Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
3 Apr

Will We Ever Accept that Exercise is Often the Best Medicine?

pillsvsexerciseFor years, experts have known that in mild to moderate cases of depression exercise is as effective (or more effective) a treatment as prescription drugs. Yet, here we are in 2014, with still climbing obesity rates and higher than ever numbers of people taking anti-depressants – a 400% jump in the last 20 years.  This past week, exercise as medical therapy got another round of press after The Atlantic highlighted the issue in their thought provoking feature “For Depression, Prescribing Exercise Before Medication.” Let me add, however, that we aren’t just missing the boat in terms of depression therapy. Research has shown time and again that exercise offers just as good if not better results for an array of medical conditions. I might be preaching to the choir with the general theme, but let’s go beyond the basic assumptions and home in on the critical underlying messages reflecting why exercise isn’t just the safest and often most effective choice but why it so often remains the least accessed therapy.

Yes, the whole picture is profoundly intuitive to any Primal type (or maybe anyone not sold on the pharmaceutical solution to living). Isn’t it a funny, head-scratching coincidence that basic exercise can prevent – and treat – psychological and physical decline? Who would’ve thought that movement was useful to our bodies – that offering our physical forms the activity they were designed to perform for eons would confer some actual benefit? Still, the actual results themselves are fun if not impressive to read. Consider this…

  • Regular exercise resulted in a 30% remission rate for those with depression who didn’t respond to SSRI medication.
  • Study participants with heart disease who exercised had the same risk of dying as those who took popular drugs such as statins, antiplatelet drugs or ACE Inhibitors.
  • Research subjects with prediabetes who took the array of common prescription medications had the same mortality risk as those who simply exercised.
  • Among study subjects who had experienced stroke, those who exercised had a significantly lower mortality risk than those who took medications such as anticoagulants and antiplatelets.

On the flip side of this coin, of course, are the negatives. We’ve established that exercise confers physical, cognitive and emotional advantages for the prevention and/or treatment of many medical conditions. Add to this equation the question of drawbacks. Does exercise have disadvantages? In all fairness, your hair gets messed up. You’ll likely sweat. You perhaps need to take an extra shower or time the day’s toilette to match your workout schedule. You need to buy a pair of shoes (but then again you can just go barefoot). You’ll need to invest a little time for heavier workouts but perhaps can try to get some of the low level movement in while using a handy-dandy treadmill desk (or, more old school, work a job with heavy manual labor or lots of activity). Then we come upon the whole inertia argument, but in response there are even effective exercise options for the motivationally challenged.

While I’m not trying to minimize the nuisance of smelly armpits or losing an hour on the sofa, let’s take a look now at the potential downsides of pharmaceutical solutions.

  • Side Effects for SSRIs: gastrointestinal disturbances, anxiety, agitation, insomnia, sleep disturbance, weight gain, sexual dysfunction
  • Side Effects for Statins: memory loss, forgetfulness, confusion, muscle damage, increased risk of diabetes, liver injury
  • Side Effects for Anti-coagulants: excessive bleeding, severe bruising, bloody urine or stool, headache, back pain, chest pain, difficulty breathing
  • Side Effects for ACE-inhibitors: dizziness, headache, fatigue, loss of appetite, gastrointestinal problems, diarrhea, numbness, fever, joint pain
  • Side Effects for Beta-blockers: diarrhea, stomach cramps, nausea, vomiting, rash, blurred vision, muscle cramps, fatigue, headache, depression, confusion, dizziness, sexual dysfunction, low or high blood glucose

The final kicker? A study out just last month showed that more than 20% of older adults being treated for multiple medical conditions are prescribed medications that worsen the symptoms of another condition. In other words, their medications work at odds or in “therapeutic competition” with each other. The more we dig ourselves into the pharmaceutical hole, it appears, the worse (and more ironic) it all gets.

Knowing all of this, why does the obvious solution feel so impossible? Why won’t people accept exercise as a genuine medical option? Why do we tend to go with a pill (at times, an awfully expensive one) rather than a simple, natural behavior change? Why are we individually invested in this choice? Why are we as a culture – or medical establishment – so invested in this approach?

We’ll spend billions of dollars researching which gene “lights up” or which protein levels rise all in the name of better understanding the physiological mechanisms of disease while the solution itself is staring us in the face. Let me back up for a moment and suggest that I’m not arguing that exercise covers any and all medical need. I’m not saying it has the absolute power to cure or prevent any particular person from developing illness in his/her lifetime. Our physiology is inherently complex. People should avail themselves of the broad medical options that allow them to lead the fullest and healthiest lives possible. That said, there’s rarely an instance in which lifestyle choices can’t make a powerful difference either unto themselves or in conjunction with conventional or complementary medical treatments.

The million dollar question in all this, of course, is how do we get people to accept exercise as a treatment? How do we convince doctors to literally prescribe exercise (understanding, of course, that some already do)? How can patients be convinced to avail themselves of the safest, perhaps most effective treatment option? The Atlantic feature chose to address this question from the perspective of psychiatrists. Their answer? To treat it “like real medicine.” For one psychiatrist interviewed, that means addressing it in his appointments with patients as he would a prescription for medication, discussing the details of studies that support the effectiveness of exercise, talking about effective “doses” and intensity levels, emphasizing the importance of consistency by comparing it to a diabetic’s occasional versus regular use of insulin.

It’s a provocative thought. What if doctors talked about exercise as medicine in their sessions? Would it be convincing to the majority of people who walk through their doors? (Would it win you over?) The results, according to doctors in The Atlantic piece, seem mixed. The most difficult factor is the obvious elephant in the living room – that the pill is there ready to be prescribed, whether it’s called “a last resort” or not. Nonetheless, can the rhetoric sway at least some people to take exercise to heart? Will homing in on the technical details of dosage and variety get people to take the usually friendly advice as medical law – and personal treatment plan?

There’s an interesting wrinkle to this that I don’t often see discussed with how we tend to downplay the value of lifestyle interventions. Research into the placebo effect demonstrates that the more costly we believe a certain placebo “medication” is, the higher we rate its “effectiveness” in treating our symptoms. The value we attach to a treatment influences the actual results we think we experience.

This point, in turn, brings up another dimension. While we (rightly) exalt the everyday accessibility of exercise, are we simultaneously downgrading its appeal to those who need it most? Let’s just brainstorm for a minute. What would happen if doctors could prescribe personal training and/or fitness center/class use as they do physical therapy? People often skip physical therapy or bow out before they’ve met their goals, but generally people take advantage of it when a doctor orders it. Would it boost people’s buy-in if we promoted general fitness training and support the same way? Are we kidding ourselves to think we can put the onus solely on the individual when the system so clearly supports the opposite choices?

There’s an interesting cultural dichotomy at work here. I think a lot of ordinary people would bristle at the suggestion that they need a trainer or that this person’s service should cost them in treating their illness. Yet, they think nothing of spending as much or considerably more on medications than they would the guidance (and motivation) of a personal trainer. Simultaneously, there’s an odd fascination with the most extreme representation of the trainer figure as millions watch Jillian Michaels et al. every week in the disturbing entertainment of televised panopticon meets “fat camp.” We’re a confounding, nonsensical populace (collectively speaking)….

On the other end of the “medical speak,” when prescribing exercise is the self-care justification. You deserve to take care of yourself. You deserve to thrive. You deserve to not have to take insulin every day or deal with the complications of statins. Is this line of reasoning any more convincing for people than dosing out activity according to medical study suggestion? My own sense is it depends on the patient.

Either way, it always intrigues me how put out we are by our bodies’ needs. Are we naturally this lazy, or has the culture just gotten to us that we feel so put upon having to exercise ourselves – having to make the effort to pick up our 100 lb gym shoes and walk out that 1000 lb front door to go for a walk? That hour we have to “waste” on fitness could’ve been used for three dozen other, more pressing needs. Why not see a pill as the ultimate “easy button” that allows us to have it all. It’s hard to kick the collective faith in that assumption even if the research suggests a much different picture. Where does medical logic fit in a modern mindset? It’s hard to tell, but the simple Primal perspective as always holds – that we naturally live through our bodies and have the ability to physically and psychologically thrive when we offer ourselves the age-old inputs our genetic blueprints anticipate. Maybe Primal logic’s time has come.

Thanks for reading today, everyone. What thoughts does all this raise for you? Is there any clarity or direction to be found in how to prescribe movement over medicine?

You want comments? We got comments:

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  1. For us older women (I will be 60 this year), I think one of the problems is that when we were young we were told NOT to exercise. I graduated high school before Title IX, which guaranteed equal access to sports for women. In high school we had no sports teams for girls. Cheerleader or majorette, that was it. I would have loved to run cross country, but there was no girls team and heaven forbid a girl would be on the boys team. I remember Kathrine Switzer was pulled off the Boston Marathon route because she was a woman. A common remark back then was if you did heavy exercise or running your uterus would fall out. So no wonder older women don’t want to exercise! After college I just couldn’t stand it anymore, I had to run. They didn’t make running shoes for women so I had to buy men’s shoes. I ran for probably 20+ years until my knees started hurting. Since I thought it would be a good idea to try to preserve them for future use, I started cycling. I ride my bike to work 2-3 times per week (28 miles round trip) and go to a weight training class twice a week. The hardest part is getting out the door. I’m always glad I did it. Inertia is the enemy. It’s easier to watch TV and eat a bag of chips, but you sure don’t feel as good.

    Ellen wrote on April 3rd, 2014
  2. My mother is 75, and walks 3 miles (minimum) a day. She always has since I can remember. She was prescribed an osteoporosis (sp?) drug awhile back (it does run in our family), but didn’t like it so she chooses to lift weights and bounce on a mini trampoline instead. He doctor is happy with her test results.
    She does eat pretty healthfully (not primal, but close – and cooks primal meals when I come over!)
    She had some minor surgery a year ago and when asked what medication she took, she replied: a vitamin D supplement and sometimes a 1/2 a baby aspirin.

    My friends parents are the same age as my mother. They are both on at least 10 different (expensive) drugs, which constantly have to be re-adjusted because they counter act with each other. Both her parents have been in and out of the hospital for heart, kidney and liver issues, and both have type ii diabetes.
    They have always looked at exercise as a burden all their lives, and could see no pleasure in it. And the fat-free “healthy” cookies were always in the house. It hurts to see her Dad in the hospital eating munchkins and processed hot chocolate as his treat. She says its genetics.
    Ha, maybe an inclination for a primal lifestyle is in the genes? I guess I hope so…

    mlou wrote on April 3rd, 2014
  3. Good article Mark! I am wholeheartedly with you on your exercise viewpoint.One of the great things about exercise is it gets the oxygen into your lungs and promotes energy.People with anxiety and fear are generally breathing, in a very shallow manner and are not bringing positive energy into their body.

    Anti depressant medication doesn’t suddenly make people happy.Instead it just tends to make them numb. Sitting in neutral I guess.This is not how you want to live your life.

    Better off visiting a psychologist, starting an exercise program, and surrounding yourself with beautiful nature and positive people, in my opinion.

    Keep up with the great articles.

    The Inspirator wrote on April 3rd, 2014
    • I went through a traumatic experience in my life and ended up on antidepressants. Feeling numb was a distinct improvement. It enabled me to function to the point where I could dig myself out. After six months I felt better and ditched the antidepressants. In that time period I lost 55lbs from extreme stress and heartache.

      ingvildr wrote on April 4th, 2014
    • Respectfully, while my antidepressant did not “suddenly make me happy,” it did not leave me numb. That may have been your experience or the experience of someone you know, but until I started on a course of antidepressents *and* therapy, I hadn’t felt anything in years that wasn’t some version of self-loathing, misery, and despair.

      Erica wrote on April 4th, 2014
  4. Maybe, just maybe the massive, lucrative pharmalogical industry and the benefits they can provide doctor’s practices help determine the doctor’s treatment.

    Adrian wrote on April 4th, 2014
  5. if someone want good health he have to accept this..exercise everyday keeps doc away :-)

    joseph101 wrote on April 4th, 2014
  6. This is very interesting. I love your work, and strive to follow it every day. At 45, people don’t believe it when they see me eating dark chocolate, or when I deny the allegation that I exercise every day. Regrettably, however, I have suffered depression. Despite doing all the “right” things. for me, exercise was actually one of the stressors. You see, 50 triathlons, including a couple of ironmen (pre-primal lifestyle) affected me self-perception. Kids come along, work gets serious, sleep becomes a luxury, but you’re still getting up early to run/swim/bike…. until you can’t. And then, even when you’re advised to give it a rest you can’t. After all, exercise is a cure for depression….you get the picture.

    Like all medecine, look at the dosage…..

    wpj wrote on April 4th, 2014
  7. I found your site when I decided to take control of my mental health as meds and hospitalization have not helped. What I heard from alot of posts is that lazy people and drs grab meds as a first. Most mental health symptoms, like mine, is feeling so low that death is welcomed. Not having the option to get out of bed let alone go for a walk. Meds can and do achieve relief. Minor relief, but relief. After that, nutrition and working up to exercise is what is important. This article is accurate but not understand the complexities of mental health disorders cause misconception.

    Hollie wrote on April 4th, 2014
    • +1

      Erica wrote on April 4th, 2014
  8. I haven’t read whole article yet…

    however some of the side effects of SSRIs included weight gain… weight LOSS or anorexia is a more common side effects…weight gain may actually be associated with well being returning and people gaining weight healthily due to a lifted mood and increased appetite…

    don’t forget serotonin syndrome, potential very dangerous… and QT interval prolongation too with some medications.

    so the combination of ‘strenuous exercise’ with SSRIs may be a risk… just my two penny.

    UKnurse

    UKnurse wrote on April 4th, 2014
  9. Good advice not followed is bad advice. The fact that exercise does all of this is irrelevant to the fact that most people don’t do it. So doctors can either give advice that they KNOW will not be followed. Or they can treat with drugs. So they do the latter.

    As well, when you’re really depressed, the LAST thing you want to do is exercise. So the fact that it might help is pretty much wholly irrelevant.

    Lyle

    Lyle McDonald wrote on April 4th, 2014
  10. I have tested this and confirmed!

    From age 8 to 14 I suffered from sinusitis and bronchitis, asthma. I weighed 210 lbs. Then lost 65lbs and suddenly I was cured of these respiratory problems I had for years. I eventually became more active and have been much stronger.

    Jeff wrote on April 4th, 2014
  11. In a nutshell,
    We have a food industry that doesn’t care about health. And a health industry that doesn’t care about food.

    Joe wrote on April 5th, 2014
  12. As far as I’m concerned the diet is more important than exercising. There are so many things that can cause us not to exercise any given day which a proper paleo style diet will at the very least keep our weight down. I personally struggle to exercise on a consistent basis and it seems to go in cycles of a couple months on and a month off but at 56 years of age I believe I’m in better shape than most 36 year olds. I credit the paleo diet that will maintain my health long enough so when I do get back into my exercise regimen it doesn’t take long for me to sprint like a 20 year old or do 20 (real) pull ups. I do believe that exercise can do everything Mark mentions and that he and many of the people on this forum are a testament to exercise, but the one constant for me is the food I eat.

    victor wrote on April 6th, 2014
  13. yep. i do not exercise, i forgot to take my fish oil and i feel the depression coming back. if i am depressed i have no will to exercise . always on the line..

    paleozeta wrote on April 6th, 2014
  14. Thanks for linking the Atlantic article. I couldn’t agree more that exercise beats any sort of antidepressant pill at least 90% of the cases. I haven’t had any good experiences to report from antidepressants, for me they only made things worse. But I guess that’s how we are as humans; we like to believe that we can replace the benefits of natural body movement with a pill we designed and engineered.
    Excellent post, I’ll make sure to share it with my friends

    Sarah Cooper wrote on April 6th, 2014
  15. what if you’re a regular exerciser, a lover of sports, and a primal eater and follower of the lifestyle and STILL suffer from regular bouts of depression, low energy and anxiety?

    drea wrote on April 7th, 2014
    • Check to see if you need some probiotics. Too much yeast overgrowth will cause all three – depression, anxiety and low energy.

      2Rae wrote on April 7th, 2014
  16. it’s the medical model. This model also ‘serves’ many people. For example, the medical companies and their lobbyists and the politicians. It does not ‘serve’ the people. There is a lot of business in disease and the system supports it. When the system rewards health, then exercise will be used as a prescription for depression.

    Robin Khan, DDS wrote on April 8th, 2014
  17. I think the spiritual aspect of exercising is often neglected. It’s an activity that requires you to focus on the present moment to some extent. When that is the case, the mind stops wandering, something that is one of the chief reasons behind depression and anxiety. Whenever the mind wanders, we always think of situations which we “want’ to have, but are out of our hands at the moment. We are not one with reality. Exercise results in elimination of this chatter, even if it’s for a short while. It’s like a meditative experience, which is very relaxing for the mind.

    This is one of the reasons why we should do exercises that we like to do, because when you enjoy the activity, you’re likely to go deeper into the aforementioned meditative state.

    John wrote on April 14th, 2014

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