The Prescription Your Doctor Doesn’t Write
by Chuck Svendsen, MD
I have a prescription that I give to all my patients, and it's quite remarkable. Here are some of the statistics around it: this treatment is just as effective as any of the medications currently available for heart failure, prediabetes and coronary artery disease [1]. It has also been found to be markedly superior to blood thinners in the treatment of stroke rehabilitation. Additionally, it has been shown to yield a consistent 50% reduction in all-cause mortality when comparing individuals that take it with those who do not [2]. So, what is this miracle drug? If you haven't already guessed, it's exercise.
Poor cardio-respiratory fitness is a more powerful predictor of mortality than traditional risk factors such as hypertension, smoking, obesity, hyperlipidemia and type 2 diabetes [3]. As if that isn't enough reason to take exercise seriously, it is also effective in preventing multiple cancers. It also shows benefits in metabolic diseases, neurologic conditions like dementia and Parkinson's, psychiatric disorders including depression and anxiety and, of course, stress management.
Fitness has such an oversized impact that it's better to be overweight and physically fit than it is to be thin and unfit. Weeldreyer et al. showed that there was no statistically significant difference in mortality for patients who are “obese-fit” and “normal-weight-fit.” Yet, patients who were “normal-weight-UNFIT” had double the risk of dying from a cardiac event [4].
What Is an Exercise Prescription?
So why aren't more doctors writing exercise prescriptions? There are a couple of reasons. Unfortunately, most doctors are not equipped with the skills to do this. Currently, only about 12% of medical schools in the US have required courses related to physical activity, and only about 20% offer any course, required or elective, related to physical activity [5]. Also, many physicians simply feel like they don't have time. Large integrated medical systems have reduced the average doctor visit to 15 or 20 minutes. That leaves little time for something as luxurious as discussing exercise. But at Astride Health, we do have the time, and we do have the training. Which brings me to you.
Now for the courageous conversation. I can hear your reply already, 'But I already exercise!' Many of us do. I have generally been very active throughout my life. But over time, our exercise routines tend to morph into something familiar — movements we've mastered, intensities we've adapted to — and they stay that way for years. I believe that the right kind of exercise is a mix of cardiorespiratory activity, strength training and mobility training, with enough variety built in to challenge you. If you’re always doing the same thing, you might have trained yourself into a narrow niche of fitness.
We ask our patients: What do you want to be doing in the future? Say when you're seventy, eighty or even ninety years old? The answers are fairly uniform. Things such as: getting down on the floor to play with my grandchildren, traveling independently and being able to put my bag in the overhead bin on an airliner. Sometimes the answers are more ambitious, and people focus on items such as playing pickleball or participating in Brazilian Jiu-Jitsu. All of these take continuous, purposeful preparation.
Training for Life
Now, instead of exercise, I'm referring to training. Not as in training for a particular sport, but simply training for life. If you want to benefit from more energy and strength today, we can do that with the right training.
If you want to play golf into your 80s, it will require training starting today. It means doing things such as working on thoracic spine mobility to swing the golf club and stability training to ensure that you can walk on uneven surfaces. It will also require a certain level of cardiorespiratory fitness to continue walking the golf course.
The fundamentals aren't glamorous, but they're what keep you independent: zone 2 cardio (low-intensity cardio where you can still hold a conversation), lower-body stability training and mobility training to ensure you don't lose your range of motion.
It's often difficult to identify your own weaknesses, though. If it wasn't, we'd all be doing these corrections ourselves. That's why I generally recommend working with a personal trainer. This doesn't require thousands of dollars of expensive equipment for the assessment or the correction, but it does require a trained eye and a guide. It also requires awareness and someone to hold you accountable. If you'd like help identifying your own blind spots and building a training plan for the life you want to live, that's exactly what we do at Astride Health.
References
1. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: meta-epidemiological study. BMJ. 2013;347:f5577. doi:10.1136/bmj.f5577
2. Lang JJ, Prince SA, Merucci K, et al. Cardiorespiratory fitness is a strong and consistent predictor of morbidity and mortality among adults: an overview of meta-analyses representing over 20.9 million observations from 199 unique cohort studies. Br J Sports Med. 2024;58:556–566. doi:10.1136/bjsports-2023-107849
3. Ross R, Blair SN, Arena R, et al. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association. Circulation. 2016;134:e653-e699. doi:10.1161/CIR.0000000000000461
4. Weeldreyer NR, De Guzman JC, Paterson C, et al. Cardiorespiratory fitness, body mass index and mortality: a systematic review and meta-analysis. Br J Sports Med. 2024. doi:10.1136/bjsports-2024-108748
5. Cardinal BJ, Park EA, Kim M, Cardinal MK. If exercise is medicine, where is exercise in medicine? Review of US medical education curricula for physical-activity related content. J Phys Act Health. 2015;12(9):1336-1343. doi:10.1123/jpah.2014-0316