Edited by: Temi Toba-Oluboka
In 2018 a staggering 85% of Canadians did not meet the national guidelines for physical activity, which is 150 min per week (1). Large population studies have demonstrated an association between exercise and a decrease in all-cause mortality (2). There is even data to suggest greater periods standing instead of sitting can lead to a reduction in all-cause mortality (16,17). There is a plethora of benefits of exercise for all ages. This includes reducing cardiovascular disease, reducing waist circumference, decreasing hemoglobin A1C, decreasing low density cholesterol, and decreasing systolic blood pressure (14). In Canada the elderly population is expected to grow 68% in the next 20 years (20). Exercise can even contribute to reduced frailty. A study by Brey et al showed that elderly patients that are at risk of becoming frail or already defined as being frail and began resistance and flexibility training, aerobic exercise, and balance training exercises 2-3 times a week led to a reduction and even a prevention in frailty (6). Exercise has been shown to improve mental health and is even recommended in the treatment of common mental health conditions such as depression and anxiety (23,29). The coronavirus (COVID) pandemic has led to increased isolation, but Canadians who exercised outdoors during COVID self-reported better mental health compared to those who changed food habits and meditated (30). Prescription medications are often used to manage a variety of medical conditions. In 2017, prescription medications comprised 14% by cost of the total Canadian health care system expenditures (31). Exercise as a treatment is free, but what do we know about exercise compared to prescribed medications? Read on and find out.
Although the Canadian health care system is often perceived as a universal and equitable system, there are concerns for many Canadians. Prescription drug coverage is not universal. In a 2019 Canadian Medical Association Journal (CMAJ) article looking at income differences found that just under 20% of individuals with a household income of $20,000 or less had private drug benefits compared to over 75% of those with a household income of $80,000 or more (8). Further, up to 10.2% of Canadians are not able to adhere to their prescriber’s recommendation due to prescription costs. This increases to almost 13% in patients undergoing dialysis. Contributing factors to not having prescription drug coverage in Canada are having a chronic illness, younger age, and province of residence (9). An Ontario report by The Wellesley Institute found that 1.5 million Ontarians do not have drug coverage, with visible minorities, younger Ontarians and recent immigrants more likely than others to lack coverage.11 Taking several medications simultaneously can lead to a decreased quality of life, increased risk of side effects and death, and increased burden on the health care system due to increased health care utilization from things such as emergency department visits (19).
There is a growing movement to get health care providers to promote and utilize evidence-based wellness approaches to combating illness. This can include exercise, nutrition, and diet. Prescribing a medication should be given a fair amount of consideration. For example, the American Academy of Family Physicians had the following 2019 recommendation “before starting any new medications, consider underlying causes to treat first, necessity of treatment, alternative non-pharmacological treatments, and benefits vs. risks of treatment.” (19) The Exercise is Medicine (EIM) website has guidelines created by the American College of Sport Medicine. They have created templates and guides to assist health care providers in assessing their patients and writing exercise prescriptions (4). The Canadian Society for Exercise Physiology was in partnership with EIM until recently (5). 79% of Canadians see a physician at least once a year (study did not mention Nurse Practitioner), and surveys have shown that Canadians view physicians as a credible source of information on how to live a healthy lifestyle (7). Maybe it is possible for a traditional medication prescription to be substituted for an exercise prescription. A written prescription for exercise provided to a patient has been shown to increase physical activity by patients. It should be written and interpreted in a similar fashion to a medication prescription with a dose, frequency, and duration (1). It is estimated that only 16% of physicians write exercise prescriptions for their patients in Canada (7). Physicians have cited this as a result of not enough time, tools or resources (7). In a study by O’Brien et al, it was found that a 6-hour exercise workshop with an exercise physiologist and physician with tools from the EIMC group increased confidence and surveys suggested many participants would begin writing an exercise prescription in the future. Further, the vast majority of participants liked the EIMC prescription pad tool (7).
It is challenging to compare the benefits of medications versus that of exercise as many medication trials are versus a placebo drug, not exercise, and are randomized control trials in nature. There is also a lack of attempts to draw comparisons between medications and exercise (2). This is in contrast to exercise benefits which generally come from studies that observe populations and attempt to establish associations (2). Some research examining studies looking at the benefits of exercise in those with anxiety or anxiety disorders had a challenging time finding a benefit because of the nature of the studies, such as the lack of similarity and consistency in approach, type of exercise, intensity, and duration (13). This poses a challenge, yet provides an area of focus for future exercise research.
There are studies that do look at the benefits of exercise compared to medications in several common conditions such as diabetes and heart disease. A large 2013 meta-epidemiological study by Naci and Ioannidis, although limited by a lack of proper comparisons, did find in their review that exercise is potentially similar in regard to mortality benefits compared to drug interventions (2). They suggest that exercise be regarded as a form of combination therapy with medications or a viable alternative (2). The study was able to find enough evidence to draw this conclusion in secondary prevention of coronary heart disease, rehabilitation post stroke, treating heart failure and in the prevention of diabetes (2). Lian et al found that walking in previous sedentary patients 30 minutes a day for 5 or more days for 12 weeks along with a lipid lowering medication, compared to medication alone decreased lipids and inflammatory markers, with a greater decrease in those who walked in the evening. The evening walking group had a double reduction in low density cholesterol compared to those just on lipid lowering medications (3). A recent 2019 study examined studies of exercise and medications in hypertension found that exercise had blood pressure reductions similar to medications. An important note was that the study did not analyze outcomes such a mortality (14). Exercise can be utilized to decrease the number and dose of medications needed. In patients on dialysis, a cycling intervention was found to decrease the amount of blood pressure lowering medications by 36%. Evidence regarding possible adverse effects of an exercise prescription is also lacking. However, a large cardiovascular rehabilitation trial of heart failure patients demonstrated after 10 years, there were no adverse events that lead to stopping exercise (2,22).
The Canadian Psychologists Association advocates that research has demonstrated that regular exercise can prevent depression and anxiety. Further, they believe it may be as effective as medications and psychological therapy. Regular exercise can also reduce everyday stress, strengthen someone’s cognitive abilities, improve academic performance, and in middles aged adults prevent cognitive decline (29). Canadian Mental Health Guidelines recommend regular physical exercise and yoga as a possible treatment on its own in mild to moderate depression and in conjunction with medications and psychotherapy in moderate to severe depression (23). In anxiety, exercise can be used to reduce symptoms of anxiety disorders but it is not as effective as cognitive behavioural therapy (24). In a large meta-analysis physical activity was found to be beneficial in protecting patients from symptoms of anxiety, with larger amounts of physical activity associated with protective effects of symptoms from agoraphobia and post-traumatic stress disorder (12). Another large systematic review and meta-analysis found that 11 studies demonstrating aerobic exercise 3 times a week for an average of 45 minutes for just over 9 weeks was effective in significantly reducing symptoms of depression (21). A 2007 study looking at patients over 50 compared the antidepressant sertraline with exercise and found the results to be similar after patient reporting on depression rating scales, after 16 weeks of treatment (25). Those in the medication group did notice the fastest response in terms of reduction of symptoms (25). It should be noted that Sertraline is still a very commonly prescribed medication for a variety of mental health conditions. Another 2007 study of 16 weeks duration comparing the same medication to exercise found Sertraline to be comparable to exercise in terms of effectiveness (26). Exercise can be a good add on treatment to those on antidepressants. A 2015 study of patients with major depressive disorder found 45% of those in the sertraline groups went into remission compared to 73% in the sertraline + non-progressive exercise and 81% of those in the sertraline + progressive aerobic exercise group (33). When patients treated with exercise or sertraline were followed up at 1 year, Hoffman et al found that “exercise during the follow-up period seems to extend the short-term benefits of exercise and may augment the benefits of antidepressant use.”(27). In adult patients with major depressive disorder all treatment groups had improved cardiovascular risk factors, but supervised exercise program was found to be more beneficial than a home based exercise program or an antidepressant at reducing cardiovascular risk at 10 years (28). Dr Craig Miller, who is an assistant professor of psychiatry at Harvard Medical School says “for some people it (exercise) works as well as antidepressants (in depression), although exercise alone isn’t enough for someone with severe depression.”(34). The challenge with exercise is getting started. The symptoms of depression such reduced energy and sleep issues, can hinder an exercise program (34).
Summary and conclusion
Regular exercise has been linked to improving many medical conditions. In 2018 a staggering 85% of Canadians did not meet the national guidelines for physical activity, which is 150 min per week. Exercise has numerous benefits and has shown to reduce many illnesses and even death. Less than 20% of Canadian households that make $20,000 or less had prescription drug coverage. Individuals with chronic disease, refugees and visible minorities are more likely than other Canadians to lack prescription drug coverage. Canadians see their physicians as a credible source for living a healthy lifestyle. A written prescription for exercise provided to a patient has been shown to increase physical activity by patients. Providers can assist by encouraging patient appropriate exercise and prescribers can use their prescription pad. Exercise can prevent depression and anxiety, and the Canadian Psychologists Association believe it may be as effective as medications and psychological therapy. Regular exercise can also reduce everyday stress, strengthen someone’s cognitive abilities, improve academic performance, and in middles aged adults, prevent cognitive decline. Exercise faired very well when compared with a particular antidepressant in the treatment of depression. However, the symptoms of depression, such as reduced energy and sleep issues, can hinder an exercise program. And unfortunately, a big challenge with exercise is getting started. Canadian Mental Health Guidelines recommend regular physical exercise and yoga as a possible treatment on its own in mild to moderate depression and in conjunction with medications and psychotherapy in moderate to severe depression. In anxiety, exercise can be used to reduce symptoms of anxiety disorders but it is not be shown to be as effective as cognitive behavioural therapy.
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