Hippocrates once said “let food be thy medicine” and indeed, what we put in our body has a substantial impact on our health. While discussing dietary patterns, macronutrient composition, and specific food compounds is beyond the scope of this post, it is generally agreed upon that eating a diet containing whole-foods and which is low in refined and processed ingredients will ultimately produce the best health outcomes.
Focusing on diet as a cornerstone of health is crucial, but exercise is another tool that can have at least an equal if not superior impact on health. I (and others) would probably go so far as to say that exercise is in fact more important than diet. While diet can help manage weight and reduce disease-specific risk factors, exercise is the only way to actively improve musculoskeletal health and cardiorespiratory fitness, increase mitochondrial biogenesis and function, and build strength and flexibility.
Due to the many well-evidenced benefits of physical activity, “exercise is medicine” has become the official stance of the American College of Sports Medicine (ACSM) and adopted as a simple and catchy metaphor to promote (and perhaps hype) the benefits of physical activity.
What does “exercise is medicine” mean, exactly? Well, medicines are used to treat disease or reduce specific risk factors for disease. Blood pressure-lowering medications, glucose-lowering medications, and other drugs are prescribed to treat a symptom and hopefully reduce one’s risk of disease progression.
To say that “exercise is medicine” implies that physical activity can have the same effects as medication. This is true — exercise reduces blood pressure and helps manage blood glucose levels in both healthy and diabetic individuals, among other benefits.
But to say “exercise is medicine” is, in my opinion, drastically undervaluing the effects of exercise.
Most medications work on only one, or perhaps a few individual risk factors. Exercise has systemic and integrative benefits, the list of which cannot be fully encompassed in a single blog post. Exercise affects nearly every organ system in our body. Even a single muscle contraction triggers a cascade of signaling events (using the muscle contraction-induced release of molecules called ‘myokines’), and promotes adaptations in cells, tissues, and organs from the brain to your pancreas and beyond.
No single medication has such wide-ranging effects; none even come close. This is the reason we will never have “exercise in a pill” as some have (wishfully) suggested. Packaging the genomic, proteomic, and metabolomic effects of exercise into a daily multivitamin is impossible. We need the real thing.
So no, exercise is not medicine — it’s better. In fact, multiple studies have shown that a structured exercise training regimen can make individuals with metabolic diseases less reliant on medication. This not only has benefits for one’s wallet, but the healthcare system in general (but perhaps not the paychecks of some involved in such systems.) Around 35% of people with the metabolic syndrome (MetS) take 2 or more medications per day to manage their symptoms (1), a number which could be drastically reduced with the effective implementation of routine physical activity into these individuals’ lives. In general, our society is much too sedentary, so physical activity promotion everywhere will have benefits, not only for those afflicted with certain diseases. However, evidence from well-controlled, randomized studies supports exercise reduces the need for medication, and could perhaps become a “replacement” for polypharmacy.
A 5-year follow up study (1) tracked risk factors, cardiorespiratory fitness, and medication use in two groups of individuals who were characterized as having metabolic syndrome and randomized to one of two groups: a control group and a group who took part in a 4-month exercise program once per year for the 5-year study period. This program involved 3-days per week of high-intensity interval training (HIIT).
Metabolic syndrome is characterized as a “cluster” of risk factors including an elevated waist circumference, elevated triglycerides, reduced HDL cholesterol, elevated blood pressure, and elevated fasting blood glucose. (2) These were used in the study to calculate something called metabolic syndrome z-score, which was one of the main outcomes of this intervention.
Unique and perhaps surprising was that over 5 years, the exercise intervention had no significant effect on weight or other metabolic syndrome risk factors compared to the control group. Cardiorespiratory fitness assessed as VO2 max was increased in the exercise training group and was actually lower in the control group at 5-years compared to their baseline — suggesting that exercise prevented the decline in aerobic fitness that naturally occurs over time. This is extremely relevant, as VO2 max is known to decline with age, and these participants were 54 and 59 years old at baseline and follow-up, respectively. The “natural” decline in aerobic fitness was not only prevented, but reversed.
As far as medication use goes, the exercise had no effect on reducing the overall number of pills taken. The exercise group in this study did not reduce their reliance on medication over 5 years. However, when compared to the control group, a significant effect was observed for medication use, due to the fact that the control group increased their medication use over 5 years. In the absence of exercise, individuals needed more medications to manage their metabolic syndrome as they got older. What we can conclude is that exercise prevents the increased reliance on medication with age. So perhaps exercise was a “substitute” for the medication which was otherwise necessary in the inactive individuals.
Even though reduced medication was not observed in this longitudinal exercise study, other interventions have observed a beneficial effect of exercise in this regard.
A 1-year intervention in individuals with type-2 diabetes found that those who were randomized to an exercise + dietary counseling intervention reduced their reliance on glucose-lowering medications compared to a group given standard care. (3) More exercise was better — medication dose was progressively reduced as exercise duration increased from 178, 296, and 380 minutes per week. Exercising for more than 296 minutes per week was also associated with improved insulin sensitivity, lowered triglycerides, and better long-term glucose regulation.
Regular physical activity was also found to reduce the use of medication and the cost of medication in a 10-year follow up study in individuals who were characterized as being overweight/obese and having type-2 diabetes. (4) 175 minutes of exercise per week (combined with other advice on diet) led to a ~6% reduction in medication use and over $5,000 in estimated savings on drugs and medical care per person. Even though the exercise amount was minimal and combined with a dietary “intervention,” the benefits seen from the introduction of physical activity are very significant — both statistically and clinically.
Medication for blood glucose control and the cost of medications were similarly reduced in a group of individuals with type 2 diabetes who engaged in an extremely high volume of exercise (15-20 hours per week) for 1 year. (5) 54% of the exercise group either completely eliminated or reduced their medication use. Furthermore, the number of pills taken and the total cost of medications were reduced in the exercise intervention group, a result primarily attributed to better glucose control and therefore a reduced number of glucose-lowering medications required to manage their disease.
One confounding factor for some of the above studies is that exercise was typically combined with a dietary intervention — caloric restriction among the most frequent, and often paired with advice on specific types of foods to eat or reduce. So, we cannot say whether the benefits in these studies were primarily due to exercise, diet, or (likely) the combination of both. Nevertheless, when otherwise inactive individuals introduce exercise into their lifestyle, their need for medication goes down in parallel with an improvement in a myriad of metabolic and cardiovascular disease-related risk factors. We know that exercise is at least playing some role in this effect, though it’s hard to quantify how much.
A reduction in or even a maintenance of medication use is also important to note in the context of aging and disease progression. Most individuals afflicted with a particular disease will, with age, progressively get worse, thus requiring more medication and more reliance on the healthcare system as they lose independence and quality of life. Exercise effectively prevents this disease-associated “deterioration” of health — either keeping it from progressing or in many cases, “reversing” it. Risk factors are reduced, and fitness and strength improved.
It is important to note that there are several disease conditions that require medication in order for people to live a quality life. Exercise cannot emulate the targeted effects and provide the sometimes-necessary supra-physiological doses of compounds that are contained in many drugs. There is a time and a place for medicine.
However, when it comes to treating the most rampant and lifestyle-related diseases in our society — diabetes, obesity, and cardiovascular disease — exercise should be the first-line treatment strategy. As far as the cost, potential side-effects, and benefits are concerned, exercise is definitely not medicine, but supremely better.
1. Morales-Palomo F, Moreno-Cabañas A, Ramirez-Jimenez M, et al. Exercise reduces medication for metabolic syndrome management: a 5-year follow-up study. Medicine & Science in Sports & Exercise. 2021;53(7):1319-1325.
2. Alberti K g. m. m., Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome. Circulation. 2009;120(16):1640-1645.
3. MacDonald CS, Johansen MY, Nielsen SM, et al. Dose-response effects of exercise on glucose-lowering medications for type 2 diabetes: a secondary analysis of a randomized clinical trial. Mayo Clinic Proceedings. 2020;95(3):488-503.
4. Espeland MA, Glick HA, Bertoni A, et al. Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes. Dia Care. 2014;37(9):2548-2556.
5. Lanhers C, Walther G, Chapier R, et al. Long-term cost reduction of routine medications following a residential programme combining physical activity and nutrition in the treatment of type 2 diabetes: a prospective cohort study. BMJ Open. 2017;7(4):e013763.