholesterol often have more than one of these problems concurrently. Thus, they need multiple drugs. To solve the poor drug compliance problem, some clinicians are very interested in the "PolyPill". The PolyPill combines 4-5 drugs into a single capsule:
|THE PolyPill FOR
|THE PolyPill FOR|
|• elevated cholesterol
|• elevated blood sugar
||• a diuretic
• a beta-blocker
• an ACE inhibitor
|• an ACE inhibitor
|• to lower thrombotic risk
||Yusuf S, et al. 2009.
||Kuehn BM. 2006.
I'm not as enthusiastic:
First, combining multiple drugs into a single formulation doesn't represent a better therapeutic strategy...it's still drug therapy. Prescribing the PolyPill in lieu of exercise is like treating the symptoms of iron-deficiency anemia without replacing iron stores, or, treating the symptoms of hypothyroidism without prescribing levothyroxine. It is illogical to treat the symptoms of a problem without first fixing the cause of the problem!
Second, concerns have been raised regarding the efficacy of 2 of the 5 drugs in the PolyPill for preventing heart disease:
• Statins: An analysis of 137,000 patients who sustained their first myocardial infarction revealed that 41% had an LDL-cholesterol level of < 100 mg/dL, a value that is generally considered acceptable (Sachdeva A, et al. 2009). In other words, people with "acceptable" cholesterol levels can still have a heart attack.
• Beta-Blockers: The October 3, 2012 issue of JAMA reports that beta-blockers fail to offer any benefit in patients with stable coronary artery disease (Bangalore S, et al. 2012).
Because of less-than-adequate results, continuing to attack lifestyle-related health problems with drugs and complex (and expensive!) procedures doesn't make much sense. The way I see it, prescribing drugs for lifestyle-related disease is about as silly as a dentist prescribing a drug to prevent cavities! A lifestyle-related health problem requires a change in behavior, not drug therapy.
Cardiovascular disease and obesity affect millions of Americans. Health care expenses for both are projected to continue to rise during the next several decades.
THE POWER OF PREVENTION
One glaring deficit in the health care system in the US is how little time, money, and effort is placed on preventive care. The TIME magazine review from 2008 gave "Preventive Care" in the US a grade of D+.
Instead, we pursue a strategy based on drug therapy and expensive procedures which only address the symptoms of the problem.
Professor Steven Blair has recently concluded that "physical inactivity is the biggest public health problem of the 21st century." After analyzing over 40,000 patients, he shows that:
"Low cardiorespiratory fitness" was the biggest contributor to death than any of the other traditional risk factors that clinical medicine currently monitors.
In fact, "low cardiorespiratory fitness" was a substantially higher determinant of death than risk factors that currently get most of the attention such as obesity and elevated cholesterol (Blair SN. 2009.) What he is saying here is that your fitness level is more important than your cholesterol level!
EXERCISE REDUCES THE NEED FOR DRUG THERAPY
Even if all patients took their drugs as prescribed, the health benefits that exercise offers far exceed what drug therapy can provide (Green DJ. 2009). While metformin does lower blood sugar and ACE inhibitors do lower blood pressure, aerobic exercise does that, too. In addition, exercise improves vascular compliance (responsiveness), strength of the heart muscle, bone density, muscle strength, weight loss, joint flexibility and stiffness, cognitive function, mood, sleep quality, balance, etc. all at once. No drug, or group of drugs can match that!
Illnesses that arise as a result of a sedentary lifestyle reflect an imbalance of normal physiology. Thus, it is more logical to base the treatment of these conditions on a physiologic approach, not a pharmacologic one.
Exercise for Atherosclerosis
People who are sedentary suffer from a process known as "atherosclerosis." This leads to cardiovascular problems such as myocardial infarctions ("heart attacks"), strokes, hypertension (high blood pressure), and even erectile dysfunction. Hyperglycemia (elevated blood glucose) also occurs and further aggravates the damaging effects of atherosclerosis on blood vessels.
"Statin"-type cholesterol-lowering drugs (eg., Crestor, Lipitor) have become one of the most widely-prescribed types of drugs in the world. However, John Ioannidis, MD, from Stanford University, has recently questioned the new guidelines recommending the use of these drugs in an editorial in the February 5, 2014 issue of JAMA titled "More Than A Billion People Taking Statins?" He feels that too many people will be given these drugs (Ioannidis JPA, 2014).
Atherosclerosis is a result of the combined damaging actions of elevated cholesterol, elevated blood pressure, and elevated blood glucose. However, the fundamental defect causing atherosclerosis is a lack of aerobic exercise....ie., it is an "exercise deficit," if you will. Therefore, the primary therapeutic agent should be exercise, not a complex array of drugs that serve only to treat the various manifestations of that process.
Paul T. Williams, PhD, at the Lawrence Berkeley National Laboratory in Berkeley, CA, analyzed health data on more than 107,000 runners in The National Runners' Health Study. Distance runners (Williams PT, et al. 2007) and marathon runners (Williams PT. 2009) required drug therapy for cholesterol, diabetes, and/or hypertension less frequently compared to those who ran much less.
Then, he discovered that walking could produce reductions in the risk of developing diabetes, hypertension, and elevated cholesterol similar to the benefits of running (Williams PT, et al. 2013), and that walkers also were less likely to require prescription drugs for these conditions (Williams PT. 2008).
Exercise for Type-2 Diabetes
Exercise for Hypertension
• Running: Twenty-four of 47 patients with hypertension were able to discontinue all drug therapy after running 2 miles per day for 3 months (Cade R, et al. 1984.)
• Cycling: Thirteen of 24 chronic renal failure patients receiving hemodialysis required less intensive drug therapy for hypertension after riding a stationary bicycle for 6 months (Miller BW, et al. 2002.)
EXERCISE REALLY IS A THERAPEUTIC AGENT!
The title of an editorial by William Roberts, MD, in the American Journal of Cardiology illustrates how versatile exercise is:
“An agent with lipid-lowering, antihypertensive, positive inotropic, negative chronotropic, vasodilating, diuretic, anorexigenic, weight-reducing, cathartic, hypoglycemic, tranquilizing, hypnotic and antidepressive qualities.”
That's pretty impressive, isn't it? The "agent" he is describing here is aerobic exercise.
What's more impressive is that this paper was published in 1984.... that was more than 30 years ago! Since then, a great deal of research now documents the effectiveness of exercise in a wide variety of human diseases (Pedersen BK, et al. 2006). Today, the title could also include: "memory-enhancing," "cancer-preventing," "anti-arthritic," and "clot-preventing" as well!
Research shows that exercise is beneficial in a wide variety medical conditions:
• Cardiovascular diseases: coronary artery disease, hypertension, stroke, heart failure, intermittent claudication.
• Metabolic diseases: metabolic syndrome, type-2 diabetes, elevated lipids, obesity.
• Musculoskeletal diseases: osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia.
• Mental health: dementia, depression, mental performance at work and in the classroom.
• Various forms of cancer.
Because of this, virtually all major medical advisory groups now endorse exercise as a viable health-promoting strategy:
• November 2007: The American College of Sports Medicine (ACSM) and the American Medical Association (AMA) jointly launched the “Exercise Is Medicine” initiative. This campaign calls on all physicians to “prescribe” exercise as they would for other traditional therapeutic agents.
• June 2008: The US Government's Dept. of Health and Human Services issued its first set of Physical Activity Guidelines.
• May 2010: The National Physical Activity Plan was released.
Healthy People has been providing exercise / physical activity recommendations for decades.
FOR SOME DISEASES, EXERCISE CAN MATCH DRUG THERAPY
But, is there any hard evidence that exercise is just as good as drug therapy for serious medical conditions?
Yes! In 2013, Huseyin Naci and John Ioannidis, MD, at Stanford analyzed 305 randomized controlled clinical trials involving over 339,000 patients. They found the following (Naci H, et al. 2013):
||EXERCISE vs. DRUG THERAPY
|Coronary Artery Disease
(secondary prevention of)
|Exercise is as good as Drug Therapy
|Exercise is as good as Drug Therapy
|Exercise is BETTER THAN Drug Therapy
|Congestive Heart Failure
|Drug Therapy is better than Exercise
• Dementia (treatment of): One study showed that donepezil (Aricept) produced an improvement in ADAS-COG score by only 0.5 points (Petersen RC, et al. 2005). However, a separate study showed that a pedometer-monitored walking program ("Fitness For The Aging Brain" study) led to an improvement of 1.3 points (Lautenschlager et al. 2008).
• Depression (treatment of): Researchers at Duke compared aerobic exercise (3 days per week, 30 minutes per session) to sertraline (Zoloft) 50-200 mg/day in patients with major depression. After 4 months, the response to exercise was equivalent to drug therapy. However, at 10 months, fewer patients in the exercise group had relapsed (Babyak M, et al. 2000).
• Diabetes (prevention of): 3200 patients who did not have diabetes, but did have an elevated fasting glucose (ie., prediabetes) were randomized to receive either metformin 850 mg twice daily or an exercise program: 150 minutes of physical activity per week. The average follow-up was 2.8 years. Metformin reduced the development of diabetes by 31%. However, exercise reduced it by 58% (Knowler WC, et al. 2002).
• Stroke (prevention of): The most recent "Guidelines for the Primary Prevention of Stroke" state that statin-type cholesterol drugs reduce the risk of stroke by about 21%, whereas "staying physically active" reduces the risk by 25-30%. (Meschia FJ, et al. 2014).
Even though only a handful of clinical studies have compared exercise to drug therapy, the results are pretty impressive!
IMPACT OF EXERCISE ON DRUG THERAPY COSTS
Obviously, if drug therapy can be avoided, or reduced, then drug therapy expenses are less. It is surprising that there is so little research on this topic, but some details are available:
• In one study, a daily 3-mile walk was estimated to lower annual drug costs in diabetics by roughly $600/yr per person (DiLoreto C, et al. 2005.)
• In the study mentioned above of dialysis patients who rode an exercise bike, the cost savings on drug therapy for hypertension was estimated to be $885/patient-year (Miller BW, et al. 2002.)
Though only a handful of research studies comparing exercise to drug therapy head-to-head have been published, the results are pretty impressive!
IN SOME CASES, EXERCISE IS BETTER THAN MEDICAL PROCEDURES
A striking example where exercise is a more effective therapeutic option than a medical procedure is the setting of coronary artery disease:
Researchers in Germany have shown that it is more effective to put patients who have had a heart attack on an exercise program than to perform a PCI procedure:
• Patients were given 1 of 2 different treatments after routine coronary angiography: One group rode a stationary bicycle for 20-min per day, combined with one 60-min group exercise session per week. The other group underwent a PCI. After 12 months, the group that exercised had a higher "event-free survival" rate than the group that received the PCI. Further, health care costs in the group that exercised were half the costs in the group that received PCI (Hambrecht R, et al. 2004).
"STEPS" YOU SHOULD TAKE
So, what can you do with all this information? The bottom line: Exercise or do some form of physical activity every day!
But, first, a couple precautionary statements:
1) Check with your personal physician before beginning any new exercise routine.
2) If you are taking medications, do NOT stop taking those medications without conferring with your personal physician.
3) Then, consider starting by going for a walk....if not every day, then, 3-5 days per week. But, eventually try to do it every day. Walk briskly and swing your arms. Try to push your heart rate up a bit. Learn how to monitor your heart rate while you are exercising. Slow down if you get out of breath, and, certainly, stop immediately if you develop chest pain!
4) Periodically, assess your progress by determining your resting heart rate first thing when you wake up.
That's it! Yes, it really is that simple to improve your health. You may find that your blood pressure and your cholesterol start to improve, and, you just might lose a little weight.
Exercise is one strategy that could make a huge impact on the health of Americans, and, in turn, health care costs, particularly for chronic diseases such as obesity, diabetes, hypertension, coronary artery disease, etc.
What would happen if we focused more attention on exercise as a therapeutic agent in health care? Answer: We might have a better impact on cardiovascular diseases, obesity, type-2 diabetes, the general health of our entire population, and, in turn, a reduction in health care expenses!
FOR MORE INFORMATION
An entire chapter in Reents' text Sport and Exercise Pharmacology is devoted to the concept of prescribing exercise to "treat" health problems. (That book was published in 2000!)
Readers may also be interested in these reviews:
EXPERT HEALTH and FITNESS COACHING
Stan Reents, PharmD, is available to speak on this and many other exercise-related topics. (Here is a downloadable recording of one of his Health Talks.) He also provides a one-on-one Health Coaching Service. Contact him through the Contact Us page.
American Heart Association. Heart Disease and Stroke Statistics - 2010 Update. American Heart Association, Dallas, TX, 2010.
Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: Maintenance of therapeutic benefit at 10 months. Psychosomatic Med 2000;62:633-638. Abstract
Bangalore S, Steg PG, Deedwania P, et al. Beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 2012;308:1340-1349. Abstract
Black HR, Elliott WJ, Grandits G, et al. Results of the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) trial by geographical region. J Hypertens 2005;23:1099-1106. Abstract
Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009;43:1. Abstract
Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516. Abstract
Cade R, Mars D, Wagemaker H, et al. Effect of aerobic exercise training on patients with systemic arterial hypertension. Am J Med 1984;77:785-790. Abstract
DiLoreto C, Fanelli C, Lucidi P, et al. Make your diabetic patients walk. Diabetes Care 2005;28:1295-1302. Abstract
Green DJ. Exercise training as vascular medicine: direct impacts on the vasculature in humans. Exercise Sports Science Reviews 2009;37:196-202. Abstract
Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease. Circulation 2004;109:1371-1378. Abstract
Hertz RP, Unger AN, Lustik MB. Adherence with pharmacotherapy for type 2 diabetes: A retrospective cohort study of adults with employer-sponsored health insurance. Clin Ther 2005;27:1064-1073. Abstract
Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med 2006;166:1842-1847. Abstract
Ioannidis JPA. More than a billion people taking statins? Potential implications of the new cardiovascular guidelines. JAMA 2014;311:463-464. Abstract
Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002;288:462-467. Abstract
Khawaja FJ, Shah ND, Lennon RJ, et al. Factors associated with 30-day readmission rates after percutaneous coronary intervention. Arch Intern Med 2012;172:112-117. Abstract
Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. Abstract
Kuehn BM. "Polypill" could slash diabetes risk. JAMA 2006;296:377. Abstract
Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:3754-3832. Abstract
Miller BW, Cress CL, Johnson ME, et al. Exercise during hemodialysis decreases the use of antihypertensive medications. Am J Kidney Dis 2002;39:828-833. Abstract
Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: Metaepidemiological study. Br Med J 2013;347:f5577. Abstract
Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scan J Med Sci Sports 2006;16(suppl. 1):3-63. Abstract
Roberts WC. An agent with lipid-lowering, antihypertensive, positive inotropic, negative chronotropic, vasodilating, diuretic, anorexigenic, weight-reducing, cathartic, hypoglycemic, tranquilizing, hypnotic and antidepressive qualities. Am J Cardiol 1984;53:261-262. Abstract
Sachdeva A, Cannon CP, Deedwania PC, et al. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J 2009;157:111-117. Abstract
Voelker R. Escalating obesity rates pose health, budget threats. JAMA 2012:308:1514. (no abstract)
Vrijens B, Vincze G, Kristanto P, et al. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. Br Med J 2008;336:1114-1117. Abstract
Williams PT. Reduced diabetic, hypertensive, and cholesterol medication use with walking. Med Sci Sports Exerc 2008;40:433-443. Abstract
Williams PT. Lower prevalence of hypertension, hypercholesterolemia, and diabetes in marathoners. Med Sci Sports Exerc 2009;41:523-529. Abstract
Williams PT, Franklin B. Vigorous exercise and diabetic, hypertensive, and hypercholesterolemia medication use. Med Sci Sports Exerc 2007;39:1933-1941. Abstract
Williams PT, Thompson PD. Walking versus running for hypertension, cholesterol, and diabetes mellitus risk reduction. Arterioscler Thromb Vasc Biol 2013;33:1085-1092. Abstract
Yusuf S, Pais P, Afzai R et al. Effects of a polypill (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): a phase II, double-blind, randomised trial. Lancet 2009;373:1341-1351. Abstract
ABOUT THE AUTHOR
Stan Reents, PharmD, is a former healthcare professional. He is a member of the American College of Lifestyle Medicine (ACLM) and a member of the American College of Sports Medicine (ACSM). In the past, he has been certified as a Health Fitness Specialist by ACSM, as a Certified Health Coach by ACE, as a Personal Trainer by ACE, and as a tennis coach by USTA. He is the author of Sport and Exercise Pharmacology (published by Human Kinetics) and has written for Runner's World magazine, Senior Softball USA, Training and Conditioning and other fitness publications.
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