Exercise Beats Drug Therapy
Stan Reents, PharmD
02/21/2020 08:49 AM
Last Revision: 09/23/2020 10:07 AM
In 2017, the RAND Corporation released a report summarizing the prevalence of chronic disease in the US. Based on health statistics from 2014, it reveals:
- 60% of adults in the US have at least one chronic disease.
- 42% of adults have more than one chronic disease.
- In adults 65 years and older, 81% have more than one chronic disease.
Most of these health problems are due to a person's lifestyle: smoking, not exercising, poor diet. Thus, "lifestyle"-related illnesses now represent the largest percentage of health care expenses in the US.
The RAND report also summarizes the number of prescriptions filled in an average year (2014 data) depending on how many chronic conditions a person has:
|NUMBER OF |
|5 or more conditions ||51 prescriptions filled|
|3-4 conditions ||24|
|1-2 conditions ||9|
Yet, despite all the new and impressive drugs and procedures that our health care system currently offers, exercise is still the best option for lifestyle-related illnesses. Here's why I think so:
THE EFFECTIVENESS OF SOME DRUGS IS ONLY MARGINAL
Certainly, some drugs are very effective and we should be thankful for that.
Antibiotics can be life-saving. For example, meningiococcal meningitis is a medical emergency. Fortunately, IV administration of simple penicillin is highly effective if begun immediately. Even a routine urinary tract infection can be serious if not treated properly. UTI's are easy to treat because there are a variety of effective antibiotics available.
And, I am very optimistic about the new biotech cancer drugs being approved. These drugs are effective without producing the terrible side effects of older chemotherapeutic drugs. President Jimmy Carter had metastatic melanoma (skin cancer). He was treated with the biotech drug pembrolizumab (Keytruda) in 2015-2016. In March 2016, he was cured.
However, some of the most widely-prescribed drugs for chronic illnesses aren't as effective as you might think:
Dementia Drugs: Most drugs investigated for treating dementia don't work (Cummings JL, et al. 2014). For some drugs that do get approved for clinical use, a tiny benefit is seen initially, then, no benefit can be detected later: In one study, donepezil (Aricept®) demonstrated some success at 12 months, but after 3 years, the rate of progression to Alzheimer's disease was no different than placebo (Petersen RC, et al. 2005). In a 36-week Italian study, donepezil (Aricept®), galantamine (Reminyl®), and rivastigmine (Exelon®) each failed to prevent the decline in cognitive function in 938 patients with mild to moderate Alzheimer's disease (Santoro A, et al. 2010).
Statin-type Cholesterol Drugs (Crestor®, Lipitor®, others): In the November 8, 2010 issue of the Archives of Internal Medicine, John Pippin, MD, critiqued the JUPITER trial, and summarized a meta-analysis of studies of statin drugs: "These findings suggest that three-fourths of patients who take statins to prevent a first cardiovascular event do not benefit from this treatment." A separate analysis revealed that a disturbingly high 41% of patients had an LDL-cholesterol level of < 100 mg/dL at the time of their first heart attack (myocardial infarction) (Sachdeva A, et al. 2009). This LDL-cholesterol value is generally considered acceptable. In other words, people with "acceptable" cholesterol levels can still have a heart attack.
Beta-Blockers: Beta-blockers have been used in clinical medicine longer than statins: The first beta-blocker (propranolol) was marketed in the US in 1967. In 1981, beta-blockers were approved for use following a myocardial infarction (heart attack). But this use has been controversial: A review from 1999 endorsed their use in this setting (Freemantle N, et al. 1999), but subsequent reviews came to the opposite conclusion (Bangalore S, et al. 2014) (Hong J, et al. 2018). In patients with stable coronary artery disease, the opinion is that "beta-blockers fail to offer any benefit" (Rossello X, et al. 2015). And in the treatment of hypertension, the always-thorough Cochrane Database Review has evaluated the literature 3 times. Each time, they concluded that there are much better choices than beta-blockers (Wiysonge CS, et al. 2017). For patients who exercise (and that would be most of us, right?), beta-blockers should be avoided altogether (Houston MC. 1992). Beta-blockers suppress exercise heart rate and interfere with energy supply.
PATIENTS DON'T TAKE THEIR DRUGS PROPERLY!
Regardless of the effectiveness of drug therapy, patient compliance is often 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 statins. 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.)
As mentioned above, people with diabetes, hypertension, or elevated cholesterol often have more than one of these chronic conditions 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:
|TO TREAT |
|THE PolyPill FOR |
|THE PolyPill FOR|
|Elevated cholesterol ||a statin ||a statin|
|Elevated blood sugar ||(none) ||metformin|
|Hypertension ||• a diuretic |
• a beta-blocker
• an ACE inhibitor
|an ACE inhibitor|
|To lower thrombotic risk ||aspirin ||aspirin|
|REFERENCE: ||Yusuf S, et al. 2009. ||Kuehn BM. 2006.|
I'm not as enthusiastic:
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 for these conditions 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 manifestations of a problem without first fixing the cause of the problem!
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 trying to prevent cavities by using drug therapy while ignoring the benefits of brushing and flossing! A lifestyle-related health problem requires a change in behavior, not drug therapy.
WHY EXERCISE IS A BETTER STRATEGY
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 (ie., exercise), not a pharmacologic one (ie., drug therapy).
People who are sedentary suffer from a vascular process known as "atherosclerosis." This leads to cardiovascular problems such as myocardial infarctions (heart attacks), strokes, and hypertension (high blood pressure). Most cases of erectile dysfunction and some cases of dementia are also related to atherosclerosis.
Atherosclerosis is caused by the combined damaging actions of elevated cholesterol, elevated blood pressure, and elevated blood glucose on arteries. But, the fundamental defect in 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 only treat the various symptoms of that process.
Statins have become one of the most widely-prescribed types of drugs in the world. However, John Ioannidis, MD, at Stanford University, has questioned the new guidelines for 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).
And here's another perspective:
A drug generally has only 1 or 2 therapeutic actions while possessing DOZENS of side effects. For some drugs, the risk of side effects overshadows their minor benefits. For example:
Analgesics/Anti-inflammatory Drugs: NSAID's are routinely used for arthritis. However, an analysis of 23 studies of using NSAID's to treat knee pain in patients with osteoarthritis of the knee revealed that these drugs were helpful for several weeks after symptoms flared up, but their long-term use could not be justified considering the risk of side effects that occur with long-term use (Bjordal JM, et al. 2004).
Compare that to exercise: Dozens of BENEFITS, yet hardly any side effects! (Roberts WC. 1984)
Even if all patients took their drugs as prescribed, the health benefits that exercise offers exceed what drug therapy can provide (Green DJ. 2009). While metformin can lower blood sugar, and statins can lower cholesterol, and ACE inhibitors can lower blood pressure, aerobic exercise does all that, too.
In addition, exercise improves vascular compliance (responsiveness), enhances the utilization of glucose and triglycerides, strengthens the heart muscle, enhances bone density, improves muscle strength, aids in weight loss, improves joint flexibility and stiffness, and improves cognitive function, mood, sleep quality, balance, etc. all at once. Further, sweating aids in the elimination of sodium. No drug, or group of drugs can match all of those benefits!
EXERCISE REDUCES THE NEED FOR DRUG THERAPY
Regular exercise can reduce the need for drug therapy even after chronic illnesses have already developed. Our Articles Library provides detailed reviews on these conditions, but, briefly:
Exercise Reduces the Need for Diabetes Drugs
• Walking: Researchers at the University of Perugia (Italy) assessed the impact of brisk walking on the need for diabetes drugs. They found that more exercise (up to a point) meant less need for diabetes drugs (DiLoreto C, et al. 2005). These results are summarized in the Impact on Drug Costs section below.
Exercise Reduces the Need for Hypertension Drugs
• Running: Twenty-four of 47 patients with hypertension were able to discontinue all blood pressure drugs after running 2 miles per day for 3 months (Cade R, et al. 1984.)
• Cycling: Twenty-four chronic renal failure patients rode a stationary bicycle during their hemodialysis sessions. After 6 months, 13 of these 24 patients required less intensive drug therapy for hypertension (Miller BW, et al. 2002.) This might not sound very impressive, but patients with renal failure often develop hypertension that requires treatment with multiple blood pressure drugs.
Exercise Reduces the Need for Metabolic Syndrome Drugs
• Aerobic Exercise Plus Resistance Exercise: Researchers in Rome, Italy, had patients with type-2 diabetes perform both aerobic exercise and resistance exercise 3 times per week. After 1 year, the patients who exercised required less drug therapy while the patients who didn't exercise required more drug therapy (Balducci S, et al. 2004):
|DRUG CATEGORY: ||EXERCISE |
|Blood Pressure |
|decreased 5.9% ||increased 5.7%|
|Diabetes Drugs ||decreased 3.9% ||increased 7.6%|
|decreased 7.8% ||increased 5.7%|
FOR SOME DISEASES, EXERCISE CAN MATCH DRUG THERAPY
Is there any head-to-head evidence that exercise is just as good as drug therapy for serious medical conditions?
Yes, though only a handful of research studies have directly compared exercise to drug therapy:
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). Exercise produced better results: A separate study showed that a pedometer-monitored walking program ("Fitness For The Aging Brain" study) led to an improvement of 1.3 points after 6 months (Lautenschlager NT, et al. 2008).
Depression (treatment of): Researchers at Duke compared aerobic exercise (30 minutes per session, 3 days per week) 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). The Duke researchers then conducted a second study: At the conclusion of the 1st study, these subjects were given the option of receiving an "exercise prescription," or, consultation with a psychiatrist and an antidepressant. The most commonly-prescribed antidepressants were bupropion (Wellbutrin®), escitalopram (Lexapro®), sertraline (Zoloft®), and venlafaxine (Effexor®). One year later, the 2 treatment options produced similar results. One detail to note: The exercisers only exercised 90-100 minutes per week, whereas it was documented that 180 min/week achieved the best antidepressant response (Hoffman BM, et al. 2011). In other words, if most of the subjects exercised 180 min/week, it is likely that exercise would have been more effective than antidepressant drugs.
Diabetes (prevention of): In the long-term Diabetes Prevention Program Study, 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. After an average follow-up of 2.8 years, exercise reduced the development of diabetes by 58%. Metformin reduced it by only 31% (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 JF, et al. 2014).
In 2013, Huseyin Naci and John Ioannidis, MD, at Stanford analyzed 305 randomized controlled clinical trials involving over 339,000 patients. They compared the response to exercise versus the response to drug therapy (Naci H, et al. 2013):
|MEDICAL CONDITION ||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|
Yes, exercise IS good medicine!
IMPACT OF EXERCISE ON DRUG THERAPY COSTS
Obviously, if exercise can reduce the need for drug therapy, then expenses for prescriptions are less. It is surprising that there is so little research on this topic, but some details are available:
Walking Lowers the Cost of Diabetes Drugs: In an Italian 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 this study, exercise was cataloged as "MET-hrs per week." This considers both how long someone exercises and how hard they exercise. One MET is how many calories you burn while sitting at rest. So, if brisk walking burns 3 times the calories as sitting, and you walk for 4 hours, that's 12 MET-hrs. If jogging burns 5 times the calories as sitting, and you jog for 3 hours, that's 15 MET-hrs.
MET-hrs can be added up. So, if during a 7-day span, you do 12 MET-hrs one day and 15 MET-hrs another day, you've accumulated a total of 27 MET-hrs that week.
It worked out like this:
|AVERAGE WEEKLY |
(MET-hrs per week)
ANNUAL DRUG COSTS
|none ||increased $393|
|7 MET-hrs per week ||increased $206|
|17 MET-hrs per week ||decreased $196|
|27 MET-hrs per week ||decreased $593|
|38 MET-hrs per week ||decreased $660|
|58 MET-hrs per week ||decreased $579|
It's easier to think of "MET-hrs per week" in terms of the amount of walking:
|MET-hrs per week: ||MINUTES/DAY ||MILES/DAY ||STEPS/DAY|
|11 MET-hrs per week ||30 minutes/day ||1.2 miles/day ||2400 steps/day|
|27 MET-hrs per week ||77 minutes/day ||3.2 miles/day ||6400 steps/day|
Cycling Lowers the Cost of Blood Pressure Drugs: 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.)
"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! See: Exercise Guidelines for Health: Official Recommendations
But, first, a couple precautionary statements:
1) If you have any pre-existing medical condition, check with your personal physician before beginning any new exercise routine.
2) If you are currently taking medications, do NOT stop taking them without conferring with your 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 blood sugar start to improve, and, you might be able to avoid taking some prescription drugs!
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, a reduction in health care expenses!
FOR MORE INFORMATION
In 2007, the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) jointly launched the "Exercise Is Medicine" initiative. The goal is to get physicians to "prescribe" exercise no differently than they prescribe drugs. Learn more at www.ExerciseIsMedicine.org.
An entire chapter in Reents' text Sport and Exercise Pharmacology is devoted to the concept of prescribing exercise to "treat" health problems. (This book was published 7 years before the ACSM/AMA "Exercise Is Medicine" campaign was launched!)
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.
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
Balducci S, Leonetti F, DiMario U, et al. Is a long-term aerobic plus resistance training program feasible for and effective on metabolic profiles in type-2 diabetic patients? Diabetes Care 2004;27:841-842. (no abstract)
Bangalore S, Makani H, Radford M, et al. Clinical outcomes with beta-blockers for myocardial infarction: A meta-analysis of randomized trials. Am J Med 2014;127:939-953. 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
Bjordal JM, Ljunggren AE, Klovning A, et al. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: Meta-analysis of randomised placebo controlled trials. Br Med J 2004;329(7478):1317. Abstract
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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
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
Knowler WC, Fowler SE, Hamman RF, et al. 10-yr follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677-1686. Abstract
Kuehn BM. "Polypill" could slash diabetes risk. JAMA 2006;296:377. Abstract
Lautenschlager NT, Cox KL, Flicker L, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease. JAMA 2008;300:1027-1037. 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. Scand J Med Sci Sports 2006;16(suppl. 1):3-63. Abstract
Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med 2005;352:2379-2388. 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
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ABOUT THE AUTHOR
Stan Reents, PharmD, is a former healthcare professional. He has been 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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