Louis Holtzhausen
Program Director: Sports Medicine
University of the Free State

Health care systems in the public and private sectors in South Africa find it difficult to keep up with the ever rising cost of health care. In fact, public health services are facing serious challenges to provide adequate services on many levels1. This article will propagate a way for medical practitioners, healthcare funders and the public to improve health and most likely decrease the cost of healthcare. It has been proved unequivocally that regular exercise is good for people’s health, that it improves quality of life, prevents disease often better than pharmacological agents do, as proved by leading epidemiologists2,3. It is for this reason that Dr Robert Sallis, general practitioner and task team leader of Exercise in Medicine™ in the United States, asked the question:

“What if there was one prescription that could prevent and treat dozens of diseases, such as diabetes, hypertension and obesity? Would you prescribe it to your patients? Certainly.”4

In fact, my contention is that if such medication was presented in tablet form and not prescribed, malpractice would certainly have been considered. Should healthcare providers and funders not be in a frenzy trying to make this medication available to as many people as possible? Added the fact that it is free, makes this a revolutionary, not to be missed opportunity to affect millions of lives for the better.


In a recently published longitudinal study on attributable factors for death of all causes among 40 842 men and 12943 women, it was shown that low cardiorespiratory fitness was more detrimental to health in terms of mortality than obesity, cigarette smoking, hypertension, hyperlipidaemia and diabetes5. In fact, low fitness carries a higher risk of mortality than obesity, hyperlipidaemia and diabetes put together! (Figure 1). It has also been shown that life expectancy is significantly higher in physically fit persons. Figure 2 demonstrates that the life expectancy of a physically fit 80-year old is similar to that of an unfit 60-year old person6! Quality of life also improves with increased physical fitness. In a study by Valiyeva et al among 6462 adults it was found that physical inactivity was the second most important risk for admission to a nursing home (or loss of independence) – second only to cigarette smoking and a significantly higher risk than obesity, hypertension, high cholesterol and diabetes7.

In a presentation on the benefits of regular exercise, the Exercise is Medicine™ movement reported from scientific reports that regular physical activity at the correct intensity4:

  • Reduces the risk of heart disease by 40%.
  • Lowers the risk of stroke by 27%.
  • Reduces the incidence of diabetes by almost 50%.
  • Reduces the incidence of high blood pressure by almost 50%.
  • Can reduce mortality and the risk of recurrent breast cancer by almost 50%.
  • Can lower the risk of colon cancer by over 60%.
  • Can reduce the risk of developing of Alzheimer’s disease by one-third.
  • Can decrease depression as effectively as Prozac or behavioral therapy.

In the South African context, exercise is an important factor in modification of disease patterns and mortality. The South African Medical Research Council (MRC) disease report in 2007 indicated the risk factors for death and disease in South Africa, as shown in Table 18. Of the top ten risk factors for death in South Africa, 28,2% are modifiable by exercise. Almost 19% of the top ten diseases causing death in South Africa are modifiable by regular exercise.


Workplace wellness initiatives are good examples of tangible benefits of physical fitness and lifestyle modification. A study on companies using workplace wellness initiatives in the United States showed a return on investment of $1.49 to $13 for every dollar spent on wellness, in terms on reduced medical expenses, reduced absenteeism and increased productivity9. In 1998, the Health Enhancement Research Organisation (HERO) reported 10% higher costs on staff members with an inactive lifestyle in study of 46 026 staff members from six large organisations over three years9.


It is clear that regular exercise should not only be promoted by the medical profession, but that physical activity should be monitored and recorded by doctors as a major modifiable risk factor for morbidity and mortality. At the cutting edge of this drive is Exercise is Medicine™, an organisation initiated by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA)4. The goals of this initiative are focused on the medical profession, the fitness industry and the public, and include:

  • For physical activity to become a vital sign to be recorded, with physicians routinely discussing it with each of their patients.
  • For the physician to either prescribe appropriate physical activity to each patient or to refer the patient to a certified health and fitness professional to get a physical activity prescription.
  • For the public to begin to ask for and expect physicians to discuss physical activity during each office visit.

There are obvious barriers to implementation of exercise prescription or referral by medical professionals. These include:

  • Lack of media advocacy.
  • No tangible success measures in the short term.
  • Physicians are lacking the time to effectively counsel patients.
  • Physicians may lack the proper training to effectively counsel patients about exercise.
  • Most medical insurance schemes do not include benefits for exercise prescription or referral for exercise prescription.
  • Patient expectations are for medication and not for lifestyle prescription.

The secret is that exercise prescription for health is really not complicated. The 2008 Physical Activity Guidelines for Americans advise that most health benefits of exercise occur with at least 150 minutes per week, or 30 minutes per day of moderate intensity physical activity, such as brisk walking. Of course additional benefits occur with more physical activity10. Detailed exercise guidelines are available in the Guidelines which are accessible on

Exercise is Medicine™ has developed toolkits for physicians, the fitness industry, media advocacy and the public to promote the message of exercise for health and can be obtained free of charge from their comprehensive website at

The South African Sports Medicine Association (SASMA) has embraced the challenge to promote physical activity as significant modifier of disease and quality of life. In 2009 SASMA has been included in the Exercise is Medicine Global Network to assist in this quest globally and specifically in South Africa.

Exercise is Medicine™ and SASMA have put lifestyle and exercise prescription and promotion within the reach of all medical practitioners by simply following the guidelines on the website4,11. I challenge all doctors to take the lead, embrace this powerful tool and make exercise part of the routine armamentarium for prevention and treatment of chronic disease.

Tables and Figures

Figure 1: Effect of Fitness (CRF) on Mortality Attributable Fractions (%) for All-Cause Deaths

(Blair SN. Br J. Sports Med. 43:1, 2009.)

Figure 2: Year-adjusted death rates per 1 000 person-years according to cardiorespiratory fitness (CRF) and age groups. White bars represent low CRF, striped bars moderate CRF, and black bars high CRF. (Sui X, et al. J Am Geriatr Soc. 55:1940-1947, 2007.)

Table 1: Risk factors and causes of deaths in South Africa. (Norman et al., MRC disease report. 2007.)

Conditions highlighted in yellow are modifiable by exercise


  1. Mail & Guardian. NHI plans to be ready for public comment by year- end. 2 September 2009
  2. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ, 174: 801-809, 2006.
  3. Paffenbarger RS Jr, Hyde RT, Wing AL et al. The association of changes in physical activity level and other lifestyle characteristics with mortality among men. N. Engl. J. Med. 328:538 – 545, 1993.
  4. Exercise is Medicine™.
  5. Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 43:1, 2009.
  6. Sui X, Laditka JN, Hardin JW, et al. Estimated functional capacity predicts mortality in older adults. J Am Geriatr Soc. 55: 1940-1947, 2007.
  7. Valiyeva E et al. Arch Int Med 2006; 166:985
  8. Norman A et al. MRC disease report , 2007.
  9. -of-workplace-wellness-initiatives/

10. 2008 Physical Activity Guidelines for Americans.

11. South African Sports Medicine Association.

LH 20100427