Issue 22 / 10 June 2019

A RECENT newspaper article that was widely distributed in the Fairfax press has prompted us to collaborate on this submission.

The article was variously headed:

“Feel free to take lifestyle medicine – I’ll see you on my operating table” (WAToday)

and

“Robert chose the pill-free route; ended up on my operating table” (The Age, The Sydney Morning Herald)

The article states that “Lifestyle medicine … isn’t really medicine,” with the inference that only drugs or surgery are medicine. Although the term “lifestyle medicine” may possibly have been used to suggest unscientific and unproven fads, the term can easily be misinterpreted and we hope that the following will set the record straight regarding the critical role of exercise as a form of medicine.

In the contemporary multidisciplinary approach to health care, the practice of medicine is far more than just the administration of drugs, the application of a scalpel or the insertion of a device. Just as policy changes around sanitation and hygiene prevented millions of deaths, notably prior to the availability of penicillin, evidence-based advice about exercise is an integral component of appropriate modern day medical care. Such advice is grounded by decades of scientific studies in fields including epidemiology and public health, psychiatry (here and here), endocrinology, and in biochemistry, physiology and molecular biology. In terms of cardiovascular diseases, exercise has a positive impact on risk factors, but also exerts additional and direct effects on heart and artery health (here, here and here).

The Fairfax article states that “lifestyle medicine [is] being recommended by fringe physicians or online pseudo-experts”. Yet, national and international organisations in cardiovascular medicine provide evidence-based guidelines and position statements that summarise vast bodies of evidence and strongly endorse exercise and physical activity. For example, the American Heart Association, the leading international global body representing cardiothoracic surgeons, cardiologists and cardiovascular physicians states:

“Physical activity is one of the best things people can do to reduce the risk of cardiovascular disease, progression of cardiovascular disease, or death from cardiovascular disease”

and that:

“Adults should do at least 150 to 300 minutes of moderate-intensity aerobic physical activity a week, or 75 to 150 minutes of vigorous-intensity activity, or an equivalent combination of moderate- and vigorous-intensity activity”

Similar statements can be found from European and Australian bodies (here and here). These agencies distil science into guidelines. They carefully consider the evidence, and the consequences of what they recommend.

We hope that the statement in the Fairfax article – “The trend to value diet, exercise and lifestyle change as superior to medicine only risks providing useless information” – will not be interpreted as suggesting that exercise is useless. For diabetes prevention, exercise and lifestyle modification are twice as effective as metformin, the most commonly prescribed medication. Lifestyle and drug therapies are not in competition. All international guidelines and recommendations consider these as complementary. It’s not exercise or drugs, it’s exercise and drugs. Any suggestion that these things are mutually exclusive is unhelpful.

The Lancet describes physical inactivity as a global pandemic which is contributing to obesity, diabetes and cardiovascular diseases. Perhaps the evidence base for exercise (and diet) should be included in more medical school curricula, as it now happens in some institutions.

As researchers and practitioners, we believe that media platforms should be used to encourage interventions of proven scientific benefit. This quite clearly and unequivocally includes exercise. Hippocrates, credited with extolling physicians to first do no harm, was also ascribed the statement:

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health”

The Australian health care system leads the world in recognising the importance of appropriately and individually prescribed exercise for health benefit. Few countries have been as visionary in providing support for the prevention of chronic diseases, or their recurrence, through partnerships between health care professionals; such collaborations have been shown to be highly cost-effective. While recognising that it is not a universal panacea and that individuals respond idiosyncratically (just as they do to drugs), the benefits of exercise and behaviour change are nonetheless recognised in Australia every day by hard-working and dedicated GPs, physiotherapists and accredited exercise physiologists who work at the coalface with patients who they help to avoid “ending up on an operating table”. As any of the above, backed by science, would tell you: don’t forget to take your pills and make sure to get some exercise.

Daniel J Green is the Winthrop Professor in the School of Human Sciences (Exercise and Sport Science) at the University of Western Australia and is a world leading researcher in cardiovascular exercise physiology.

Professor David Dunstan is Head of the Physical Activity laboratory at the Baker Heart and Diabetes Institute in Melbourne. He is Professor within the Centre for Exercise and Nutrition at the Mary MacKillop Institute for Health Research at the Australian Catholic University and Adjunct Professor at the UWA.

Mark Hargreaves is Professor of Physiology and Pro Vice-Chancellor (Research Collaboration & Partnerships) at the University of Melbourne.  His research interests focus on exercise and carbohydrate metabolism in health and disease.

Professor John Hawley is Director of the Mary MacKillop Institute for Health Research at the ACU and is Head of the Institute’s Exercise & Nutrition Research Group.

Professor Jeff Coombes is Director of the Centre for Research on Exercise, Physical Activity and Health in the School of Human Movement and Nutrition Sciences at the he University of Queensland.

Associate Professor Chris Askew is an accredited exercise physiologist.  He holds a conjoint position with the University of the Sunshine Coast and the Sunshine Coast University Hospital where he leads the VasoActive research group.

Associate Professor Andrew Maiorana is the Lead in Exercise Physiology at Fiona Stanley Hospital in Perth and is affiliated with the School of Physiotherapy and Exercise Science at Curtin University.

Louise Naylor is a Senior Lecturer in the School of Human Sciences (Exercise and Sport Science) at UWA. She is an exercise physiologist at Fiona Stanley Hospital.

Associate Professor Andre Le Gerche is Head of the Sports Cardiology Laboratory at the Baker Heart and Diabetes Institute. He is a cardiologist at St Vincent’s Hospital, Melbourne and is Visiting Professor at the University Hospital of Leuven in Belgium.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

11 thoughts on “Exercise is cardiovascular medicine: an evidence-based primer

  1. robert mcritchie says:

    I know of no prospective trial proving that exercise is beneficial. In 2019 prospective double blinded etc trials are the only gold standard acceptable for proving the an intervention is successful. It would require 1000’s and 10-20 year follow up and there would be no funding-a lifetime project. Retrospective population studies are no longer valid scientifically. Proof of the value of exercise cannot be claimed as there is no valid proof.

  2. Simon Cummings says:

    And thr earth is flat and there is no such thing as climate change, Robert Mcritchie?

  3. Anonymous says:

    so,is there any risk metric level 1 evidence for your claims?

  4. peter giblin says:

    no one has yet to define the relevant scientific measurable risk metrics.

  5. Dr Louis Fenelon says:

    There is no doubt there is benefit from physical activity, so I’m taking the comments from robert mcritchie as a joke.
    It may not be the number one health issue, but the burden on our health care system caused by obesity and chronic disease is only worsened by physical deconditioning. When 30 somethings have to lean on their shopping trolley because they cannot support their own weight, well, we are heading for big trouble.
    What is slightly inaccurate is the most beneficial duration of exercise stated in the article. Those numbers represent the habit you have to learn to remain most protected. However, the most beneficial amount of exercise is going from none to any amount of exercise. That’s a really important message to get across because it’s those who do none who are at most risk and impact society most adversely. We can motivate them. It’s a start.
    You start because of motivation and continue because of habit.

  6. John Orchard says:

    I agree with some of what was written by Nikki Stamp about some of weird advice peddled by alternative practitioners, but like the authors of this Insight piece, I disagree with the headline (and where it reflected a general assumption that real medicine was drugs & surgery which was superior to lifestyle advice, including exercise). The Insight piece is completely on the money with respect to the evidence, although I would only disagree with the last paragraph stating that the Australian health system leads the world in this area. Exercise Physiologists are the only health practitioners in Australia who are subject to GST, whereas Sport & Exercise Medicine physicians are the only specialist physicians who are excluded from being part of the Chronic Care scheme under Medicare. Medicare rebates for SEM physicians in Australia are less than half the rebates for physicians from the same college practising in New Zealand. Only when exercise-based practitioners have equal status in Australia under Medicare as drug and surgery based practitioners will we be able to call our health system world-leading in this regard: further reading:
    https://www.mja.com.au/journal/2018/208/6/how-exercise-medicine-has-evolved-sports-medicine https://www.johnorchard.com/resources/article-Sport-Health-Vol-36-John-Orchard-Medicare-Article.pdf

  7. Anonymous says:

    robert mcritchie: This trial was linked to in the article? https://www.nejm.org/doi/full/10.1056/NEJMoa012512
    Exercise halved the incidence of T2DM vs medication, clearly beneficial.

    There’s also this one that comes to mind: https://www.ncbi.nlm.nih.gov/pubmed/22005747 – In an area where no pharmacological treatment has been proven effective (diastolic heart failure, or heart failure with preserved ejection fraction), exercise works.

    The fact that “you know of no prospective trials” clearly cannot be claimed as evidence that they do not exist.

  8. Danny Green says:

    Thanks Robert Mcritchie for your comment.

    You are right! RCTs are extremely hard to do at scale for exercise interventions. HFaction is one that tried – supported by LOTS of money from the NIH.

    Typically RCTs of drugs/devices are company sponsored of course, and there’s no comparable sponsor for exercise interventions.

    I guess we accept anti smoking agendas despite there being no RCT evidence that smoking causes heart attack or stroke!?

  9. Mark Hargreaves says:

    Review of evidence in support of exercise as medicine – not a universal panacea, but a pretty good bet?

    Scand J Med Sci Sports. 2015 Dec;25 Suppl 3:1-72. doi: 10.1111/sms.12581.
    Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases.
    Pedersen BK, Saltin B.

  10. Manos Stamatakis says:

    I do not think that the absurd Fairfax article deserved much attention but congratulations to Daniel Green and his colleagues for their excellent and very balanced response.

  11. Robyn says:

    Although the article itself may not be worthy of comment as it is factually incorrect, it continues in a line of media articles which are critical of anything which is not ‘conservative’ pharmaceutically based medicine. we need to keep pushing back with the truth.

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