Are pills better than exercise?

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.

Statins:

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?

JMM

10 comments

  1. When I broke my leg, dislocated my shoulder and tore one of my rotator cuff muscles, had my inflamed appendix removed, and received my vaccinations (not concurrently) I considered myself fortunate indeed to be the recipient of late 20th century western medical care.

    When I work with my patients with heart disease, diabetes, arthritis, osteoporosis and a myriad of other chronic conditions I know that I am helping them to take advantage of a “medicine” that is powerful, evidence-based, cost-effective, and virtually adverse event free- secondary prevention For a good many of these people an effective exercise regime would have seen them not succumb to these problems in the first place- primary prevention. Exercise participation should be the default position for nearly all of humankind. If you’ve got out of the habit, don’t feel guilty or look for reasons not to exercise. “Start easy and build gradually” works for most. After all when you walked into your Cardiologists’ office your were exercising!

    “But based on what I see everyday, the prescription of real exercise is way underused.”

    And find yourself a family physician/specialists that are in the exercise camp, like Dr. J.

  2. Simon,

    Sorry to hear about your broken leg, dislocated shoulder and rotator cuff tear.

    Was that from riding Cyclocross? 🙂

    Jay

    1. Hello Jay,

      Thanks for your concern but no, these were all the result of non sport-related mishaps!

  3. So, what do you say to your patients who do start exercising, lose 50 pounds and still have high blood pressure and diabetes after a full year?

    1. Hello Emmy,

      Well, i’d probably ask a load of questions first about you, your health, and your exercise program. I’ll make the following general points:

      1. I think it’s a myth that weight loss alone is the best way to get healthy. The goal of a “fat loss” program should be just that and every effort should be made to preserve lean mass.

      2. There’s an enormous difference between exercise and fitness. Low intensity exercise can be very useful for achieving fat loss but will not help you to achieve optimal health. The general rule is to start with the lower intensity stuff and then increase the intensity. Higher intensity exercise is also very useful in diabetes as this burns more sugar in the blood/muscles/liver than the lower intensity variety.

      3. Look at exercise as a medication- is the type and dosage right?

      4. Finally, there are a very small percentage of the population who are “non-responders” in that they do not significantly increase their fitness with an exercise program. I have not heard of study subjects in tightly controlled research where they have failed to achieve some clinical benefit from an exercise program but i am willing to concede that this may be the case in some individuals.

      I hope this helps.

      Simon

      1. Thanks Simon, but with LQTS my exercise program is prescribed by my cardiologist and carried out an occupational medicine facility. Upping the intensity isn’t an option. And, I know a lot of people who have lost a significant amount of weight and have seen no benefit as far as the “cure” that we are almost promised by health care providers.

  4. Hi Emmy,

    Your LQTS puts you in a small group of people for whom exercise can be problematic. This is a condition that is squarely in the domain of the Cardiologists not a humble Exercise Physiologist. Yes, promises of anything in health can be difficult to follow-through on. Even now medicine doesn’t have all the answers.

    Simon

    1. Thanks Emmy and Simon.

      I would add only this: If one is at ideal body weight and still hypertensive, I usually rec a medicine.

      Though Simon’s point about exercise requiring appropriate dosing is pertinent.

      Long QT patients are indeed outliers to the ‘rule.’

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