Exercise is Medicine: A Historical Perspective

Abstract

Much of the early information about exercise and medicine appeared in the ancient, medieval, and Renaissance medical literature in the context of the "six things nonnatural." These were the things that were under everyone's own control, directly influenced health, and became the central part of the new "physical education" movement in the early 19 century in the United States. They were known then as the "Laws of Health." Until the early 1900s, "physical education" was dominated by physicians who specialized in health and exercise. However, physical education changed to a games and sports curriculum led by coaches who introduced competition and athletic achievement into the classroom. As that happened, physicians disappeared from the profession. Through the last half of the twentieth century, as exercise became more central to public health, the medical community began to view exercise as part of lifestyle, a concept embracing what was once called the "six things nonnatural."

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Exercise is Medicine: A Historical Perspective
Jack W. Berryman
Department of Bioethics and Humanities and Adjunct, Department of Orthopaedics and Sports Medicine,
School of Medicine, University of Washington, Seattle, WA
BERRYMAN, J.W. Exercise is medicine: a historical perspective. Curr. Sports Med. Rep., Vol. 9, No. 4, pp. 00Y00, 2010. Much of
the early information about exercise and medicine appeared in the ancient, medieval, and Renaissance medical literature in the context
of the ‘‘six things nonnatural.’’ These were the things that were under everyone_s own control, directly influenced health, and became the
central part of the new ‘‘physical education’’ movement in the early 19
th
century in the United States. They were known then as the ‘‘Laws of
Health.’’ Until the early 1900s, ‘‘physical education’’ was dominated by physicians who specialized in health and exercise. However,
physical education changed to a games and sports curriculum led by coaches who introduced competition and athletic achievement into the
classroom. As that happened, physicians disappeared from the profession. Through the last half of the twentieth century, as exercise
became more central to public health, the medical community began to view exercise as part of lifestyle, a concept embracing what was
once called the ‘‘six things nonnatural.’’
INTRODUCTION
The belief that exercise could be considered medicine, or
part of medicine, is not new. In fact, before mainstream
Western medicine and healthcare became more focused on
‘‘sick care’’ at the beginning of the 20
th
century, a major part
of a physician_s duties focused on the preservation and pro-
motion of health and the prevention of disease. In this con-
text, physicians emphasized the importance of exercise and
diet, or what became known as regimen. This strong emphasis
on health, rather than disease, dates back to the two most
prominent physicians of the ancient world: Hippocrates
(460Y370 B.C.) and Galen (129Y210 A.D.).
EXERCISE AND THE NONNATURAL TRADITION
It was Hippocrates who wrote two books on regimen and
noted that ‘‘eating alone will not keep a man well; he must
also take exercise. For food and exerciseI.work together
to produce health (23). Galen, who borrowed much from
Hippocrates to arrive at his own significant contributions
to medicine, structured his medical ‘‘theory’’ around the ‘‘nat-
urals’’ (of, or with nature Vphysiology), the ‘‘nonnaturals’’
(things not innate Vhealth), and the ‘‘contra-naturals’’
(against nature Vpathology). Central to this theory was
health and the uses and abuses of the ‘‘six things nonnatural:’’
1) air, 2) food and drink (diet), 3) sleep and waking AQ1,4)motion
(exercise) and rest, 5) excretions and retentions, and 6) pas-
sions of the mind. If the nonnaturals were observed and prac-
ticed in moderation, health would be the result. But if not
followed, performed in excess, or put into imbalance, disease or
illness would result (3).
These six categories embraced all of the activities relating
to health over which a person had control. Accordingly,
along with some drugs and minor surgery, following the
nonnaturals was critical therapy. Exercise then, as part of
‘‘motion and rest in the nonnatural tradition, was incorpo-
rated in much of the early regimen, hygiene (health), and
preventive medicine literature, and to a lesser extent, the
therapeutic literature, through the late 19
th
century. While
exercise was a recommended treatment for a variety of ail-
ments including gout, dyspepsia, and consumption, among
others, the primary use of exercise was for prophylaxis (3).
The classical Western medical notion that one could im-
prove one_s health through one_s own actions Vfor example,
by eating right, breathing fresh air, and getting enough sleep
and exercise Vproved to be a powerful influence as medical
theory developed beyond Galen_s influence over the cen-
turies. Ancient medicine made it clear to physicians and
laypeople alike that responsibility for disease and health was
1
EXERCISE IS MEDICINE
Address for correspondence: Jack W. Berryman, Ph.D., FACSM, Box 357120,
University of Washington, Seattle, WA 98195 (E-mail: berryman@u.washington.edu).
1537-890X/0904/00Y00
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not the province of the gods and goddesses. Every person,
either independently or in counsel with their physician, had
the opportunity to attain and preserve health. When the
Middle Ages gave way to the Renaissance, with its individu-
alistic perspective and its recovery of classical humanistic
ideals, this notion of personal responsibility for health
acquired even greater attention, and it was understood gen-
erally that ‘‘we die by the way we live (6).
EXERCISE IN THE MEDICAL LITERATURE
Examples of a continuation of the nonnatural tradition and
the necessity of exercise for good health abound in the med-
ical literature. Spanish physician Christobal Mendez, who
wrote the Book of Bodily Exercise in 1553 said, ‘‘The physician
must organize his patient_s life and the things called unnatu-
ral, such as eating and drinking, evacuation and retention,
sleep and vigil, movement and rest, and the passions of the
soul and alteration of the air’’ (37). He further argued that ‘‘if
we use exercise under the conditions which we will describe,
it deserves lofty praise as a blessed medicine that must be kept
in high esteem (37).
Although Galenism and the ‘‘humoral theory of medicine’’
were displaced by new ideas, particularly through the study of
anatomy and physiology, the Greek principles of hygiene and
regimen continued to flourish in 18
th
century Europe. For
some physicians in the 1700s, though, such intervention
tactics were practical alternatives to traditional therapies that
employed bloodletting, blistering, and heavy dosing with
compounds of mercury Vor, ‘‘heroic’’ medicine, where the
‘‘cure’’ was often worse than the disease.
In London, in the early 1700s, physician Francis Fuller
published Medical Gymnastics: A Treatise Concerning the Power
of Exercise. In his most poignant discussion of the role of
exercise as medicine, he stated:
‘‘That the Use of Exercise does conduce very much of the
Preservation of HealthI.is scarce disputed by any; but that it
should prove Curative in some particular Distempers, and
that too when scarce anything else will prevail, seems to
obtain little Credit with most People, who tho_they will give
a Physician that hearing when he recommends the frequent
use of Riding, or any other sort of Exercise; yet at the bottom
look upon it as a forlorn method, and the Effect rather of
his Inability to relieve _em, than of his belief that there is
any great matter in what he advises: Thus by a negligent
Diffidence they deceive themselves and let slip the Golden
Opportunities of recovering, by a diligent Struggle, what
could not be procured by the Use of Medicine alone (20).
Similarly, in Scottish physician William Buchan_s highly
popular Domestic Medicine, first published in 1769, he sug-
gested that ‘‘of all the causes which conspire to render the life
of man short and miserable, none have greater influence than
the want of proper Exercise’’ (10). He also explained that
‘‘exercise alone would prevent many of those diseases which
cannot be cured, and would remove others where medicine
proves ineffectual’’ (10). Later that century in Paris, French
physician Clement Tissot wrote Medical and Surgical Gym-
nastics in 1780. With the subtitle of Essay on the Usefulness of
Movement, or Different Exercises of the Body, and of Rest, in the
Treatment of Disease, Tissot argued for the importance of both
active and passive exercises as well as the centrality of exercise
for rehabilitation after surgery (46).
In antebellum America, the ‘‘six things nonnatural’’
became known as the ‘‘Laws of Health and were put forward
along with herbs and water cures as alternatives to the
‘‘heroic’’ healing practices of drugging, bleeding, and purging
practiced by most traditionally trained physicians. Here, one
of the earliest examples is New York physician Shadrach
Ricketson_sMeans of Preserving Health and Preventing Diseases,
published in 1806. He noted that he often saw people ‘‘whose
inclination, situation, or employment does not admit of ex-
ercise, soon become pale, feeble, and disordered’’ and warned
that ‘‘idleness and luxury create more diseases than labour
and industry’’ (42).
Prevention literature and hygiene instruction also were
popular in American medical practice before 1860 because
there still were not many known cures. It was an era when
many laypeople and physicians alike had much faith in na-
ture_s healing powers. In fact, the term ‘‘natural’’ was used in
medical writing to signify a state of well being. And it is im-
portant to understand that the Greek ‘‘physis’’ meant ‘‘nature’’
or ‘‘natural’’ and was the root of ‘‘physick,’’ the term used for
medicine into the 1700s and also for our more modern term
‘‘physician.’’ As such, improvements in public health mea-
sures, a reliance on and trusting of nature, and plans for edu-
cating the public on living habits all received attention in the
medical literature.
THE NEW ‘‘PHYSICAL EDUCATION’’ PROFESSION
The ‘‘Laws of Health,’’ or the nonnatural tradition itself,
found further expression in pre-Civil War America through a
new literature and profession devoted to ‘‘physical educa-
tion.’’ Physicians began using the term ‘‘physical education’’
in journal articles, speeches, and books to represent the task of
teaching the ‘‘Laws of Health,’’ or instruction about how
one_s physical body worked. ‘‘Physical education, then, was
much more than exercising the body. Its subject matter was
devoted to maintaining health (3). Books like Thoughts on
Physical Education by Transylvania medical school physician
Charles Caldwell in 1834 (11) and Physical Education and
Preservation of Health by Harvard medical school physician
John Warren in 1845 (50) helped birth the ‘‘physical educa-
tion’’ movement in America. It was Warren who explained
that it was ‘‘a general law, that health may be preserved to a
late period of life by the use of those things, which are
friendly, and the avoidance of those which are noxious. Most
diseases are the consequences of violations of the laws of
nature, sometimes the result of ignorance, more frequently of
inattention’’ (50).
By the 1880s, the ‘‘physical education’’ movement led to the
formation of the American Association for the Advancement
of Physical Education, a professional group founded by, domi-
nated by, and presided over, by M.D.s who had faculty ap-
pointments at major universities like Johns Hopkins, Yale,
and Harvard. Of its first 12 presidents, 11 were physicians.
Further, 12 of the 16 members of the Society of College
Gymnasium Directors were M.D.s in 1897, the editor of the
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American Physical Education Review in the early 1900s was an
M.D., and the entire executive committee of the American
Society for Research in Physical Education in 1903 were M.D.s
(2,21,49). In addition, the following year, 15 out of the 20
members of the American Physical Education Association_s
National Council were physicians, including the President
and Vice President (1). Most of the physicians who taught
‘‘physical education’’ took anthropometric measurements, pre-
scribed exercise, gave health lectures, and supervised the new
gyms built on college campuses that the Superintendent
of Public Instruction in Massachusetts called ‘‘Palaces of
Health’’ (21,49).
One such physician, J. William White, a faculty member at
the University of Pennsylvania, wrote in Lippincott_smagazine
in 1887: ‘‘Let it be understood that the main object and idea
of exercise is the acquirement or preservation of health; that
it is by far the most important therapeutic and hygienic
agency at the command of the physician of today; that it can
be prescribed on as rational a basis with as distinct reference
to the correction of existing troubles or the prevention of
threatened ones as any of the drugs of the pharmacopeia’’
(51). Accordingly, because of their perceived importance, by
1900 all states required instruction in the ‘‘Laws of Health,’’
which were embodied in the curriculum of ‘‘physical educa-
tion.’’ Interesting too, one of the earliest books about ‘‘phys-
ical fitness’’ as we know it today, was Health, Strength &
Power, written by Harvard M.D. Dudley Sargent in 1904 (43).
Further testimony to this long-established link between
exercise, health, and medicine was another University of
Pennsylvania physician and physical educator_s book, Exercise
in Education and Medicine, published in 1909 by R. Tait
McKenzie (36).
THE REFORM OF AMERICAN MEDICINE
By the early 1900s, the field of medicine in the United
States began to undergo significant changes. ‘‘Heroic’’ medi-
cal practices were replaced with less invasive treatments that
evolved out of the scientific research that was beginning to
dominate the profession. Bacteriology and the new germ
theory impacted past beliefs about public health, disease, and
infections, new surgical techniques put more emphasis on
treating than preventing, new drugs could now cure, and
x-rays along with other instruments moved diagnosis beyond
previous limits. Priority was given to fighting infectious dis-
eases like yellow fever, smallpox, influenza, diphtheria,
typhus, cholera, and tuberculosis, and to finding effective
vaccines. As the American Medical Association gained more
power and control, it became evident that hundreds of
physicians were being trained at subpar colleges of medicine.
This alarming trend was made more public by the Carnegie
Foundation Report on Medical Education in 1910. Its author,
Abraham Flexner, recommended closing 120 of 155 medical
schools as ‘‘worse than useless’’ and leveled a scathing blow on
the profession (18). Quickly, medical training changed. The
number of training colleges decreased, the course of study
became longer, the curriculum became more scientific, a
greater emphasis was placed on cure rather than prevention,
residency programs were instituted, and most physicians
began to specialize. In addition, the number of general hos-
pitals and teaching hospitals increased rapidly. One outcome
of these changes was that fewer physicians were being trained
and those who were did not look at ‘‘physical education’’ as a
field of potential employment or one where their expertise
would be best utilized or appreciated. Accordingly, exercise
began to lose the attention previously displayed by many
physicians.
CHANGES IN ‘‘PHYSICAL EDUCATION’’
At about this same time in the early 1900s, ‘‘physical edu-
cation’’ was beginning to experience a shift in emphasis from
body development and health instruction to games and sports.
What began in the late 1850s as the Muscular Christianity
Movement, where high moral standards of character, cit-
izenship, and sportsmanship were viewed as valuable by-
products of team sport participation, gained momentum
throughout the last half of the 19
th
century through college
and high school sports and the YMCA. After basketball_s
invention at the Springfield, MA, YMCA in the early 1890s,
schools and colleges entered into a massive gymnasium-
building spree to accommodate this new indoor game that
attracted girls as well as boys. As such, basketball joined
football, baseball, track and field, swimming, and tennis,
along with several other sports and games, to become the new
subject matter of physical education (39). Now, to teach and
coach these new games, schools and colleges needed men and
women with expertise in one or more sports, not physicians.
In addition, many of these new sports specialists also were
asked to teach classes in health. Gyms once filled with a
variety of exercise equipment and built to support a curricu-
lum dominated by anthropometric measurements adminis-
tered and analyzed by physicians now featured basketball
courts and bleachers for adoring fans. The new role of physical
education in high schools and colleges became viewed as
‘‘education through the physical’’ as opposed to its previous
goal of ‘‘education of the physical,’’ and these remodeled or
newly built gyms became the classrooms for physical educa-
tion classes throughout the land (21,49).
Play, games, and sports were viewed as physical exercise just
like gymnastics, exercise machines, or calisthenics had been
earlier, but because of the ‘‘play movement’’ of the early 20
th
century, the philosophy of the Playground Association of
America, and research in education, psychology, sociology,
and anthropology, the moral and educational benefits of
playing games overshadowed their health promotion values
(39). Physical education became a sports skills curriculum and
forged direct relationships with intramural, interscholastic,
and intercollegiate sports. And, as games and sports became
central to physical education classes, their competitive nature
catered to those students more highly skilled and neglected
the majority who were not athletically inclined. The problem
with using football, basketball, or softball as the subject mat-
ter of the physical education curriculum clearly was stated in a
1905 article in JAMA: ‘‘The men on the teams are the very
ones whom Nature has endowed superabundantly with phys-
ical capacity, but on them the physical director spends most
of his energies, while the average student is left to get his
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physical development by yelling from the bleachers’’ (19). It
was at this time too, that many in the medical community
viewed competitive sports as being harmful or potentially
dangerous because the level of exertion generally exceeded
the rule of moderation basic to the ‘‘Laws of Health.’’
The number of colleges producing physical educators
grew rapidly and the most important part of the training
curriculum dealt with teaching games and sports. That phys-
ical education had changed to accommodate sports started
to become clear by the 1910s. In another Carnegie Report,
American College Athletics published in 1929, investigator
Howard Savage found that only 23 out of the 177 college
directors of physical education surveyed had majored in the
subject, yet 85% had spent three years on a football team. He
also found that 63 out of 130 colleges surveyed had granted
their head football coach a faculty appointment, and 55 of
those 63 were professors in physical education departments
(44). This prompted Savage to state: ‘‘Of all the field of higher
education, physical education shows the largest number of
members with the rank of professor who have only a bach-
elor_s degree or no degree whatever’’ (31). Savage concluded
by criticizing educators for redefining the purpose of physical
education, granting coaches faculty appointments, and pre-
paring coaches to fill positions as physical educators. In a
similar study of high school sports in the early 1930s, it was
found that in 90% of the 760 schools surveyed, the physical
education director and football coach were the same person
(31). The ‘‘Sports Creed’’ emphasizing citizenship, teamwork,
character, democratic living, and sportsmanship had replaced
the ‘‘Laws of Health’’ as the focal point for physical education
(15). And, as that took place, the new physical education
curriculum focusing on competitive sports required the hiring
of coaches, not physicians, and favored those students blessed
with physicality, providing very little exercise for those not so
fortunate. The anointed role exercise once played in the
larger health scheme of America had become lost in new
physical activities whose success was measured in win-loss
records rather than the overall health of the student body.
PROBLEMS WITH THE ‘‘NEW PHYSICAL EDUCATION’’
That the ‘‘new physical education’’ was not helping the
overall health of millions of American men started to be-
come apparent as early as World War I when one third of the
3 million drafted were deemed physically unfit, and those ac-
cepted had to be taught the basic rudiments of hygiene and
diet (21). There also were those within physical education,
like professor Charles McCloy, an exercise physiologist at
the State University of Iowa, who believed his colleagues
had gotten carried away with sports and games and argued in
the professional literature for a return to the goals of bodily
health and physical development from the mid-1930s through
the 1950s in articles like: ‘‘How about some muscle?’’ (32),
‘‘Endurance’’ (34), ‘‘Forgotten objectives of physical educa-
tion’’ (33), and ‘‘Why not some physical fitness?’’ (35). Simi-
larly, the undisputed leader of the physical culture movement,
largely popular outside of education, Bernarr Macfadden, who
was ridiculed by medicine and physical education alike, was
forthright in his belief in the importance of the ‘‘Laws of
Health’’ and began to promote his ‘‘Physical Culture Creed’’
in the 1930s (16). Except for having seven ‘‘laws’’ instead of
six, Macfadden_s ‘‘creed’’ was identical to the ancient non-
naturals. Further evidence of the failure of the ‘‘new physical
education’’ resurfaced again with dismal fitness results for
World War II draftees and enlistees and more poignantly in
the Kraus-Weber youth fitness test results of the early 1950s
that showed the poor fitness of American boys and girls when
compared with those in Austria, Italy, and Switzerland. These
startling findings led to direct federal government inter-
vention with the formation of the President_s Council on
Youth Fitness in 1956 (4,27).
THE REFORM OF PHYSICAL EDUCATION
Like medicine in the early 1900s, the physical education
profession came under more scrutiny in the early 1960s. In his
book The Miseducation of American Teachers in 1963, James
Koerner criticized the inferior intellect of faculty, said stu-
dents in training spent too much time in methods courses,
and lamented nonacademic subjects like physical education
as part of the ‘‘trivia of education’’ (26). That same year, in yet
another Carnegie Foundation Report, The Education of
American Teachers, author James Conant criticized under-
graduate programs for offering courses in football funda-
mentals and advanced basketball, but was harsher when he
discussed graduate education. He wrote: ‘‘If I wished to portray
the education of teachers in the worst terms, I should quote
from the descriptions of some graduate courses in physical
education’’ (12). Conant went on to conclude: ‘‘To my mind, a
university should cancel graduate programs in this area’’ (12).
This kind of direct criticism, coupled with the call for more
science and mathematics as a result of the Soviet Union_s
launches of Sputniks I and II and the college athletic scandals
of the late 1950s where physical education departments were
chastised as the purveyors of ‘‘snap courses’’ for athletes, led to
some serious soul searching within the physical education
profession.
The most important call for change from within physical
education came from Berkeley professor Franklin Henry, who
in 1964 published ‘‘Physical education: an academic dis-
cipline’’ (22). Deans and department chairs of several Big 10
universities who had come to the same conclusions as Con-
ant, albeit 10 yr earlier, agreed with Henry and reacted with a
flurry of changes in the late 1960s. Curriculum reform, higher
admission standards, departmental reorganization, and an
emphasis on research were examples. More importantly,
though, the call for more rigorous programs led to a search for
a legitimate field of study. How could physical education
become an academic discipline? Agreeing that they really had
no field of scientific study comparable to others at major
universities, physical educators began to focus on the study of
exercise and sport, and departments with titles like exercise
science, human movement, and kinesiology were born. Tra-
ditional ties with athletics were severed, and as physical
education became more scientific, like medicine had done
earlier, and the many ramifications of exercise began to be
studied, new research coming from laboratories housed in
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these new departments began to prove what the nonnatural
tradition and the ‘‘Laws of Health’’ had preached for centuries
(29). It was becoming evident that both physical activity and
physical inactivity were key elements of health.
EXERCISE RETURNS TO THE MEDICAL ARENA
The new exercise science research in the 1960s was built
upon the unique and groundbreaking studies of exercise at
the Harvard Fatigue Laboratory in the 1930s and _40s and
T.K. Cureton_s Fitness Laboratory at the University of Illinois in
thelate1940sand_50s (4,5), among a few others, along with
the findings of epidemiologists Jeremy Morris and Ralph
Paffenbarger, who linked physical inactivity with a variety
of chronic diseases (14). Scientists in these fields, largely lo-
cated in the recently restructured physical education depart-
ments, looked beyond the American Association for Health,
Physical Education, and Recreation (AAHPER) and joined
physiologists and cardiologists in the newly formed American
College of Sports Medicine (ACSM) for their professional
affiliation and utilized its journal, Medicine and Science in Sports,
as an outlet for their research.
A large contingent of physicians were both founders and
charter members of ACSM and, through their efforts, brought
exercise back into the medical arena via partnerships with
groups like the American Heart Association and the Ameri-
can College of Cardiology (4). It was the study of ‘‘heart
health’’ particularly that led to early publications like Hypo-
kinetic Disease: Diseases Produced by Lack of Exercise, by Hans
Kraus and Wilhelm Raab (28). That exercise was gaining
more scientific and medical credibility was further evidenced
in Warren R. Johnson_s large edited volume, Science and
Medicine of Exercise and Sports (24). Unique to this research
was that it focused generally on ‘‘normals’’ or highly trained
humans as compared with much of the earlier work in phys-
iology and medicine that looked at sick and diseased patients.
These researchers studied the healthy as opposed to working
with the ill and were challenged by learning how to keep
healthy people healthy. Accordingly, much of the new exer-
cise science research dealt with various aspects of physical
activity, fitness, and health (4). For those who maintained
ties with AAHPER, they found a unique publishing outlet in
their newly named journal in 1980, Research Quarterly for
Exercise and Sport.
As more and more research linked heightened fitness levels
and increased physical activity with disease prevention,
health maintenance, psychological well being, and longevity,
American youth fitness test results in the 1970s and 80s cre-
ated alarming newspaper headlines like: ‘‘Youth Going Soft
Again,’’ ‘‘Many Children Flunk Fitness Tests,’’ ‘‘2 out of 3
Kids Fail AAU_s Fitness Test,’’ ‘‘America_s Kids Are Physical
Wimps, President_s Council Says,’’ and ‘‘Youngsters Are
Getting Fatter, Not Fitter.’’ Interestingly, Pulitzer Prize win-
ning author James Michener was doing the research for his
book Sports in America when these chilling reports were being
published and asked himself, ‘‘What could account for the
inferior performance, especially when in Olympic competi-
tion, or any other kind, our top athletes performed as well
as those of other countries and oftentimes much better?’’ (38)
He answered in his book: ‘‘The explanation was simple. Our
educational system was stressing so heavily the public games
played by a few semi-professional athletes posing as scholars
that the general health of the student body was going un-
attended, and the tests proved this’’ (38).
EXERCISE, LIFESTYLE, AND PUBLIC HEALTH
The rekindling of interest in the role exercise played in
health was further intensified by data that showed that more
than one third of all deaths in the United States were due
to unhealthy lifestyles (disobeying the ‘‘Laws of Health’’),
along with the rise of new wellness, self-help, and holistic
health ideals, the acceptance of complementary and alter-
native medicines, and the popularity of jogging and other
fitness activities like aerobics, bicycling, and running. Exer-
cise was now becoming fashionable and trendy, and an en-
tire new clothing and footwear industry was built upon the
health benefits of exercise. At this time too, proving that
medicine and public health had done their jobs well in the
first half of the 20
th
century, only 1% of those who died before
age 75 did so from infectious disease. Unfortunately though,
chronic and degenerative diseases like coronary heart disease
(including atherosclerosis, heart failure, hypertension, and
stroke), obesity, type 2 diabetes, some cancers, osteoporosis,
and sarcopenia replaced infectious diseases and were begin-
ning to cause great human suffering and premature death,
affecting 90 million Americans and costing nearly two thirds
of a trillion dollars in health care expenses as well as lost pro-
ductivity (9). Because of these changes and conclusive data
emerging from the physical activity epidemiology literature,
the ancient ‘‘Laws of Health’’ began to regain their lost position
in mainstream medicine, with exercise playing a major role.
It was in the 1970s that the ACSM, American Heart
Association, National Institutes for Health, and the Centers
for Disease Control, among others, began to take a more
serious interest in exercise and health as evidenced by posi-
tion stands, roundtable discussions, conferences, reports, and
books. And mainstream medical journals like JAMA and
The New England Journal of Medicine began to publish articles
on many different aspects of physical activity, including the
need for exercise advice in the clinical setting. It was in 1979
that the Surgeon General_s Report on Health Promotion and
Disease Prevention called for an attack on chronic disease with
increased attention to physical activity and nutrition (47).
During the 1980s, the U.S. Public Health Service identi-
fied physical fitness and exercise as one of 15 areas of focus for
the national objectives for improving people_s health, popular
books and bestsellers like the Diamond_sLiving Health were
published (13), The Physician and Sportsmedicine magazine
began its ‘‘Exercise is Medicine’’ campaign, and a striking study
published in JAMA in 1989 demonstrated a direct correla-
tion between low levels of physical fitness and a high risk of
death from all causes (7). These findings and similar data
from some of the world_s best physicians and leading scientists
were expressed more fully in the publication of Physical
Activity and Health: A Report of the Surgeon General,in1996
(48). Books too, like David Nieman_sThe Exercise-Health
Connection VHow to Reduce Your Risk of Disease and Other
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Illnesses by Making Exercise Your Medicine, began to appear in
the late 1990s (41). By 2001, when another Surgeon General_s
Report on Health Promotion and Disease Prevention was released,
physical activity and fitness were at the top of the list of 22
priority areas for improving the nation_s health (40).
The culminating event in the revival of the once accepted
and then abandoned view that exercise is in fact medicine was
the historic meeting on November 5, 2007 at the National
Press Club in Washington, D.C., jointly sponsored by the
American Medical Association and the American College of
Sports Medicine. Here, the Presidents of both organizations
introduced their co-sponsored health initiative, Exercise is
Medicinei. ACSM president Robert Sallis, a California-
based family physician, explained to reporters that ‘‘if we had a
pill that conferred all the proven health benefits of exer-
cise, physicians would widely prescribe it to their patients and
our healthcare system would see to it that every patient had
access to this wonder drug.’’ Similarly, AMA president, the late
Ronald Davis, asked his colleagues if they ‘‘learned that a single
prescription could prevent and treat dozens of diseases, such as
diabetes, hypertension, and obesity, would you prescribe it to
your patients?’’ Also in attendance was Rear Admiral Steven
Galson, the Acting Surgeon General, who warned that ‘‘the
practice of engaging in regular physical activity is one which
must be adopted broadly Vby individuals and families every-
where Vif we, as a nation, are to make truly sustained progress
in health promotion’’ (17). Soon thereafter, we began to see
both regional and national advertising campaigns focusing on
the prescription of exercise for health.
CONCLUSION
It is clear today that physical activity is a viable and rela-
tively inexpensive way to combat most of the nation_s most
serious diseases that are, for the most part, preventable.
This brings us back to a much earlier time when physicians
advised patients about their lifestyle as dictated by the ‘‘Laws
of Health’’ or the ‘‘six things nonnatural.’’ For example,
behavioral causes currently account for 40% of all deaths in
the United States, and obesity and physical inactivity com-
bined, along with smoking, are the top causes of premature
death (45). All three have held central positions in the
nonnatural tradition for centuries. With respect to exercise
in particular, a recent JAMA article advised that ‘‘physical
activity, while not a drug, can behave like one’’ (30). The
author suggested that ‘‘health care professionals, including
physicians, are encouraged to prescribe physical activity for
health. It is plausible that there is a minimum dose of physi-
cal activity for health benefits, that these benefits increase
with increasing dose, and that beyond a certain dose, adverse
effects outweigh benefits’’ (30). Even more recently, in the
British Journal of Sports Medicine, Steven Blair argued that
‘‘evidence supports the conclusion that physical inactivity is
one of the most important public health problems of the
21
st
century, and may even be the most important’’ (8).
Finally, the publication of ACSM_s Exercise is Medicine: A
Clinician_s Guide to Exercise Prescription in 2009 (25), brings us
back to a point where we were hundreds of years ago when
prescribing lifestyle modification was a regular and expected
duty of one_s physician. With recent data suggesting that
nearly two thirds of patients would be more interested in
exercising to stay healthy if advised by their doctor, we may be
coming to a time in history where we can begin to regain
national health through more effective guidance and coun-
seling from the medical community coupled with the exper-
tise of knowledgeable and well trained exercise practitioners
motivated by health outcomes instead of medals and trophies.
References
1. American Physical Education Association YThe National Council. Am.
Phys. Educ. Rev. 1904; 9(1): back cover.
2. Am. Soc. Res. Phys. Educ. 1904; 9:60Y2.
3. Berryman JW. The tradition of the ‘‘six things non-natural’’: exercise and
medicine from Hippocrates through ante-bellum America. ESSR. 1989;
17:515Y59.
4. Berryman JW. Out of Many, One: A History of the American College of
Sports Medicine. Champaign (IL): Human Kinetics; 1995.
5. Berryman JW. Thomas K. Cureton, Jr.: pioneer researcher, proselytizer,
and proponent of physical fitness. Res. Quart. Exerc. Sport. 1996; 67:1Y12.
6. Berryman JW. Ancient and early influences. In: Tipton CM, editor.
Exercise Physiology: People and Ideas. New York: Oxford University Press;
2003, p. 1Y38.
7. Blair SN, et al. Physical fitness and all-cause mortality: a prospective study
of healthy men and women. JAMA. 1989; 262:2395Y2401.
8. Blair SN. Physical activity: the biggest health problem of the 21
st
century.
Br. J. Sports Med. 2009; 43:1Y2.
9. Booth FW, Gordon SE, Carlson CJ, et al. Waging war on modern chronic
diseases: primary prevention through exercise biology. J. App. Physiol.
2000; 88:774Y87.
10. Buchan W. Domestic Medicine: Or, A Treatise on the Prevention and Cure
of Diseases, by Regimen and Simple Medicines. Boston: Joseph Bumstead;
1813, p. 43,86.
11. Caldwell C. Thoughts on Physical Education. Boston: Marsh, Capen &
Lyon; 1834.
12. Conant JB. The Education of American Teachers. New York: McGraw Hill;
1963, p. 201.
13. Diamond H, Diamond M. Living Health. New York: Warner Books; 1987.
14. Dishman RK, Washburn RA, Heath GA, et al.Physical Activity Epi-
demiology. Champaign (IL): Human Kinetics; 2004.
15. Edwards H. Sociology of Sport. Homewood (IL): Dorsey Press; 1973.
16. Ernst R. Weakness Is a Crime: The Life of Bernarr Macfadden. Syracuse
(NY): Syracuse University Press; 1991.
17. Exercise is Medicine. Video of news conference available from: www.
exerciseismedicine.org.
18. Flexner A. Medical Education in the United States and Canada, Bulletin
No. 4, Carnegie Foundation for the Advancement of Teaching. New
York: Carnegie Foundation; 1910.
19. Football and its dangers. JAMA. 1905; 45:1656Y7.
20. Fuller F. Medicina Gymnastica: Or, a Treatise Concerning the Power of
Exercise,with Respect to the Animal Oeconomy; and the Great Necessity of it,
in the Cure of Several Distempers. London: John Matthews; 1705, p. 1,2.
21. Hackensmith CW. History of Physical Education. New York: Harper &
Row; 1966.
22. Henry FM. Physical education: an academic discipline. J. Health Phys.
Educ. Rec. 1964; 35:32Y3.
23. Hippocrates. Hippocrates: With an English Translation by W. H. S. Jones.
London: William Heinemann; 1953.
24. Johnson WR, editor. Science and Medicine of Exercise and Sports. New
York: Harper; 1960.
25. Jonas S, Phillips EM. ACSM_s Exercise is Medicine: A Clinician_s Guide to
Exercise Prescription. Philadelphia: Lippincott Williams & Wilkins; 2009.
26. Koerner JD. The Miseducation of American Teachers. Boston: Houghton
Mifflin; 1963.
27. Kraus H, Hirschland RP. Muscular fitness and health. J. Health Phys.
Educ. Rec. 1953; 24:17Y9.
28. Kraus H, Raab W. Hypokinetic Disease; Diseases Produced by Lack of
Exercise. Springfield (IL): Thomas; 1961.
29. Kroll WP. Perspectives in Physical Education. New York: Academic Press;
1971.
6Current Sports Medicine Reports www.acsm-csmr.org

Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
30. Lee I-M. Dose-response relation between physical activity and fitness:
even a little is good; more is better. JAMA. 2007; 297:2137Y9.
31. Lewis GM. Adoption of the sports program, 1906Y39: the role of accom-
modation in the transformation of physical education. Quest. 1969; 12:
34Y46.
32. McCloy CH. How about some muscle? J. Health Phys. Educ. 1936;
7:302Y3.
33. McCloy CH. Forgotten objectives of physical education. J. Health Phys.
Educ. 1937; 8:458Y61, 512Y3.
34. McCloy CH. Endurance. Phys. Educator. 1948; 5:9Y11.
35. McCloy CH. Why not some physical fitness? Phys. Educator. 1956;
13:83Y6.
36. McKenzie RT. Exercise in Education and Medicine. Philadelphia: W.B.
Saunders; 1909.
37. Mendez C. Book of Bodily Exercise. New Haven: Elizabeth Licht; 1960,
p. 6Y7,22.
38. Michener JA. Sports in America. New York: Random House; 1976, p.
67Y8.
39. Mrozek DJ. Sport and American Mentality, 1880Y1910. Knoxville: Uni-
versity of Tennessee Press; 1983.
40. National Center for Health Statistics. Healthy People 2000: Final Review.
National Health Promotion and Disease Prevention Objectives. Washington,
D.C.: U.S. Government Printing Office; 2001.
41. Nieman DC. The Exercise-Health Connection. Champaign (IL): Human
Kinetics; 1998.
42. Ricketson S. Means of Preserving Health, and Preventing Diseases: Founded
Principally on an Attention to Air and Climate, Drink, Food, Sleep, Exercise.
New York: Collins, Perkins; 1806, p. 152Y3.
43. Sargent DA. Health, Strength & Power. Boston: H.M. Caldwell; 1904.
44. Savage HJ, et al.American College Athletics, Bulletin No. 23, Carnegie
Foundation for the Advancement of Teaching. New York: Carnegie
Foundation; 1929.
45. Schroeder SA. We can do better: improving the health of the American
people. N. Engl. J. Med. 2007; 357:1221Y8.
46. Tissot JC. Gymnastique Medicinale et Chirurgicale. New Haven: Elizabet
Licht; 1964.
47. U.S. Department of Health, Education, and Welfare. Healthy People: The
Surgeon General_s Report on Health Promotion and Disease Prevention.
Washington, D.C.: U.S. Government Printing Office; 1979.
48. U.S. Department of Health and Human Services. Physical Activity and
Health: A Report of the Surgeon General. Atlanta: U.S. Department of
Health and Human Services, Centers for Disease Control and Pre-
vention, National Center for Chronic Disease Prevention and Health
Promotion; 1996.
49. Van Dalen DB, Bennett BL. A World History of Physical Education: Cultural,
Philosophical, Comparative. Englewood Cliffs (NJ): Prentice Hall; 1971.
50. Warren JC. Physical Education and the Preservation of Health. Boston:
William D. Ticknor; 1846, p. 90.
51. White JW. A physician_s view of exercise and athletics. Lippincott_s.
1887; 39:1008Y33.
Volume 9 cNumber 4 cJuly/August 2010 Exercise is Medicine 7

Copyright @ 2010 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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