Exercise in the Treatment of Chronic Disease: An Underfilled Prescription

It is clear that chronic disease has become the plague of the 21st century. In fact, 7 of the top 10 causes of death in the United States are chronic diseases, with heart disease and cancer leading the way and accounting for almost half of all deaths (⁶). All told, chronic diseases cause about 70% of the deaths among Americans every year (³). This is not surprising because nearly half of all adults have one or more chronic diseases and nearly a quarter have two or more (²). In addition, the prevalence of chronic disease increases dramatically with age, suggesting these conditions will only become more common as our nation’s Baby Boom generation transitions into Medicare.

We also know that caring for patients with chronic disease can be both complex and costly. Patients with noncommunicable and chronic conditions account for nearly 86% of our nation's health care costs, which were US $2.9 trillion in 2013 and show no evidence of declining (³). It is frightening to think about the devastating effect that escalating health care costs will have on our nation’s economy, as we spend almost 18% of our gross domestic product (GDP) on health care, not to mention the ever rising amount individuals pay each month for health insurance premiums, copays, and deductibles. It is clear that we cannot continue down the same path we are on with regard to health care in the United States.

It is amazing that chronic diseases are in large part preventable, yet we tolerate the behaviors that lead to the conditions. They are typically related in some fashion to three behavioral choices — exercise, diet, and smoking. We have done a good job in the United States (and around the world) to decrease smoking. It would be hard to find someone older than 5 yr in the United States who could not tell you that smoking is hazardous to your health. And efforts to combat smoking, while slow, have been successful, because the rates of cigarette smoking in both students and adults have steadily decreased over the past 50 yr (¹).

We also have devoted tremendous time and money to the issue of diet and obesity in the United States. It is hard to turn on the TV or pick up a newspaper without reading yet another story about how fat we are as a nation and the escalation of obesity rates. I think many of us in health care have become discouraged by seeing the yearly U.S. Centers for Disease Control & Prevention maps that show obesity trends in the United States over the past 35 years continue to worsen each year despite our best efforts. Unfortunately, it is hard to find consensus on any plan to reduce the burden of obesity both in the United States and around the world. And only recently we have seen an almost tectonic shift in the nutrition world regarding the dangers of dietary fat, which has been incorrectly demonized for years.

Exercise, on the other hand, has really been the forgotten risk factor, with relatively little money and effort devoted to assessing and prescribing exercise in the health care setting. Certainly, this makes no sense in light of the tremendous evidence regarding the health benefits of exercise in both the primary and secondary preventions of virtually every chronic disease. How can it be that we continue to search in vain for a wonder drug or gene therapy, spending billions of dollars on research with little or no return on that investment? In fact, a recent British Medical Journal article highlighted the fact that the 48 cancer drug treatments approved between 2002 and 2014 have extended life in cancer patients by an average of just two months and at a cost of many billions of dollars each year (⁷). And a recent commentary in the Journal of the American Medical Association points out that advances in the popular fields of gene therapy, stem cell therapy and precision medicine have not had any measurable effect on population mortality, morbidity, or life expectancy in the United States, despite that fact that US $15 billion of the US $26 billion National Institutes of Health research budget has been devoted to studies in this area (⁴). Yet, we continue to ignore the evidence around exercise as a medicine to treat and prevent not only cancers, but every chronic disease.

So where do we go from here? I think it is time to dedicate more effort and money toward increasing physical activity levels for all Americans, starting with our children in school and continuing on to adults of all ages. I would argue that of the three big behaviors linked to chronic disease (exercise, diet, and smoking), a patient’s physical activity habits are likely the easiest to modify and doing so will have the biggest impact on their health. To make this happen in the health care setting, every clinician should assess each patient’s physical activity habits and offer an exercise prescription as first line therapy to both prevent and treat chronic disease (⁵). It is fast becoming a standard of care in clinical practice to use a Physical Activity Vital Sign (PAVS) to assess every patient’s physical activity habits by asking two questions:

1. “On average, how many days per week do you engage in moderate or greater intensity physical activity (like a brisk walk)?”
2. “On average, how many minutes do you engage in this physical activity on those days?”

The product of the responses represents that patient’s PAVS in minutes per week, and patients not achieving the minimum U.S. Physical Activity Guideline recommendation of 150 min·wk⁻¹ should be advised of the health benefits of consistent physical activity. The goal is for every physician to respond to the PAVS with — either “Good job; I see you are doing 150 min of PA each week. Please keep it up.” Or “Today I noticed your blood pressure is high and your PAVS is zero. There is a connection there. Before I start you on a medication, why don’t you try walking briskly 30 min each day to lower your blood pressure. If that does not work, then we will try a medication.”

Beyond that, I should be able to refer my sedentary patients to a fitness professional who can help them get more active. Why is it that I can refer my obese patients to a bariatric surgeon who gets paid to staple their stomachs, but I cannot refer them to a fitness professional who can help get those same patients more active and perhaps avoid this risky and often temporary surgical treatment? Why is my only option for treating my patient with osteoporosis costly drugs that often bring unpleasant and risky side effects? Why can’t I refer that same patient to a fitness professional for a resistance exercise program that has been proven to lower the risk of fractures? These are questions that I believe demand answers.

So, in that vein, I was pleased to see the American College of Sports Medicine (ACSM) offer up new editions of great resource books for clinicians and patients regarding the use of “Exercise as a Medicine.” The first book is ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities, 4th edition. This is a great resource for any health care professional to optimize each patient’s health by keeping them physically active. It provides evidence-informed guidance to individualize exercise programs for persons with chronic disease and comorbid conditions. The second book is ACSM's Complete Guide to Fitness & Health, 2nd edition, which is a great resource for patients who need activity recommendations to improve their health. This book offers a plain language, science based reference that allows patients to shape a physical activity plan to their unique health and fitness needs across the life span. Both of these books continue to be key resources for health care professionals and patients who need to use exercise as a medicine for what ails them.