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If the Benefits of Exercise Were Available in the Form of a Pill, We Would All Take It. Without Fail

I write about what I struggle with.

I have stolen that line from Viz Andrei, author of "Economy of Truth: Practical Maxims and Reflections". I like it, because it reminds me that writing should naturally involve some overreaching and challenge. It is the reason why I enjoy writing. To jot down ideas, to sit with things for a while. To perhaps put to test my own thoughts, and hopefully come to a better understanding. We all work through a simplistic, complexity and elegant simplicity paradigm. We probably wouldn't care for the simple things if someone hadn't struggled through some complexity to make it possible and more palatable for us. That's also perhaps the distinction between information and knowledge. How we begin to attain understanding. Writing as a tool can be a strong ally in that process.

"For the simplicity on this side of complexity, I wouldn't give you a fig. But for the simplicity on the other side of complexity, for that... I would give you anything I have".

For years I have often jotted down my thoughts regarding the impacts of exercise on mental health. Primarily, the impact it has had on my own mental health, but also in others around me. A recent systematic review in the Journal of British Sports Medicine has got me opening up the archives and looking at old notes. The title; Effectiveness of Physical Activity Interventions for Improving Depression, Anxiety and Distress: an overview of systematic reviews.

As always, I urge people to read reviews like this in full, not to miss any nuance. A brief summary for those who want to get to the point; The review included the findings of a combination of 1037 randomised control trials & meta-analysis of 128,119 participants. Research findings suggest that physical exercise interventions (subgroups of physical interventions include - aerobic, resistance training, yoga) are effective in improving symptoms of depression and anxiety in clinical populations. Additionally, it was found physical exercise interventions had slightly greater effects observed than psychotherapy and pharmacotherapy. This led the authors to conclude...

"The findings from this umbrella review underscore the need for physical activity, including structured exercise interventions, as a mainstay approach for managing depression and anxiety".

I promise I'm not going to get all Tom Cruise on you here. But this only confirms what anyone who has consistently partaken in physical activity already knows.

For a while now there has been concern surrounding advocates of the use of exercise as an intervention for mental health. Almost as if the suggestion of such an intervention trivialises the issue. And sometimes it can. But rarely does anyone argue the advice is sound from a it's probably a good thing to do perspective. Almost along the lines of your granny saying "you need to eat your greens". As an actual prescribed medical intervention however, it has been scoffed at and under-utilised, especially when directly compared to therapy and pharmacotherapy. So, for it to be advocated as an appropriate intervention, which has largely been shown (in this umbrella review) to out perform therapy and pharmacotherapy for those who don't exist in the extremes of such conditions... well, that is a pretty powerful thing to consider.

I have seen individual coaches, nutritionists and doctors, in the past be vilified for even suggesting physical activity might be a better option than pharmacotherapy for mental health. "Stay in your lane". Now I do agree, there is a tendency for people to blindly fight their corner when being so invested with a certain approach, and looking at specific treatments through a lens of "this is the best single thing for everyone" is obviously problematic. I would never suggest disregarding a treatment or a combination of treatments based on presuppositions and belief alone, I think that is a dangerous rhetoric. I also agree wholeheartedly, we have to be careful to not overstep the mark and operate within the boundaries of appropriate practice. At the end of the day, some fresh faced PT who has written 'life coach' in their instagram bio might not be the best person to prescribe mental health interventions. But come to think of it, who actually is? Who is in the best place to prescribe such interventions? Is it your GP? Really? Do we even know the mechanisms / reasons as to why exercise helps, and then have a detailed understanding of the most appropriate exercise interventions? Here are some things to consider, and why this desperately needs looking at in more detail...

  • The American Psychological Association clinical practice guidelines still states that physical exercise sits outside of conventional treatments and considered 'alternative medicine'.

  • In this country, in total, 8.32 million people were prescribed pharmacotherapy for largely depression and anxiety related conditions (14% of the population). Anti-depressants amongst children has also risen by 40% between the ages of 5-12 between 2015-2021.

  • Total time spent teaching physical activity and promoting physical activity during UK medical school education is 4 hours across the curricula, compared with the 109 hours spent teaching pharmacology. Only 56% of medical schools in the UK teach the CMO guidance for exercise to future doctors (at least 150 minutes moderate intensity activity, 75 minutes’ vigorous activity, or a mixture of both).

  • Sport England’s Active Lives survey (200,000 adults) suggest that almost four in 10 adults do insufficient physical activity, with 25% of the population doing less than 30 minutes per week.

  • Estimations of adults who are obese, considered as one of the main drivers in increasing type 2 diabetes prevalence, has almost doubled in 20 years.

  • For every thousand 10-11 year olds in this country, 238 are obese.

  • Aerobic fitness / VO2 max has long been considered one of the best indicators for all cause mortality. To put it simply, in one of the largest observational studies over 3 decades, someone of low cardiorespiratory fitness has a five fold greater risk of all cause mortality versus someone of elite cardiorespiratory fitness.

The issues are quite apparent. It is not sheer coincidence that the rates of inactivity, extortionate amounts of prescription pharmacotherapy, and lifestyle behaviours, increasing all cause mortality related risk factors, go hand in hand. If medical schools are failing to provide sufficient understanding of exercise prescription, or even teaching some pretty basic knowledge of how specific exercise interventions can benefit physical and mental health to doctors, AND not even consider exercise to be an appropriate intervention for mental health, despite overwhelming evidence, then it is a systematic failing. And that is very clear in our society. It is broken at every level. The irony of notions like 'protect the NHS' when a virus is sweeping through society, but failing to provide adequate education, and champion the biggest preventative measure we can implement for all cause mortality, is surely not lost... Surely...

We colour the information we take in based on our previous experiences. This shapes our world view.

I grew up in a single parent household, for many years living on the breadline. Council housing, my mum paying for food with cheques that the shop keeper knew would bounce, but accepted it anyway. She would pay him midweek when income support would come in. Occasionally a choice between food or money on the lecy key, sitting in darkness. My diet consisted of bread and ham, sometimes spam, when things were really bad. We scraped by for 3-4 years, in a pit of relative poverty. The impact that had on me, amongst many other things that happened during this time, meant that I wasn't the most attentive at school. I was too distracted to learn, education wasn't a priority. Maslow's hierarchy of needs; there was no self-actualisation in sight. Volatility, instability, uncertainty, distress, all commonplace. I often think academic success in our education system is about being mature enough to recognise its value and then learning the rules of the game. To recognise how it can, and will, give you options. You need stability for that. Only when I failed miserably in exams did I realise how it can either open or close doors. But it wasn't a thing that I was focussed on. Instead, anxiety was an issue for me. Anxiety felt like it filled every corner of my brain at times. It occupied my thoughts for the majority of the time through my early teenage years.

Anxiety can suffocate you. For me, it would manifest in different thoughts and behaviours, but largely mine was in the form of health anxiety. Perhaps stemming from a lack of control, or fear of not being able to control circumstance. Fear of uncertainty and being left more vulnerable. I remember once not even trusting the air I was breathing was safe, imagine that? My family have a history of both depression and anxiety. All of them medicated for many years. I remember my first discussion with a GP, who diagnosed me with Generalised Anxiety Disorder. In 10 minutes, they prescribed me Propranolol (anxiety medication and sometimes used for things like migraines). I didn't take it because I was resistant to it, probably because, righty or wrongly, I perceived it to be something out of my control, or something that could potentially change me. I didn't like the possibility of that. Prescribing medication for someone with health anxiety is kinda paradoxical come to think of it *googles side effects*.

I probably wouldn't go as far to say as exercise was the sole thing that saved me during this time, but it unquestionably gave me purpose, enjoyment, freedom, control. Occasionally, yes, perhaps escapism, but I loved it for that. It was my thing, it still is my thing, it gave me an identity. It gave me confidence. It built up some much needed armour. Again, retrospectively this perhaps is problematic in the extreme, as when you assign so much value to one thing, the very thing that keeps you afloat for it to be possibly kicked out from underneath you i.e. through injury, then you can come crashing down hard. For example, there is no coincidence that depression is often seen in athletes post sporting career. This is why context is so important in discussions like this. As mentioned though, these are in the extremes. What I have got from exercise and sport is simply immeasurable. The positive influence it has had on my life goes beyond what you could probably write down in words.

Objectively, the ways in which exercise actually has positive impacts on physiological and psychological wellbeing is almost impossible to document. It is multifaceted, it is intertwined, from structural physiological changes on a cellular level, to changes in neurotransmitter activity, to intangibles like increased self confidence in social gatherings. It cannot be isolated, the small changes in initial conditions; a butterfly effect. Often we might look at treatment intervention effects for say something like depression through a reductionist lens, but as an example, diabetics are increasingly more likely to experience major depressive disorder than those in the general population. There are hypothesis as to why, but we know cellular and metabolic health is compromised in diabetics. If however, you can improve mitochondrial content & health, and regulation of blood sugar through exercise, it doesn't take a genius to understand what impact that may have on depressive symptoms. From the physical to the psychological, the title of this article really tells you how important I think exercise is. It's not even a matter of opinion. Lets put it this way, if you could roll up 150 minutes per week of aerobic activity, 90 minutes of resistance training, and then condensed those physiological and psychological adaptations into a pill, then it would be the most powerful drug on the planet. By far. It would be something comparable to Limitless esq proportions. Perhaps if you have a strong enough dose, over a long enough time frame, you might even turn into Bradley Cooper. But unfortunately, it doesn't exist.

I have dealt with anxiety all my life. A consequence of anxiety is occasional panic attacks that have been severe for me at times. A panic attack occurs due to the activation of our sympathetic nervous system. The activation per se is not the issue. It's activation, but like a tape stuck on a loop, over something you perceive to be a threat. But in reality there is no threat. You're unrecognisable to yourself during these moments. That's why it is so hard to talk to someone rationally in the height of such an episode. Once you're on the rollercoaster, it is incredibly difficult to get off, especially when you believe the threat is so real. The fight, freeze or flight response is part of our evolutionary make up which has enabled us to survive. But when your wired like me, fearing the worst or being hyper-vigilant to external stimuli is a real battle. It is constant activation, alertness, hypersensitivity, hyperawareness. It is exhausting on the come down, when you do eventually come down. And then you're left with this buzz, this restlessness that needs work. You're suddenly reminded, there is probably a reason rollercoasters only last for about 2 minutes... can I get off now?

I have learnt to be at ease with these feelings over time, I'm able to deal with it better these days. I think it's important to remember that these things don't necessarily disappear. It requires work, it also requires some acceptance; discomfort is harmonious with the human existence. When I experience more stress in my life, when I sleep or eat badly, and particularly when I don't exercise, I am more prone to sliding backwards on the slope. Exercise was/is a big part in helping me get comfortable with being uncomfortable and riding the wave. The reason is actually often attributed to the fact exercise can almost be considered graded exposure therapy to those who experience anxiety and panic attacks. That is, the physiological responses to exercise (raise in HR, sweating, muscular tension, increase in CO2 / increased ventilation) are all the same physiological responses experienced in this fight, freeze or flight state. The only difference is perception & control. This is also said for performing rapid breathing drills popularised by Wim Hoff and others alike. Purposeful hyperventilation can cause dizziness, tingling in hands and feet, a raise in HR, and thus mimics some of the feelings of a panic attack. The difference is exercise comes with a vast amount of beneficial physiological and psychological adaptations, where as breathing really fast in an ice bath, meh, less so.

I look back and think, in 10 minutes I was diagnosed with Generalised Anxiety Disorder and prescribed medication that would 'settle me down'. Propanolol works by blunting the fight, freeze or flight response. It blocks the receptor sites for adrenaline and norepinephrine. Whilst I don't deny it would have helped in the moment, my issue wasn't with the fight or flight response. It was in the reasons why it was being activated in a chronic way. It was my thought processes. Thoughts that were heavily influenced by my environment. Exercise exposed me to those same physical feelings, in which I could experience these feelings under a different set of circumstances and achieve a sense of control. Rather than numb it, I learnt to manage it and become more at ease with those sensations. Over time, I became a happier person because I felt stronger, I felt more confident, it was empowering; self-efficacy. It also enabled me to be more social, play different sports. Accessibility to other groups of people and a change in environments should not be understated either. Ultimately, the threat response and negative pathways my brain had developed became less potent, because I was more robust, physically and mentally. Neuroplasticity is a thing. I was less vulnerable, as I have said, it gave me some armour. Resiliency.

The question I have, is why, from 18 years ago, from that appointment to now, are we still struggling to recognise the value and impact of consistent physical activity? Why is it something that is almost considered as 'a nice to have' but not primary. If anything, as mental health has become more widely appreciated and discussed within society, we have doubled down on medication as a primary response, with huge linear increases in anti-depressant prescriptions over two decades. Why isn't exercise, as stated in this review, not the mainstay approach for depression and anxiety for the majority of people when the benefits are so powerful? I want to reiterate here I am not anti pharmacotherapy, there are of course situations where that would be the absolute best course of action. It can be miraculous for some. There is also nothing truer for the individual faced with the choice of medicating than the fear and potential guilt associated with accepting the medication, as it cements the reality that there is something wrong, and need for pharmacotherapy is warranted. There should be no shame in that, and positioning the discussion in that way is not helpful to those suffering. However, with this said it should not deter us from challenging and being critical of its prevalence in prescription, its utility over the long term, and our reluctancy to question this path dependency in mental health care.

I think when I try to answer these questions myself, it only just reminds me of the scale of the issue. For example, there are clear socioeconomic barriers, and further inequalities in participation of exercise interventions for disadvantaged populations. Which is a concern, as low income populations are most at risk of mental & physical ill-health, for a variety of reasons. As I have spoken about above, from a simple hierarchy of needs perspective, it comes second to making sure you can put food on the table and keep a roof over your head. I have seen people argue "but exercise is free, you can just go for a run" but this is an oversimplification when it comes to competition for time and directed efforts. Again, it is about the primary desire and motivation to fill basic needs for the individual and their family. When all your adaptive energy is focused on making sure you have enough money to get to the end of the week, then it doesn't leave much left in the tank. This is why interventions also absolutely have to be achievable and realistic. Whilst exercise can and will help improve many issues, it doesn't and won't work if it isn't realistic and doesn't connect with people. Saying "just go for a run" does nothing to facilitate change. Behavioural and attitude changes are paramount for interventions to be successful over the long term. The COM-B model for example (capability, opportunity and motivation - barriers) has been proposed as a helpful framework used to try to identify barriers and facilitators to help enact change amongst specific demographics.

Exercise ultimately takes time and energy, there is no way around that. There has to be a reward for effort. We have to create opportunities. We have to make it accessible. It has to be enjoyable. It has to be appropriate for the individual. These are all difficult tasks. Especially when at the very foundation education across the board of its benefits is incredibly lacking. There absolutely has to be a change in primary care education for a paradigm shift at the societal level. We are so concerned with treating illness, we seem to forget to teach people how to be well in the first instance. Exercise needs to be at the forefront of peoples minds, with more grassroots initiatives, more community focused interventions. Compliance is improved with instructor led classes, appropriately scaled interventions, social support and inclusivity. Funded referral schemes from primary care to dedicated trained and qualified performance 'hubs' across the community would be gold standard in my opinion. Additionally, technological access to individualised programmes and general guidance would also be valuable, with clear commitment and investment in a multi disciplinary approach.

Before anyone says, Jamie, you're daydreaming... I'm not oblivious to the constraints of primary care practitioners. Ten minute appointments and patient expectations almost lends itself to a supply demand like economy. Got a bad back, want to feel better, I need and desire instant relief doc *insert pain killer prescription here*. Mood is incredibly low, struggle to concentrate and make decisions, can't get up in the morning *insert anti-depressant here*. It is the upfront manifestation and response to a set of complex underlying issues. The impact however is evident, and what is not debatable is the statistics above are hugely problematic. We are failing most individuals, communities, and society as a whole by not deploying the strongest weapon we have in this fight. Exercise.

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