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Is The Prescription Of Real Exercise Underused?

I recently wrote about the incredible sensations that come with vigorous exercise. Perhaps it was the post ride cannabinoid flurry, but it’s possible that I went too far in suggesting that ‘we’ (doctors, patients, the whole of Western Society) default first to pills before healthy living.

Two commentors called me out on this snark. They wrote about valid points.

One comment focused on the fact that her AF medicines were causing side effects that made vigorous exercise difficult. The second objected to my inference that exercise alone could substitute for the many benefits of modern medicine.

To the idea that medicine-induced side effects diminish quality of life, I would offer these words:

First one must consider the disease being treated. Few would argue that it’s not worth suffering through Cancer chemotherapy to stay alive, or to endure nausea or diarrhea from antibiotics used to treat a threatening bacterial infection. The same concept holds for surgery. Sometimes we have to endure over the short-term to get better in the long run.

These extremes, however, are much different than the treatment of chronic diseases–like AF–for which other options exist. As an advocate for exercise and a doctor, I cringe at the thought that any of my recommendations cause a person to feel too sluggish to sweat. If a treatment of a chronic ailment is making you worse, tell your doctor. Ask for other options. If dismissed get another opinion. My view holds that the long-term withholding of exercising (be it because of medicine side effects or avoidance) almost always constitutes bad medicine.

The second objection to my snark about pills begs for further explanation. Dr. Jay, another heart rhythm doctor and avid runner, points out that medicines have a firm role in the treatment of mankind. He’s spot on. Count me as a fan of novel drugs that enhance the duration and quality of human life.

The “big four” classes of medicines for heart patients include ACE-inhibitors, beta-blockers, blood-thinners and statins. If you have heart disease, there’s a really good chance that you’ll live longer and better on one or more of these drugs. Doctors call treating existing disease secondary prevention. The evidence base supporting the role of these drugs for the treatment of established heart disease is not debated.

To add to Jay’s correctness, there’s many more examples of ‘good medicines.’ Diabetes doctors can tell the story of insulin, primary care doctors that of antibiotics and pediatricians that of vaccines.

My point in the exercise-is-beautiful post was directed at the use of medicines when prescribed before lifestyle changes. Two examples here include the use of statins and blood pressure medicine.


Let’s go back to the Dr. Groopman and Dr. Hartzband WSJ article on Designing a Smarter Patient. To highlight the importance of being an educated patient, they use the example of Susan–a 50 year-old nurse assistant with high cholesterol. They say she eats healthy foods, is physically active, but still has high cholesterol. They also say she is a “bit overweight.”

Susan’s doctor wants her to take a statin to prevent a future event (primary prevention). Susan, however, has learned that when she considers her overall (good) health, the risk of heart attack or stroke doesn’t warrant taking a pill. She’s also learned that lowering a lab value (biomarker) may not translate to better outcomes. The authors do a nice job of explaining this important concept. At the end of the piece they note that Susan’s doctor is still trying to convince her to take the statin.

What I would add to the Susan story is that her doctor might have prescribed a formal exercise plan rather than a pill.

Being “physically active” as a nursing assistant, or at most jobs (bike messenger excluded) isn’t the same as carving out 30-60 minutes per day to really exercise. That’s the thing; most doctors won’t tell patients that exercise has a dose-response (including an upper-limit.) Or that being truely fit lowers cardiac risk, maybe as much as owning boastful biomarkers does. But you can’t get fit swallowing a pill. You can’t even get fit exercising three times a week. It’s a daily process. Fitness requires nurturing, planning and priority. Susan doesn’t have to train for an Ironman; she just has to find an exercise that works for her and do it as part of normal life.

Blood pressure medicine:

Let’s take the middle-aged patient with high blood pressure. It’s a serious problem because even mild increases of blood pressure, so called pre-hypertension, predicts cardiac events. Treatment here is appropriate. But again, many patients and doctors reach for a blood pressure-lowering medicine. The secret I’d like to let out is that there are other (safer) ways of treating high blood pressure:

  • Reduce nightly alcohol intake. Did you know that more than two drinks is highly correlated with high blood pressure?
  • Reduce salt consumption;
  • Stop taking NSAIDs;
  • Lose weight;
  • And of course, either start a vigorous exercise program, or increase the dose of exercise.

Dr. Jay said exercise is not a panacea. Correct indeed.

But based on what I see everyday, the prescription of real exercise is way underused. And if dosed properly, I’m convinced that exercise would dramatically improve the health of our people and of course, our country.

Not to mention that it makes you smarter, more sexy and…you may even win a tee-shirt or twenty dollars in a race.

What’s not to like?

*This blog post was originally published at Dr John M*

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