Exercise is medicine.
But can be overdose?
Just imagine for a second a new drug treatment launched onto the market last week.
Suspend belief for a moment. This is a drug to end all drugs. Let me give you a brief description of the remarkable properties of this therapeutic intervention.
It is free, universally available and if widely adopted, would have a profound effect on the UAE healthcare industry. Such claims about a new therapy usually would be met with derision but if we call this treatment X365, manufactured in a magical factory in a magical land, I will outline the remarkable profile of its action at a cellular level and its properties both in prevention of most diseases and illnesses as well as treatment for many established conditions.
The outcomes of this drug match or even exceed the very finest drugs already available and are largely free of side effects.
The power of this treatment can be equated with the same outcome as smoking cessation, CBT for anxiety and depression, non-steroidal anti-inflammatory drugs for common musculoskeletal problems, some antihypertensives, various anti diabetic drugs, statins, as well as cancer and dementia prevention. It also offers an anti-aging remedy. Surely this panacea is fantasy, yet it exists.
If you haven’t guessed already, X365 is a simple treatment called exercise and if prescribed either at 150 minute a week of moderate exercise or 7 minutes a week of vigorous activity, can bring about these remarkable outcomes.
Patients often ask what does moderate or vigorous exercise mean? To feel warmer, breathe harder and feel your heartbeat faster. At this level, you can talk, but not sing during activity (for example a brisk walk). Vigorous intensity causes adults to get warm quickly, breathe much harder, perspire and find it more difficult to maintain a conversation (cycling, jogging or swimming).
The simplicity of this intervention may diminish the message yet if adopted by our population, vast proportions of the health sector would become redundant. The savings and improved economic productivity would be huge. Yet in the UK, over 50% of the population don’t reach this modest amount of activity, with 25% managing less than 30 minutes a week. Physical inactivity is the 4 th leading cause of death globally and has a greater risk to our health than obesity. Perhaps you are stifling a yawn, thinking we know this already.
But the facts are astonishing. Regular exercise brings about a reduction of all-cause mortality of 30%. I will list just a few of the health benefits of exercise. Cardiovascular disease up to 35% reduction, Type 2 Diabetes 40%, colonic cancer up to 30%. Breast cancer 20%, depression 30%, hip fracture 68%, dementia 30%. The control of respiratory diseases such as asthma and COPD are significantly improved. These figures can be enhance further with improvements in nutrition.
So how does it work?
The mechanism of action lies at a cellular level. Exercise has anti inflammatory properties and improves cellular health. A quick bit of science…
At the mitochondrial level (mitochondria are the little batteries that power our cells), exercise slows the accumulation of free radicals and oxidative cellular damage. This is why antioxidants in our diets are helpful. Theories of aging are concerned around the accumulation of free radicals and the associated damage.
There is a myth that all of the benefits from exercise come from weight loss. In fact weight loss only contributes to 10% of the benefits of exercise. In other words, put bluntly and rudely, it is better to be fat and fit than thin and unfit. That of course has a caveat with regard to joint pathology and osteoarthritis.
More specifically exercise reduces something called fibrinogen, a key factor in the clotting process; it also reduces the inflammatory response within the endothelial cells of the arterioles hence reducing atheroma, increases insulin sensitivity, increases HDL cholesterol, lowers blood pressure, increasing the stoke volume and reducing the heart rate.
It does of course reduce body fat but in particular visceral fat, the most toxic form.
From the musculoskeletal aspect, exercise builds muscle, reduces obesity and weight effects on joints, improves tone, balance and cartilage surfaces, reducing the development of osteoarthritis and providing a significant improvement in pre-existing OA.
Power anti-inflammatory myokines are increased and immunity is boosted with an increase in Natural Killer cells.
As mentioned above regular exercise lowers anxiety, improves mood, memory and learning (particularly in children) and reduces the risk of developing dementia. These improvements are mediated through beta endorphins, monoamine concentrations, increase growth of nerve cells. There is an increase in proteins that help survival of nerve cells and a positive effect on the hippocampus- it actually increases in volume with sustained exercise and improves short term memory.
Depression and dementia are associated with a reduction in the hippocampus volume and a reduction in Brain Derived Neurotrophic Factor BDNF. Anyway enough of the technical stuff, let’s think about the prescription.
I think because this is something so idiotically simple, the message is lost-it can’t be that simple but it is. Initially the guidance was just about aerobic activity but as you can see below this has changed recently with the introduction of muscular strengthening twice a week. There is also now specific guidance for children and infants to maximise their physical and mental development. Also remember, it is never too soon or too late to start. Prof Greg Mclatchie, a famous Professor of Sports Medicine, once controversially said, ‘The problem with old age is lack of fitness, not age”. I enclose below the UK Chief Medical Officer’s current recommendations for adults and the USA guidelines are broadly similar.
*The CMO’s current recommendations for physical activity state that:
- All adults aged 19 years and over should aim to be active daily.
- Over a week, this should add up to at least 150 minutes (2.5 hours) of moderate intensity physical activity in bouts of 10 minutes or more.
- Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or combinations of moderate and vigorous intensity activity *.
- All adults should also undertake physical activity to improve muscle strength on at least two days a week.
- They should minimise the amount of time spent being sedentary (sitting) for extended periods.
- Older adults (65 years and over) who are at risk of falls should incorporate physical activity to improve balance and coordination on at least two days a week.
- Individual physical and mental capabilities should be considered when interpreting the guidelines, but the key issue is that some activity is better than no activity.
Saying exercise is good for you is like saying breathing is good for you-an understatement. Having mentioned earlier that physical inactivity is a killer and even more dangerous than obesity, why do we have an epidemic of inactivity. So, let us consider the barriers to exercise?
There is a fascinating book by Christopher McDougall, “Born to Run” in which he describes a mysterious lost tribe of Mexican Indians, the Tarahumara, who still live quietly in canyons separated from the modern world and are reputed to be the best distance runners in the world. They run barefoot everywhere, even into late middle age and think nothing of running over 50 60 km to meet for lunch. One of his many theories is that after the ice age, Homo Sapiens won over the Neanderthals who incidentally were stronger and had bigger brains but were covered in hair and heavily muscled, a major disadvantage when chasing antelope across the warm savannah.
So perhaps we are hard wired to work to extremes for our dinner and eat as much as we can when feeding since then we didn’t know where and when the next meal might come from-is it any wonder then in the 21 st century with Deliveroo and Spinneys close to hand why (in the West), we no longer need to chase down our meals to survive.
Doctors need to consider exercise before prescribing expensive drugs and treatments.
A recent study of final year medical students found that they lacked knowledge of current physical activity/exercise guidelines. 52% were unaware, 80% had had no formal lifestyle guidance training, 48% were unaware of motivational training.
These are some statements that I use to motivate my patients and help them understand how physical activity helps:
- Physical activity is essential for our body. We were designed to move.
- When we are sedentary the batteries (mitochondria) in every cell charge up. When we don’t move they leak free radicals. These free radicals age us more quickly and can lead to diseases such as dementia, diabetes, cancer and heart disease.
- When we exercise, the charge in the mitochondria drops and the free radicals stop leaking out. Activity also leads to healthier cells, slowing the aging process.
- *When we are sedentary:
- The cells in our brains die off more quickly, leading to an increased risk of dementia.
- Our bodies become resistant to insulin, leading to an increase in diabetes and also causing an increased risk of cancer.
- Our blood vessels become inflamed and damaged leading to an increase in heart disease.
- Our immune system is weaker, allowing cancer cells and viruses to get through our defences.
- The fat around our internal organs (visceral fat) builds up, releasing free radicals that can lead to diabetes, heart disease, cancer and dementia. As you exercise, this is the first fat that is burnt off, leaving you healthier and slowing your rate of aging, even though there may be no change in your weight.
- Don’t forget: exercise without weight loss is better for your health than weight loss without exercise.
The vision and leadership needed for mass participation has already commenced with the ’30 minute x 30 days’ Dubai Fitness Challenge was announced by His Highness Sheikh Hamdan bin Mohammed bin Rashid Al Maktoum, Crown Prince of Dubai and Chairman of the Executive Council of Dubai Government and Dubai Sports Council with the aim of motivating residents to take up physical activity.
Here at UPANDRUNNING we see both musculoskeletal problems and family medicine issues and exercise prescription is our is a huge part of our preventive input and treatment strategies. There are searching questions to be asked of the insurance industry over their support and funding of established disease rather than the prevention of illness since we are warriors of the prevention agenda. Physical activity is not just a health issue. It brings people together to enjoy shared activities and contributes to building strong communities whilst supporting the economy to grow. We consider exercise and nutrition for what they are. Not a lifestyle choice but the backbone to all our therapeutic efforts. So, if exercise is the elixir of life drink deeply.
Can there be too much of a good thing.
Can be overdose?
Normally we see the expected cardiovascular changes in healthy athletes as fitness improves with an enlargement of the heart and a lower resting heart rate. However, in over exercise we see deteriorating performance and a raised resting heart rate, weight loss, poor sleep, cessation of periods in women, reduced immunity and susceptibility to viruses, and longer-term bone density issues and stress fractures as well as occasionally certain nutritional deficiencies.
In more senior athletes there are concerns that very high intensity of training may weed out those with a predilection to ischemic heart disease or cardiomyopathies (the U shaped risk curve) and hence the importance of cardiopulmonary testing and echocardiograms for some of our patients.
Psychological effects of over exercising include anxiety, depression, lethargy and loss of motivation as well as staleness and burnout. There is a link with eating disorders and over exercise may be a manifestation of this. The female athlete triad consists of menstrual disturbance, disordered eating and loss of bone density. A disordered self-image or full blown eating disorder may use exercise to expunge guilt in the same way as laxatives or vomiting in bulimia.
I’m afraid among some performance athletes such as dancers, gymnasts where self- appearance is given significant importance, coaches and parents can actually trigger eating disorders with careless remarks during formative years or a latent anorexic parent become an unwitting accomplice. We all have dreams for our children and sometimes we project our own thwarted aspirations into their futures. This can occur in any realm but it is all too prevalent in sport and can lead to unrealistic expectations and demands on young people.
The term REDS (relative energy deficiency in sport) is used to describe the negative effects of chronic low energy availability (LEA) (calorie restriction). Over exercising or under fueling, occurring consciously or subconsciously, can cause Relative Energy Deficiency In Sport (REDS). American professional middle distance runner Mary Cain stated, ‘I got caught in a system designed by and for men, which destroys the bodies of young girls,’ as she cast light on her toxic coach/athlete relationship and exposed unhealthy coaching and nutrition practices.
Her courage has inspired a social media movement calling for changes to women’s sport and a recognition of the phenomenon of body shaming. In a an excellent editorial by Kathryn Ackerman in the British Journal of Sports Medicine in January 2020, the authors call for “a drastic paradigm change in women’s sport, coupled with education at all levels to improve the long-term health and athletic achievement of female athletes. The shift needs to include:
- Raising awareness of the negative effects of chronic low energy availability (LEA) (calorie restriction) so athletes can make wise choices for their own long-term health.
- Updating and developing best-practice protocols and safe standards for monitoring body composition/weight.
- Eliminating toxic training environments featuring abusive body shaming."
It is difficult to know initially if an individual is over exercising. Often the only sign is a raised resting heart rate and a drop in performance. The development of the some of the symptoms listed above may be the first clue. Obviously, a falling BMI (body mass index) may be obvious to all. At UPANDRUNNING we have a performance lab and our Sports physiologists are able to measure changes in performance through cardiopulmonary testing and other technical parameters when individual athletes are struggling.
Paradoxically over exercising can occasionally lead to weight gain with boys/men who are on a bodybuilding scheme and particularly if they stray into the murky world of anabolic steroids. The obsession with the male physique and appearance can be (in my view) a male version of an eating disorder resulting from low self-esteem.
Many aspiring athletes forget that rest is a vital part of the training cycle. After overreaching, in order to improve fitness, muscles and other tissues need rest to allow metabolic and structural changes to occur at a microscopic level.
So, what can trigger over exercising?
I think this multifactorial and my answer is based on my own observations and 37 years in practice. In many, it is a natural competitiveness and a desire to be as good as one can be with a loss perspective along the way. In a few cases it can be related to poor coaching, parental pressure or in some societies coercive sporting regimes with perverse incentives. In some individuals, I think it can be related to obsessive personality traits and in others a manifestation of an eating disorder or latent psychiatric issues.
However, the start of symptoms is often related to a steep training curve or increase in competition and the resulting burnout can also coincide with exams, increased work pressure or a life event. Finally, and this might sound fanciful, there appears to be an older generation of athlete who perhaps has taken up exercise later in life and in a furious attempt to deny “Old Father Time”, seeks immortality pursuing ever more daunting triathlons or iron man competitions and hence our concerns over the u- shaped risk curve.
Generally speaking, it is important to maintain perspective, exercise is good for mental health and there is plenty of research to reflecting a reciprocal link between stress and physical activity.
For help and support come to UPANDRUNNING. We frequently see cases of burnout and the physical and psychological consequences of over exercise on a daily basis from falling performance and BMI’s to stress fractures, anxiety and depression, overuse injuries and so on-it’s what we do! We provide a multidisciplinary approach from Sports doctors, nutritionists, performance experts and network with psychologists and mental health experts. We provide Cardiopulmonary testing for older patients for reassurance and safety checks and have an in house cardiologist where required.
**Dr. Lawrence Lear is a Family Medicine and Sports Medicine Doctor and Medical Director at UPANDRUNNING Sports Medicine Clinics Dubai. He is a Fellow of the Royal College of Practitioners and Master of Sports Medicine. He has 37 years of clinical experience but is never complacent. He would like to be considered warm and approachable. He always takes a careful detailed history and thorough examination and does not cut corners, He believes in making a concise and accurate diagnosis and uses tools such as ultrasound to confirm that diagnosis. He never over investigates or over treats and gives simple, concise explanations regarding the diagnosis and treatment plan and he always involves you the patient in developing that plan.
Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015;25 Suppl 3:1–72.
World Health Organisation. Global recommendations on physical activity for health, 2010.
Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55:305–12.
Radenkovic D, Aswani R, Ahmad I, et al
Lifestyle medicine and physical activity knowledge of final year UK medical students
BMJ Open Sport & Exercise Medicine 2019;5:e000518. doi: 10.1136/bmjsem-2019-000518
Merghani A, Malhotra A, Sharma S, et al
The U-shaped relationship between exercise and cardiac morbidity Trends in Cardiovascular
Medicine, Volume 26, Issue 3, April 2016, Pages 232-240
William Bird BMJ Learning
Physical Activity in the Treatment of Long Term Conditions
UK Chief Medical Officers' Physical Activity Guidelines UK Chief Medical Officers' Physical Activity Guidelines Department of Health and Social Care 7th September 2019
Mental health in elite athletes; International Olympic Committee Consensus Statement 2019- BJSM
REDS (Relative Energy Deficiency in Sport): Time for a revolution in sports culture and systems to improve athlete health and performance-Editorial); Katheryn Ackerman-BJSM
