Abstract
“People who are the most nature-connected care more about the planet, and are more likely to be conservation-minded.”
Modern life can be oppressive. Americans spend an average of 93% of our time inside (86% in buildings and 7% in vehicles) https://www.nature.com/articles/7500165 and look at screens over 7.5 hours daily. https://datareportal.com/reports/digital-2023-global-overview-report Talk about sedentary. 81% of Americans now live in cities, where there is little nature left. https://www.census.gov/newsroom/blogs/random-samplings/2022/12/redefining-urban-areas-following-2020-census.html
There has been no improvement in physical activity levels since 2001. In the U.S., gym memberships have doubled since 2000 https://www.statista.com/statistics/236123/us-fitness-center--health-club-memberships/but obesity is 40% greater than 20 years ago. https://www.cdc.gov/nchs/products/databriefs/db360.htm
Most urban designs and social media don’t help. Many jobs are sedentary. Clinicians dutifully advise patients to exercise, but that isn’t working out.
Few physicians realize that we have a secret weapon to help people to be physically active, as Maddock and Frumkin carefully, comprehensively and clearly describe. 1 It’s location.
Location matters not just because moving your body outside rather than inside is better for your health. It’s also because it’s better for the planet. People who are the most nature-connected care more about the planet, and are more likely to be conservation-minded. Yet, we infrequently or never engage in the seven “noticing nature” behaviors below. https://nt.global.ssl.fastly.net/binaries/content/assets/website/national/pdf/noticingnaturereport_final.pdf • Take a photo or draw a picture of natural views, or a plant or an animal—80% of us infrequently or never do this. • Smell wildflowers—79%, as above • Watch wildlife (e.g., bird watching)—78% • Watch clouds—71% • Take time to notice pollinators—butterflies, bees, other native pollinators—62% • Listen to birdsong—62% • Watch the sunrise or sunset—57%
Comprehensive expert reviews like Maddock and Frumkin’s are rare in nature-based medicine, and the field is relatively new in the U.S. https://pubmed.ncbi.nlm.nih.gov/37426731/For decades, medical schools in Japan, South Korea, Denmark, the Netherlands and the UK have all offered medical education in elements of nature-based medicine, including the importance of green and blue (water-associated) exercise. New Zealand physicians have written green prescriptions since 1998; Scottish physicians have been authorized to prescribe nature to their patients since 2018, and Canadian physicians since 2020.
Maddock and Frumkin emphasize the importance of recreational programming in schoolyards and parks to attract people outside. 1 The authors know that to make parks, blue spaces, walkways and bike pathways more accessible, public health specialists and parks and rec managers will need to collaborate with landscape architects, arborists and city planners. It’s been done—rooftop gardens, pollen-less street trees, open organic green space, and streams and ponds exist in model cities which integrate nature explicitly, such as Vancouver BC, Asheville, North Carolina and Madison, Wisconsin. So, it's possible.
But doing more and better urban planning with nature in mind isn’t easy. Try fighting the infill of urban spaces, packed densely with apartments and offices, and beholden to the God of efficient use of city services. Cities’ tightly trafficked building corridors can and do worsen hypertension, depression, anxiety, crime rates and cardiovascular disease, never mind chronic stress and obesity. Clinicians need to know what to do now—we can’t wait for cities to wisen up, to stop killing trees to make way for more smaller cubicles, or to lower urban noise levels, or to subsidize and feature community gardens, regenerative farms and blue spaces.
Imagine the impact if every patient leaving our clinics walked away with a park or beach prescription and the message that the health of our planet is the foundation for our own personal health.
Imagine if we wrote for gardening classes for dementia risk reduction https://www1.racgp.org.au/ajgp/2023/april/nature-prescribing-in-general-practice or a half hour public park visit for 30 minutes weekly to improve depression and high blood pressure. https://www.nature.com/articles/srep28551.pdf What if we prescribed two hours daily moving outside with your device off to slow myopia, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10683767/pdf/iovs-64-14-38.pdf now at 80% prevalence in Singapore and up to 40% in California? Or walking for 30 minutes outside three times weekly to a place of choice to lower all cause mortality and cortisol levels by over 21%? https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2019.00722/full Or simply walking regularly to improve cognition as we age, enlarging the left hippocampus and engendering neurogenesis? https://www.sciencedirect.com/science/article/pii/S1053811917309138 What if we referred people to a botanic garden (cared for without toxic synthetic artificial chemicals) for a birding class, as it appears to reliably improve mental health and burnout? https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196%2824%2900023-8/fulltext
Sending patients outside to move is a risky therapeutic maneuver because we lack patience, nestled within our pill-popping culture. Plus, one quarter of us are afraid of insects or spiders, a fear which can be addressed. Happily, we can rewrite the narrative in which most of us are stuck. We can be catalysts for our patients who can benefit by sustainable relationships with nature, especially using gardens, parks, lakes, beaches and orchards.
How do we think about this? As food is information for your genes, prompting them to produce a particular protein or watch other genes, nature is information for our actions and interactions, coding our own behaviors over eons. For example, the science of chronobiology has much to offer. It studies the timekeeping mechanisms within organisms and their adaptations to cyclic changes in the environment. The field suggests the importance of sunlight not just for vitamin D production, but for circadian rhythm, for optimizing sleep/wake cycles and for managing stress.
Nature offers wellness information which our bodies can’t get elsewhere. The soil’s health and microbial civilizations may interact beneficially with our own microbiota, perhaps explaining parks’ benefits in part. Nature’s primary mechanism of action may be through the immune system, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548093/possibly through the power of anti-inflammatory phytoncides, aromatic plant chemicals released by trees to communicate with one another. This effect is underestimated in the West, but not in Asia. Both Japan and Korea have pioneered forest bathing, and documented its positive effect on natural killer cell count and activity, up to a month after the intervention. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793341/A breath of forest air, after all is an ancestral inhaler.
You needn’t be a mystic or extremist to make outside movement a pillar of healing. Even being open to the practices of earthing, gardening, outdoor breathwork, forest bathing and outdoor walking, especially near water is a start. Here are five ways to put the Maddock and Frumkin paper into action: 1. Remember an underappreciated benefit of nature—it’s social. Be open to finding nature down the street, at a public green or blue space, or in an outside yoga, dance or pickleball class. You meet other people when you are outside. 2. Model your nature connection yourself by having a healthy plant or aquarium in the waiting room, pictures of nature on your office walls, and your walking shoes or or tennis racquet by the door where everyone can see them. Show that you walk the talk. Like every other lifestyle behavior loaded with good science, patients adopt it more often when their clinician models it. https://www.cmaj.ca/content/cmaj/185/8/649.full.pdf 3. Try to have a walking meeting outside, weather permitting. I Walk with patients for exercise or lead a Walk With a Doc group in your city. 4. Experiment with a clinic or office garden space, even if small: succulents are easy to grow and virtually no-care. A small herb garden or planter can delight and inspire patients, especially kids, when they taste a fresh herb or spice straight from the doctor’s office. Growing something is an intimate connection with the outdoors and a transitional activity if you are indoors. 5. Ask patients to buy something to eat from someone who grew it, or even better, to grow anything themselves. Radishes and lettuces just require watering and a pot, and most herbs and spices grow nearly as easily. Most (55%) U.S. adults already consider themselves gardeners. https://axiomcom.com/2023-vegetable-garden-study/
I recommend apps to patients and clinicians to help with movement: how we use devices determines their role. Try apps that help our patients to get outside, like RunKeeper, MyFitnessPal, Longevity Playbook and the Apple Watch fitness app. Look into partnership with a local branch of businesses which champion the outdoors responsibly, such as Patagonia, REI and TerrexEI (North Face and other brands). I especially like these companies for their environmental consciousness and high quality.
Objections to medicalizing movement outside can be anticipated. First, exercising mimicking therapeutics are on the horizon…why bother with the real thing and risk injury, interaction with strangers and weather? Second, nature kiosks with cypress scents are now operating in Tokyo shopping malls. If nature therapy is being commercialized in the city, why not take advantage of it and tell patients to hope for a future kiosk near them? Third, time is the most precious commodity for many people and almost everyone with a to-do list feels like there is too little time. Re-ordered priorities can be fearsome to reconsider.
The planet is burning, and the roaring of the fire is getting louder, as obesity, diabetes, dementia, depression, anxiety and COPD rates rage. There is wisdom in the multiethnic traditions of a walk after a meal, and regular movement during the day, as documented by studies of centenarians, including those recounted in the popular Blue Zones
What role will our medical leaders and institutions play in this critical moment? Will they choose to remain inside, bathed by the light of LED monitors and dulled by the buzz of HEPA filters, or will they opt outside? What can you do? Can you greet others on the pickleball court or hike on a trail or walk near a body of water after work? Can you block out an hour a day to feel like you’re part of something we’re all part of, and that your troubles are small compared with the vastness of outdoors, or the awe of a sunset? Do pastures or potagers hold your future or do pedagogy and papers (like this one)?
It is time to save patient lives without forgetting our own. Why not return to our profession’s roots, remembering that hospital gardens were once both formularies and farms? Look ahead, walk the talk more, and prescribe movement outside.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.