Exercise as a clinical management tool

Paco Miralles
 

In the consultation of any internist...

• Mr Sebastián (68 years old), your glycated haemoglobin is in adequate parameters. Your diabetes doesn’t appear to have affected your kidney because you are not losing albumin. The tension controls are correct and I do not notice hypoglycaemia in the provided tests. Your diabetes is under controll.
• Do I continue with the same treatment?
• Yes, let's review the treatment. With insulin, we will maintain the same scheme that has worked so well. I remind you: from the basal, the long-lasting, you put 24 units, with a fixed guideline in meals of 8 units and correct it with the scheme written in the report (I don’t reproduce it so as not to bore you more). The rest of the treatment will stay the same.
• And I continue with the exercise?
• Sure! Keep walking for at least 45 minutes along the promenade (those of us who are lucky to live in a coastal city, especially Malaga).

You, a seasoned reader, if you have reached this point, will have observed how meticulous we, the clinicians, are with pharmacological treatment and how laconic in speaking of exercise. We limit ourselves, at best, to generically prescribing aerobic activity. It’s as if we prescribed 30 units of insulin to our patient Sebastián without further specifications. It's better than nothing. But it has long been recommended to expand aerobic exercise with a program of strength and flexibility (and balance in the elderly). We should follow the acronym FITT to prescribe exercise: frequency, intensity, time and type of exercise. We comment on the need to exercise, but sometimes, we strongly recommend it. We rely more on drugs.

I firmly believe in exercise as a fundamental weapon in the prevention, treatment, improvement of quality of life and rehabilitation of patients, but this time I want to comment on the importance of exercise as a health management tool and to add value to the clinical process.

We know very little about exercise

Many reasons lead clinicians to be so inaccurate in this treatment plan. I understand that it’s our specific ignorance of the subject that leads to a lack of integration in the usual therapeutic scheme. We study a lot about drugs and little about exercise, so we don’t know the evidence of the benefit that sport brings to health.

In a meta-analysis, the mortality between exercise and pharmacological interventions or placebo in heart failure, coronary disease, stroke and diabetes was compared. The analysis was difficult because of the asymmetry in the number of studies, with a clear disadvantage for those referring to the field of exercise, as it’s easy to imagine. We observed that sport and pharmacological interventions offered practically the same mortality results except in stroke rehabilitation, where exercise was associated with a greater reduction in the probability of death than in drugs.

Exercise, as recently found in a BMJ editorial, is the miracle cure. It has practically no side effects and contraindications. How can we, doctors, be so sparing in their prescription?

A sedentary lifestyle is very expensive

We estimate inactivity to be the source of up to 6% of coronary pathology, 7% of cases of type II diabetes (the annual cost of diabetes is 5.8 billion euros in Spain) and up to 10% of cases of colon and breast cancer. A sedentary lifestyle is related to 9% of premature deaths, which means years of lost productivity and, in many cases, a period before death with high consumption of health resources and poor quality of life.

As the numbers are often cold, it’s difficult to contextualize them. If we specify them, perhaps we will see it more clearly. According to the General Sports Council, if the Spanish population were to exercise more, they could save some 5,000 million euros per year, which is equivalent to the construction of 10 hospitals. With this money, the Spanish research and science budget could also be practically doubled.

Annual healthcare spending on specialized and primary care accounted for about 52 billion euros in 2017 in Spain. 80% of health spending in the autonomous communities is concentrated in four diseases: COPD, diabetes, heart failure and hypertension. In all of them, exercise has shown beneficial effects in both prevention and treatment and rehabilitation. Abandoning the sedentary lifestyle would not only decrease its incidence but would improve the quality of life of those who have already developed it, probably reducing the consumption of health resources and providing more years of quality of life.

Is it profitable to invest fot the population to exercise?

There are multiple programs in different companies that endorse it and the literature related to the subject grows exponentially. Based on three models of economic return for each euro invested per capita in exercise - the Europe 2005, Wladimir 1994 and PIEC 2004 models -, after 15 years of starting the exercise program, a return of 50 Euros was estimated for each euro invested, which meant a saving of 330 million euros in health spending with the investment of a single euro per capita. Last year this figure has been highlighted again during the celebration of the International Congress for the promotion of health organized by the University of Oviedo.

In an environment of increasing spending, where we try to reinvent healthcare management daily, the recommendation of exercise should become a strategic point, rather than a mere superficial comment on patient care. Those responsible for health policies, both in the public and private sectors, should remember each of the euros intended to reward exercise is an investment and not an expense.

We dedicate significant sums of money, energy and the efforts of professionals to reduce the expendable part, which doesn’t add value to our healthcare activity and which sometimes rises to 40%. We do it through awareness campaigns for professionals financed by public bodies; Scientific societies also invest time and money in similar campaigns, and this commendable work is also carried out by multiple organizations, foundations and associations. But again, we start at the end. We spend more on our professionals unlearning to achieve better management than on teaching them to set standards that save from the beginning.

We spend minor effort in medical schools, in scientific societies, and in public and private systems, to educate physicians that exercise should not only be part of medical treatment but a powerful management tool for the sustainability of the system. Once again we face the worst enemy of any system: inertia. When we project important results but towards the future, it’s difficult to gain the commitment of everyone: teachers, clinicians, leaders and managers.

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