To push patients to be healthier, some doctors write exercise prescriptions

To push patients to be healthier, some doctors write exercise prescriptions

Studies show that people who spend time outdoors see improvement in mood, energy, stress and general well-being, as well as some aspects of physical health. (Ammentorp Photography / Alamy Stock Photo/Alamy)
By Ranit Mishori March 10

About a decade ago, a colleague told me about a cool new initiative, something called “Exercise Is Medicine.” The idea made total sense to me: Rather than just tell my patients about exercising, I would hand them an actual prescription for exercise, just like the ones I give patients for high blood pressure or diabetes. The thinking behind it was that an official “doctor’s order” for exercise, in the form of a prescription-pad-style piece of paper, would be taken more seriously by patients than a mere suggestion.

I quickly started giving out these prescriptions, going so far as to find some official-looking templates online and printing them out. I wrote out “dosages” based on each patient’s age and medical condition, and relying on evidence-based recommendations.

For example, for a person with diabetes, I might write a prescription that says:


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●Frequency: At least 3-4 days a week.

●Intensity: Exercise at a moderate level.

●Time: Exercise 30-60 minutes per day (all at once, or break it up into a few sessions of at least 10 minutes each).

●Type: Aerobic or rhythmic exercises using the large muscle groups (walking, cycling, swimming). Weights 2x week.

We physicians often don’t have time during a typical office visit of 15 or 20 minutes to discuss ­lifestyle-related recommendations for improving health. Many of us tell patients, “You need to lose weight” or “stop smoking” or “exercise more” — but in practice we tend to skimp on the details. The exercise-prescription idea was supposed to help eliminate this vagueness by giving patients more-specific information to act on.

Many doctors have now expanded the prescription approach for exercise to a whole range of behaviors and activities associated with a healthy lifestyle. The assumption is that if the prescription pad can get more people exercising, then maybe it could also get patients doing other activities — dance lessons or an art class or a stroll in the park — that have been found to improve physical and mental health. In fact, over the past couple of years, such prescribing efforts have really taken off:

● Physicians in Vermont, for example, have been giving out prescriptions for hiking and, in general, spending time in nature. That idea’s getting picked up elsewhere, including South Dakota, Maine, California and New Mexico, and is supported by multiple studies showing that people who spend time outdoors see improvement in mood, energy, stress and general well-being, as well as some aspects of physical health.

●The American Academy of Pediatrics has promoted the ParkRx Initiative, which was started in 2013 by the Institute at the Golden Gate and the National Recreation and Park Association with support from the National Park Service. The initiative is intended to help doctors prescribe “nature during the routine delivery of health care” by, among other things, showing them parks close to where their patients live.

●Prescription programs for healthy eating have popped up in more than a dozen states, championed by hospitals and physicians’ offices, as a means of battling diabetes, obesity and other conditions associated with nutrition. For example, a Chicago program called Food Rx pairs “doctor’s orders” with food coupons and information about community resources.

●In Hawaii, state lawmakers last year considered a bill to classify homelessness as a medical condition — multiple studies have documented the link between homelessness, poorer health and a lower life expectancy — and allow doctors to write a prescription for six months of subsidized housing. (The bill did not pass.)

Such interventions are known as “social prescribing,” in which health-care professionals are asked to identify and recommend interventions outside the exam room or hospital that might help patients adopt healthier lifestyles.

These efforts highlight what are called the social determinants of health and the recognition that social factors — including where you live, what you eat, how active you are, your access to health care, your income level, etc. — can be more important to your health than medical factors such as genetics.

Addressing these social determinants, studies have shown, may, in fact, be more effective in managing chronic conditions and prolonging life than medications and other clinical interventions.

The social prescribing trend focuses not only on food, exercise and housing, but also on “softer” activities such as making art, singing, participation in social gatherings — and their presumptive benefits on well-being and social connectedness. That’s because loneliness is also increasingly being thought of as a social determinant of health that is linked to physical- and mental-health conditions and even early death.

In Britain, social prescribing is sanctioned by the National Health Service and is being embraced by primary-care physicians who send their patients to community-based organizations and activities in response to an increase in lifestyle-associated conditions (including diabetes, obesity, heart disease) and social isolation.

Isolation is rising in Europe. Can loneliness ministers help change that?

Research has shown that such interventions are helpful, some more than others. There is irrefutable data showing that exercise is good for you, regardless of your age, gender, physical abilities or medical conditions. And there is beginning to be ­more-robust evidence for benefits from spending time in nature, dancing, singing, engaging socially and keeping your brain active.

And yet, as I consider the science, I ask myself: Does the act of actually prescribing these activities make a difference in patients’ lives? Are they more likely to act on these recommendations when packaged as an official-looking Rx?

The evidence on that is less clear. The literature on writing prescriptions for exercise shows that it may help more doctors discuss and recommend exercise (which is, of course, a good thing). But evidence that it is improving patients’ health is not really there.

A recent study concluded, “Whether social prescribing can contribute to the health of a nation for social and psychological well-being is still to be determined,” while an article in the journal Public Health noted, “Further research is required to optimize social prescribing benefits.”

The practice of social prescribing faces another kind of challenge, which I see firsthand. As a family physician who works with both affluent and poor patients, I realize that my use of this approach has exposed deep inequities in their access to resources. On the one hand, I get professional satisfaction from recommending hikes in Rock Creek Park, running along the Mall or singing in a chorus (partly because of the evidence and partly because those are activities I do myself). But can I really ask a patient who works two jobs and cares for her children to find 30 minutes a day to squeeze in a walk in a park? Or a patient who lives in an unsafe neighborhood to take a daily jog around the block? Or one who has no car to take two buses to get to an art class on the other side of town?

As for how successful my social prescribing has been, so far it’s too small a sample size to have statistical meaning. But from a purely anecdotal standpoint, I will admit to mixed results so far. Some patients have reported back that they had taken my recommendations to heart and begun to change their lifestyles. Others shoved my prescription in their bag and probably never looked at it again. I’m waiting for a big study or two to show me whether this trend can make a difference.

Many trends begin as great, well-intentioned ideas. Before we start proselytizing, we need to make sure that the resources are there, that the evidence of benefits is there and that we, as physicians, are well trained in how to push a change without causing any harm.

Correction:An earlier version of this story misidentified the organizations that launched the ParkRx Initiative.

Draining Millennials of Their Blood to Rejuvenate Boomers

Draining Millennials of Their Blood to Rejuvenate Boomers

Alkahest's vampire cure for aging experiment yields equivocal results

Ronald Bailey|Nov. 28, 2017 2:01 pm

Lightpoet/DreamstimeThe California anti-aging therapy startup Alkahest launched a small clinical trial back in 2016. Subjects suffering from mild to moderate Alzheimer's disease received four weekly infusions either of plasma—the liquid, cell-free part of blood—obtained from donors 18 to 30 years old, or of a placebo (a saline solution).

The trial was inspired by heterochronic parabiosis, a technique in which scientists grafted young and old mice together so that the animals shared their circulatory systems. The result was that the older mice's muscles, livers, hearts, brains, and other organs and tissues were rejuvenated significantly.

In my 2015 article "The Vampire Cure for Aging," I explained that Alkahest wanted

to see if infusing blood plasma from young people into patients suffering from mild to moderate Alzheimer's disease will improve their cognition. The company expects to enroll 18 patients in the coming trial, half of whom will receive infusions of human blood plasma donated by men under age 30 once weekly for four weeks. The other half will receive saline. The trial will chiefly focus on the safety of the treatment and compliance by participants. Additionally, researchers will compare both groups to see if those treated with blood plasma perform better on a number of tests for Alzheimer's disease and if changes suggestive of cognitive improvement can be identified in their brains.

Alkahest is now reporting the results of the trial at various scientific conferences. As it happens, the company was able to enroll only nine patients in the randomized double-blind portion of the trial while including nine others in the open-label portion, in which all the subjects received transfusions of young plasma. An analysis of assessments once all participants had been treated showed no significant changes in participants' mood or their performance on tests of cognition involving tasks such as memorizing lists or recalling recent events. However, on two of three different caregiver assessments of functional abilities such as making meals and shopping, participants showed statistically significant improvement.

Other researchers have pointed out that it is hard to draw conclusions from such a small trial that lasted for such a short time. In Science, neuroscientist Zaven Khachaturian observes that the positive effects reported by the caregivers could merely be a placebo effect: "[Patients] could feel better because somebody paid attention to them."

In any case, the company announced, "We look forward to advancing our lead clinical candidate, a proprietary plasma fraction, as a potential treatment for mild to moderate Alzheimer's disease." Their proprietary formulation will largely contain growth factors found in blood plasma.

Another California biomedical startup, Ambrosia, is running a "clinical trial" that transfuses plasma from people aged 16 to 25 into folks willing to pay $8,000 for the treatments. Some 600 people so far have reportedly signed up for the study. Since there is no placebo group, the company is reporting reductions in various blood biomarkers, including some associated with risks for cancer, cholesterol levels, and amyloid proteins associated with Alzheimer's disease.

In reporting on Ambrosia's anti-aging treatments, my colleague Mike Riggs recently asked, "Is It Wrong for Old People to Receive Blood Infusions From Teenagers?" As long as they're doing it voluntarily, my answer is no. Riggs further observed:

There are nearly a billion humans over the age of 60 on the planet today. There will be more than two billion of them by 2050. I hope to still be around then. I'm sure many critics of parabiosis hope to as well. If the tech bros of Silicon Valley want to offer up their bodies and their money in hopes of making that possible, why would any of us discourage them?

Why indeed?

California’s Single-Payer Health Care Plan Would Cost More Than the State’s Whole Budget

California’s Single-Payer Health Care Plan Would Cost More Than the State’s Whole Budget

Like in Colorado, New York, and Vermont, California is learning that a single-payer plan would be prohibitively expensive.

Eric Boehm|May. 23, 2017 2:45 pm

MIKE NELSON/EPA/NewscomStop me if you've heard this one before. A state considers implementing a single-payer health care system, then learns it would have to use its entire annual budget, plus some, to fund the idea.

The latest stop on this magical mystery tour of progressive health care plans is California, where U.S. Sen. Bernie Sanders (I-Vermont) has been campaigning on behalf of a proposed state-run single-payer system. On Monday, state lawmakers in Sacramento got their first look at the price tag for the proposal, which rings in at a whopping $400 billion annually.

The Sacramento Bee notes that, even after accounting for an estimated $200 billion that could be saved by replacing current state-run health programs with the single-payer program, the state would still need to come up with $200 billion annually.

This year's state budget in California, by the way, is about $180 billion. That means that implementing a single-payer health care system would require doubling (at least) the state's current tax burden. The analysis of the health care proposal presented to lawmakers on Monday suggests a 15 percent increase to the state's payroll tax to provide the necessary revenue.

The cost analysis is seen as "the biggest hurdle to creating a universal system," the Bee reports.

If this sounds familiar, that's because it is. Just last week, we reported on a similar single-payer proposal in New York State, which would require doubling (and possibly quadrupling, depending on which projection you believe) the state's tax burden. Vermont's attempt to implement a single-payer health care system collapsed in 2014 because the costs were too high. Colorado voters rejected a proposed single-payer system in 2016 when faced with the prospect of increasing payroll taxes by 10 percent to meet the estimated $25 billion annual price tag.

The list of states that have tried to go single-payer is still a small sample size, but a fairly wide ranging one. It includes states with large populations and small ones. States with a variety of economies and tax systems. States that are growing quickly and those that aren't.

Despite that range of variables, one thing remains constant: state-level single-payer health plans would require massive increases in tax revenue, equal or larger than the amount of revenue consumed by every other state-level program in a single year.

California's proposal is particularly expensive because it's not just a single-payer proposal, but a generous one. As Vox details, "the state would pay for almost all of its residents' medical expenses—inpatient, outpatient, emergency services, dental, vision, mental health, and nursing home care—and Californians would not have any premiums, copays, or deductibles." Undocumented immigrants would be covered too.

Even in the state that spends the most money each year, the $200 billion increase is asking for a lot. Californians pay an average of 11 percent of their income in state and local taxes, the sixth highest of any state, according to the Tax Foundation, a Washington, D.C.,-based think tank that favors lower tax rates, and the state's top income tax rate of 13.3 percent is already the nation's highest.

"Needless to say, doubling California's tax burden would give them the highest taxes in the country by far," Joe Henchman, vice president of state projects for the Tax Foundation, told Reason on Tuesday.

The proposal "will cost employers and taxpayers billions of dollars and result in significant loss of jobs in the state," warns the California Chamber of Commerce.

A single-payer system at the federal level would have the same fiscal problems, of course, but unlike state governments that are required to balance their budgets annually, a nationally single-payer system would just be added to the federal government's ever-growing tab. That's not necessarily better, but it would offer something of a solution to the problem of how to pay for a hugely expensive new entitlement. Until Democrats control the federal government, though, state-level efforts like the ones in New York and California are likely to continue percolating.

There's one other thing that's fairly consistent among the states that have proposed single-payer systems in recent years: When voters find out how much a single-payer system will cost, they are much less likely to support one.

Single-payer advocates learned that lesson last year in Colorado at the ballot box, as the state turned blue for Hillary Clinton even as 79 percent of voters said "no" to single-payer health care.

Other polling bears out that relationship. A recent poll commissioned by the California Association of Health Underwriters, found that 66 percent of California residents are opposed to single-payer health care. Opposition increased to 75 percent when those polled were told the price tag for the system is $179 billion annually—which is actually lower than what the legislative analysis suggests.

There's also this analysis from the Kaiser Family Foundation, which shows how support for single-payer health care declines when there is a price tag attached to the idea.

Kaiser Family Foundation

When free health care provided by the state government isn't free, it's a much more difficult sell. Progressives in California have their work cut out for them.

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