Clinical playbook: A practical guide to prescribing 'exercise as medicine'
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Exercise truly is medicine. It has so many benefits for both our physical and emotional health and not only short-term but also long-term positive influence.
—Becky Lowry, MD
All people with diabetes (and prediabetes) should engage in regular physical activity. Resistance training is also beneficial, as it improves the physiology of our body's metabolic engine—muscle!
—Liz Joy, MD
When did you last prescribe a patient exercise?
Exercise can be a powerful intervention, with numerous health benefits.
“Exercise truly is medicine. It has so many benefits for both our physical and emotional health and not only short-term but also long-term positive influence. It impacts chemicals in our bodies to improve our sleep quality, lower our stress, and even improve our mood and energy levels. Along with healthy nutrition and other lifestyle behaviors, it is protective for our heart and brain health,” Dr. Becky Lowry, Chief Wellness Officer for The University of Kansas Health System and internal medicine specialist, told MDLinx.
Regular exercise can help with weight management and reduce the risk of cardiovascular disease, diabetes, metabolic syndrome, and some cancers. It can reduce the risk of serious adverse outcomes of infectious diseases like COVID-19 and strengthen bones and muscles. Exercise can also improve sleep and daily function, boost longevity, prevent falls, reduce pain, and improve mood.[]
Here’s how to prescribe exercise as medicine for three patient groups.
Exercise as medicine for older people
When prescribing exercise for older patients, cognitive function can be as much a factor to consider as physical function.
“Approximately one in five U.S. adults aged 60 years and older reports that dementia is the health condition they fear most, and more than half report at least some level of concern about developing the disease,” said Liz Joy, MD, a family, sports & lifestyle medicine physician, former president of the American College of Sports Medicine (ACSM), and chair of the ACSM’s Exercise is Medicine Governance Committee, in speaking with MDLinx.
“I tell my patients that heart health is brain health and vice versa.”
Together with nutrition and good sleep, exercise can have an important impact on cognitive function in older people.
“In aging and older adults, the impact of exercise and fitness on cognition is impressive. Fit, active adults are less likely to develop dementia even if their genetics would suggest they are at higher risk,” Dr. Joy said.
She suggests activities like group fitness classes for this group, which can have additional social benefits.
“Group exercise has been demonstrated to have an even greater impact on cognitive outcomes due to the synergistic aspects of physical activity and social interaction," Dr. Joy said.
Even if an individual comes to exercise later in life, experts say it’s never too late to start.
“Even if you start when you're 75, you'll get benefits to your bone, benefits to your muscle, and hopefully improve some ability to regain memory and reduce risks of Alzheimer's,” Bert Mandelbaum, MD, sports medicine specialist, orthopedic surgeon, and co-director of the Regenerative Orthobiologic Center at Cedars-Sinai Orthopaedics in Los Angeles, told MDLinx.
Related: Body in motion: Why exercise may be the most under-prescribed intervention for physiciansExercise as medicine for those with diabetes
Just over 40 million people, or about 12% of the population of the United States, is believed to live with diabetes.[]
Regular physical activity is a key management tool for those living with diabetes.[]
“All people with diabetes (and prediabetes) should engage in regular physical activity,” said Dr. Joy. “Resistance training is also beneficial, as it improves the physiology of our body's metabolic engine —muscle! For my patients with diabetes, they are more likely to have other cardiometabolic risk factors, all of which should be evaluated before prescribing a moderate exercise program. However, people can engage in light activity—a casual walk, for instance— without getting the OK from their doctor,” she said.
She notes that there are important factors physicians should keep in mind when “prescribing” exercise to a patient who has diabetes.
“There are other unique challenges for people with diabetes. Those on insulin and certain oral medication may be at risk for hypoglycemia or low blood sugar. I generally connect those patients to a Certified Diabetes Educator (CDE) for counseling around the timing of medication, food, and exercise. Others with more advanced diabetes may have developed consequences of the disease like reduced proprioception and vision loss, which put them at greater risk for falls. So a supervised program that focuses on balance might be a good choice to get started.”
Exercise as medicine for people on a GLP-1
Nearly 12% of Americans have used a GLP-1 for weight loss, with 14% of people surveyed by RAND saying they would be interested in taking the drugs for weight loss purposes.[]
When prescribing exercise for this group, Dr. Joy says it is important to focus on building muscle.
“The GLP-1 RAs promote rapid weight loss, so muscle loss is definitely a concern, more so for women and older adults, both of whom have lower levels of anabolic (muscle preserving) hormones,” she told MDLinx.
“I advise people to get on the resistance training band wagon if they are taking GLP-1 RAs. I find that most have low (or zero) self-efficacy around strength training and need to work with an exercise professional to engage in strength training safely.”