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Medically Referred Exercise Program Provides Health Benefits

We review three studies showing how medical referrals to an exercise program can benefit health outcomes, the influence of exercise on brain DNA damage and related neurological conditions, and the potential for physical activity as a helpful adjunct treatment for COVID-19 recovery.

The Health Benefits of Exercise Report is a newsletter and article series in which we select three peer-reviewed articles, summarize the key findings, and provide social media images for you to share with your community. You can read previous articles here.

As the COVID-19 pandemic persists, maintaining a physically active lifestyle continues to present a challenge. However, we know that exercise is a key measure to help prevent chronic health conditions that still affect millions of people and increase the risk of severe COVID-19. This month’s edition of the Health Benefits of Exercise Report covers:

  1. A study showing medical referral for exercise programs may benefit health outcomes,
  2. A narrative review on the influence of exercise on brain DNA damage and the impact on related neurological diseases, and
  3. A discussion of the potential for physical activity to help counteract some adverse effects of COVID-19 through its effect on a molecule called PPARa.
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Medical Referral to an Exercise Program Provides Health Benefits

Physician referred exercise programs are not a new concept. They have the potential to better integrate healthcare with prevention and wellness services in a way that promotes positive behavior change and improved health outcomes for patients. However, physician, community, and government support are all important to the success of such programs. A study published in the European Journal of General Practice looked at the feasibility of a medically referred exercise program in Murcia, Spain.

The program involved a few key components:

  • Exercise prescription and referral training for physicians and nurses at 54 community healthcare centers
  • Government assistance in matching participants with sports facilities near their homes
  • Credentialed instructors with experience in similar programs and exercise training in adults
  • Group exercise sessions with participants grouped by age and tailored to individuals’ conditioning

The program ran for 10 weeks and consisted of one hour sessions three times per week for 30 total sessions. Participants were adults with either hypertension (high blood pressure) or dyslipidemia (elevated blood lipids) visiting their primary care physician.

According to the findings, 82.7% of people agreed to the referral program when asked by their doctor or nurse, 72% officially started the program. Of those who started the program, 81% completed more than 20 of the 30 sessions.

Data analysis found a statistically significant improvement in both men and women for every study variable, including:

  • body weight,
  • BMI,
  • aerobic fitness,
  • muscle strength,
  • flexibility, and
  • balance.

Self-reported variables—mood and physical fitness levels—also improved. In addition, 49.4% of participants strongly believed that they would keep up with regular exercise over the next six months.

This study has a few key limitations, a significant one being the lack of a comparison or control group. Without a comparison or control group, this study cannot tell us how much better—or not—this particular physician referred exercise program is in comparison to other models or different treatment types—like a handout or web app.

This study is helpful because the program in this study is similar to those currently offered by health clubs. It is convenient to the participant’s home, offers the social aspect of group training, and provides individualized exercise with credentialed instructors. The program was free, which is not typical of health club programs; however, many gyms offer affordable pricing for physician referral programs. Some evidence suggests programs that have some cost attached, or “skin in the game,” can be more effective than free programs.

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Exercise Has Benefits for Brain DNA

A variety of internal and external factors can cause damage to DNA. This damage can cause the death of neurons, leading to memory impairment and deterioration of neural function. This damage has been implicated in neural pathologies like Alzheimer's and Parkinson’s. Evidence suggests physical activity may be neuroprotective. A narrative review published in the journal Neural Regeneration Research discussed the influence of exercise on brain DNA damage and what that might mean for brain health.

The authors note that changes in DNA—for example, DNA methylation—are related to certain brain diseases and that regular, lifelong exercise in adequate amounts can potentially minimize these effects. Exercise may reduce the production of harmful oxidants (molecules that can damage cells they interact with in the body) and increase antioxidant capacity (the body’s ability to counteract harmful oxidants), subsequently decreasing some damage to DNA. Physical activity may also play a beneficial role in repairing damaged DNA, though the mechanism for this remains unknown.

Data from earlier studies in both rodents and humans suggest that physical exercise induces genetic adaptations regulating plasticity in neural communications and brain function. The authors conclude that “exercise may be fundamental in the control of the neurological disease.” However, they note the need for more information about what types of exercise are most beneficial.

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Exercise May Be a Helpful Adjunct Treatment for COVID-19 Recovery

In a healthy person, a molecule called PPARa helps regulate lipid metabolism in lung tissue and plays a role in endothelial cells’ health (cells lining the inside of blood vessels). Authors of an article published in the journal Medical Hypotheses suspect that in some COVID-19 patients, a reduction in PPARa—due to viral infection with SARS-CoV-2—may be an important factor in lung inflammation and subsequent lung injury. The authors indicate that exercise may be beneficial in helping to counteract some of these effects.

When a person contracts SARS-CoV-2, disruptions to PPARa caused by the infection can lead to inflammation and damage to the lung. PPARa may have anti-inflammatory effects, with the authors noting that using drugs that activate PPARa, called PPARa agonists, may play a therapeutic role by helping to reverse some of the changes to inflammation and metabolic processes caused by SARS-CoV-2 infection. In particular, one drug, called fenofibrate, prevented lipid accumulation in cells infected with the virus, blocking its replication.

This medication may help counteract some adverse effects typically associated with SARS-CoV-2 and lower levels of PPARa, and according to the authors, exercise may have a similar effect. They outline several studies and conclude that there is limited but compelling evidence supporting a role for exercise in moderating PPARa levels in various organs and tissues. They note “exercise has also been shown to benefit endothelial function and inflammation, and may play a role in regeneration and repair of injured endothelial cells.”

The authors also point out that viral infection-related reductions in PPARa, and the associated changes to metabolism and inflammation, may affect exercise capacity. They assert that “changes in PPARa from COVID-19 may prime the body for fatigue, inactivity and obesity. Exercise and increases in cardiorespiratory fitness may thus be needed for secondary prevention to mitigate the possibility of further disuse, chronic disease and disability.”

In addition to the key roles exercise plays in immune function and metabolic health, if this hypothesis proves to be correct, it could also counteract some adverse effects of COVID-19 infection related to inflammation and lung injury.

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Related Articles & Publications

  • The Preventive Role of Exercise in the COVID-19 Outbreak

  • More Activity, Lower Mortality in People with Chronic Disease

  • Physical Inactivity & the COVID-19 Pandemic

Author avatar

Alexandra Black Larcom @ihrsagetactive

Alexandra Black Larcom, MPH, RD, LDN, is the Senior Manager of Health Promotion & Health Policy for IHRSA. She spends her days working on resources and projects that help IHRSA clubs offer effective health programs in their communities, and convincing lawmakers that policies promoting exercise are an excellent idea. Outside the office you'll most likely find Alex at the gym, running on the Charles River, or, in the fall, by a TV cheering on the Florida Gators.