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Exercise has long been recognised as a cornerstone in the management of type 2 diabetes and several other chronic conditions. However, concerns over adherence and real-world effectiveness often undermine its clinical application. Recent discussions, including the article ‘Why exercise may never be effective medicine: an evolutionary perspective on the efficacy vs effectiveness of exercise in treating type 2 diabetes’, 1 published in this journal, highlight these challenges. However, this view oversimplifies the issue and underestimates the transformative potential of properly implemented exercise. This article aims to reframe the narrative that labels exercise as the ‘Ugly Duckling’ of diabetes treatment and to extend the discussion to other conditions where exercise acts as medicine—such as hypertension, obesity, metabolic steatotic liver disease and depression.