COMMENTARY

Seeing Exercise as the Best Medicine . . .

John Mandrola

Disclosures

October 22, 2014

Researchers from Dallas, TX and the editors of the journal Circulation have done physicians a great service. They have demonstrated the raw power of perhaps our most potent prescription for delivering health to our patients. No, it's not a new capsule or closure device.

More on that prescription later; first, here is a recent case from my clinic:

He was a sedentary, middle-aged man, a teacher, whom I was treating for a pesky arrhythmia and high blood pressure. The most obvious finding on his exam was softness.

"You are here for a yearly follow-up; how have you been the past year?"

"I've been great. I'm not short of breath. I've lost weight. My heart rhythm is smooth. I sleep better. And the best part is I have more energy."

"That's great. You look well, too. What did you do?"

"I filled your prescription."

Hmm, I thought to myself. I don't write many prescriptions.

"You told me to exercise every day that I eat and maybe even pick a goal. So I did. I started out by walking, then advanced to running, and next month, I plan to race a half-marathon."

The Study

Sports cardiology researchers from Texas Presbyterian Hospital set out to show that cardiac adaptation to regular exercise turned on training load, not just genetics.[1] They enrolled 12 sedentary human volunteers in a 1-year training program. The lucky 12 underwent supervised training, frequent MRI scans, and even cardiac catheterization at the beginning and end of the study.

The endurance training was notable for its "doability." After the subjects were screened for good health, they began exercising 30 to 45 minutes three to four times per week by brisk walking, jogging, swimming, or cycling. Then, after a couple of months of base training, exercise intensity and duration was gradually increased. After 9 months, a long run was added to a steady dose of interval training. At the end of the study, average exercise time per week was 7 to 9 hours.

The results were striking; heartwire journalist Steve Stiles covered the details here. The short story was that the right and left ventricles of "ordinary Joes and Janes" underwent structural changes seen in elite-level athletes. RV mass and volume increased significantly and immediately. Months later, when more intense intervals were introduced, the researchers observed the same eccentric hypertrophy in the LV. VO2max surged by an average of 20%. Cardiac compliance, diastolic volume at a given pressure, increased significantly—but nowhere near as much as elite athletes.

At the end of the study, all the previously sedentary subjects completed their endurance goals: a marathon for 10 of them, an Olympic-distance triathlon for one and a cycling "century" (100 miles) for one.

Thoughts

Although this is an exercise physiology study with important and novel findings, I want to focus on what it says to regular-Joe doctors and patients.

Consider for a moment the reaction if such structural improvements happened with a pill or procedure. The pressroom would be electric. It would be front-page news. The headline: Prescription transforms the heart of a slacker into one of an elite athlete.

As both a doctor and bike racer, I am amazed at the capability of the human heart. This study only fosters the intrigue. Regular people who made a commitment to exercise regularly developed cardiac changes seen in elite-level athletes. That is big.

And it is how wellness often begins. It begins with a click, a spark. The teacher in my case decided to adhere to my prescription. He began slowly, just with walking. Then something happened. His body changed, not just the heart, like in this study, but many other things. Glucose metabolism improved, brain function sharpened, and mitochondria grew more efficient. Seemingly overnight, an unhealthy person became healthy. His high blood pressure and arrhythmia were unnecessary.

It's not part of this case, but this patient's wife also flipped to health. And he's a teacher—so his students bore witness to his change. (Health can be contagious, too.)

To be sure, a doctor need not advocate for full marathon training for every patient. I'd argue, though, a commitment to using our bodies is not extra; it's normal. Some might think 7 to 9 hours per week is unobtainable or impossible. Life is too hard. Kids have to get to practice, and the like. And I get that. Here are two responses: One is that many of the favorable changes seen in this study occurred early, before peak training. Second is that we only have one heart and one body and one life. Health needs to be a priority choice.

I don't know about your neighborhood, but in mine, exercise prescriptions are underused. Two months ago at the European Society of Cardiology 2014 Scientific Sessions in Barcelona, the buzz centered on LCZ696 (Novartis), a new drug for heart failure. It was exciting, indeed, but compared with the transformative power of regular exercise, its relative value seems incremental.

Some patients say they don't like to exercise. My answer to that is easy. If a patient said they didn't like taking our pills, an alarm would go off in our head about compliance—well, now we'd think adherence. We would make the case for the drugs' benefits. "You need these medications," we would say.

It's the same with regular exercise. "You need to move." That's what I say.

JMM

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