Series Introduction: How to "Prescribe" Exercise

These posts will be very detailed with a variety of linked articles and you should treat them like a therapeutics lecture. To kick us off, we're going to focus on why exercise is so important and look at some data. Let's go back to school.

Series Introduction: How to "Prescribe" Exercise
Photo by Victor Freitas / Unsplash

I have a simple question for all of the healthcare providers in our audience, and it's related to the most important and effective preventive treatment available. While in (insert pharmacy, nursing, medical, etc...) school, what did you learn about exercise?

Maybe you're able to pull something out of the depths of your brain to answer that question, such as the ADA recommendation to get 150 minutes of moderate-intensity exercise per week (30 minutes per day for 5 days). Perhaps you even recommended that regimen in SOAP notes or while practicing patient counseling.

I think this must be the least helpful advice that's regularly "taught" in schools. In fact, I think it's a genuine disservice to both patients and providers. Mind you, this is coming from someone who genuinely believes that his school did a fantastic job overall. Having said that, imagine recommending 150 minutes of exercise per week to a patient. Instead of smiling and nodding with a blank stare, the patient actually takes charge of their health and asks some logical follow-up questions:

  • What kind of exercise should I do?
  • What does "moderate intensity" look like?
  • How should I track my progress?
  • What side effects can I expect from exercising?
  • If my goal is X, what's the best type of exercise for me to do?

Of course, there are many other follow-up questions that would be logical for patients to ask. The point is that not a single healthcare provider in this country is armed with the knowledge to reasonably answer these questions in school. Not one.

As much as we like to blame the lack of prophylactic approaches in medicine on corrupt politicians trying to keep healthcare focused on responding to illness rather than preventing it, there is close to zero time spent on these topics in school. In order for HCPs to actually help patients in this way, they'd have to teach themselves. Again, this is the most important and effective treatment we have available, and providers are left to figure it out for themselves. Unfortunately, most of us just ignore it completely.

If you are one of the providers out there interested in preventing illness and relaying useful, actionable information to your patients, this post is meant to be an introduction to a new world. Every other week we will provide you with information on the pillars of exercise for longevity and disease prevention: aerobic capacity, strength, and stability. These posts will be detailed with a variety of linked articles which you can treat like a therapeutics lecture. To kick us off, we're going to focus on why exercise is so important and look at some data. In the following posts, we will walk you through how to "prescribe" different types of exercise for your patients going forward. Let's go back to school.

Photo by Florian Kurrasch / Unsplash

Everyone knows that exercise is good for you, and no one would really be surprised to hear that exercise is associated with a longer life. Still, the magnitude of the benefit may surprise you. Let's start with aerobic exercise and cardiorespiratory fitness. Your first bit of homework is to check out the short article below:

Does Being In Good Shape Actually Make You Live Longer?
We’ve all heard stories about someone who was in great shape but still experienced an untimely death. This happens often enough that many people start to ask, “Does being in good shape really make a difference?”

That post will take you on a deep dive into a publication by Mandsager et al. in 2018, and the results may shock you. For instance, smoking tobacco is known to increase all-cause mortality, AHR=1.79; 95% CI: 1.12– 2.97, according to Lim et al. in 2022. On the other hand, having low cardiorespiratory fitness carries a massive increase in all-cause mortality, HR=3.90; 95% CI, 3.67-4.14, compared to individuals with high respiratory fitness. That is an incredible increase in risk! These findings were later supported in the Journal of the American College of Cardiology by Kokkinos et al. in 2022. Of course, there are limitations to these studies, and I suggest you read them for a deeper understanding.

Getting back to aerobic capacity and cardiorespiratory fitness, you may be wondering what they are. They represent your ability to deliver oxygen to your muscles and your muscles' ability to utilize that oxygen. This manifests in perceived exertion while doing aerobic activities such as walking, jogging, swimming, or hiking. From the perspective of activities of daily living (ADLs), your aerobic capacity will partially determine your ability to do yard work, clean the house, walk around the grocery store, or take the stairs up from the basement, particularly as you age.

Your aerobic capacity can be measured in a lot of different ways, but the most notable is a VO2 max test. This is the measurement used in both the Kokkinos and Mandsager publications above. Here's another article for homework:

What is Your VO2 Max and Why is it Important?
When it comes to endurance training, the term “VO2 max” is often thrown around, typically without any understanding of its actual meaning. To put it simply, your VO2 max is a measurement of how quickly you can utilize oxygen (O2) while exercising at max capacity.

Unlike cardio, most people don't intuitively associate strength with longevity. That would be a mistake. In fact, the associated increases in longevity with strength rival that of cardiorespiratory fitness. Check out this publication by Artero et al. in 2011 which found that men in the bottom 50% of cardiorespiratory fitness were still 48% less likely to die of any cause if they were in the top 33% of strength compared to the bottom 33%. The takeaway is that muscle and strength are very important. So much so, there's more homework:

How Protein and Muscle Can Save Your Life
You consume 3 macronutrients throughout your day: fat, carbohydrates, and protein. All 3 play essential roles in the body, but protein is perhaps the most important for maintaining a long health span.

Muscle mass really is essential for longevity, and it should not be ignored by HCPs focused on disease prevention. For example, Bunout et al. found that appendicular fat-free mass (muscle mass in the arms and legs) was a predictor of all-cause mortality, HR=0.85; 95% CI: 0.74–0.98, P=0.03. When you understand fall-risk, the mortality risk associated with accidental falls (leading cause of accidental death for individuals >65 years of age), and how muscle is highly protective against falling, this data starts to make a lot of sense.

The benefits of strength and cardiorespiratory fitness are amazing and should really be considered medicine. For more information on that particularly bullish statement, check out this publication by Ionnidis et al. in 2015 which compared the efficacy of exercise to mainstream medications.

All of the data we've covered so far has been related to lifespan, and we haven't even touched on healthspan yet. The quality of life (QoL) increases seen with regular exercise are well-known and accepted. Similar to cardiorespiratory fitness, I think that's pretty intuitive. Unfortunately there's not nearly as much hard evidence on this topic because the endpoint is subjective, but most people understand it to be true. There is one great study of older adults in the UK by Veronese et al. in 2022 which demonstrated that sarcopenia (muscle loss related to aging) was highly associated with a poor QoL, OR = 5.82; 95% CI: 3.45–9.82. I can also anecdotally confirm this from my own personal experience with exercise and QoL.

Look out on Wednesday, September 20th for the next article in this series where we will start to cover how to actually "prescribe" exercise, and we will take a deep dive into aerobic training methodologies for those interested in helping their patients live longer. Stay tuned.