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“Given the strong effect of fitness on the risk of death
from any cause, the risk of disability, the risk of death from cardiovascular
causes, and longevity, perhaps assessment of this variable should also be made a
routine component of all clinical assessments, by including a simple question
regarding exercise habits during each office visit.” Editorial, The
New England Journal of Medicine (August 4, 2005)
Those annoying questionnaires your doctor’s
receptionist insists you fill out ask about every ailment you
and every member of your family have had since childhood, drugs you take,
surgeries, and heaven knows what else. But do they ask about your exercise
habits? Probably not. In fact, a highly regarded surgeon I talked to recently
seemed surprised when I told him that sedentary living is a primary risk factor
on par with smoking. Well, that may be about to change.
A lawyer friend sent me an Associated
Press story with the downbeat headline “Study:
Exercise Can’t Halt Effects of Age.” The study, originally
reported in the online edition of the American Heart Association journal Circulation
(July 25, 2005), found that aerobic fitness declines with
each passing year-3 to 6 percent per decade during our 20s and 30s increasing to
>20% every 10 years in the 70s and beyond-regardless of physical activity
habits. “I hope it is wrong,” my friend wrote.
Maybe not wrong. But overly pessimistic, at least for
those who continue to train at a competitive level. Here’s why.
The study determined exercise habits on the basis of
“self-reported leisure-time physical activity on the basis of the amount of
time spent performing 97 [unnamed] activities.” Apparently people who garden,
cut their own grass and take an occasional walk were lumped in with those who
continue to challenge their physical capacities on a regular basis.
As we reported in Age Factor article 26a, The
Competitive Edge, like most things in life, the results of exercise go
hand-in-hand with effort; the greater the effort the greater the reward. The
typical decline has little, if any, application to those who continue to train
at a competitive level. Many experts believe that almost all age-related decline
is due to a sedentary, unhealthy lifestyle. (See # 26a for details.)
At minimum, a 70-year-old competitive athlete will
have the strength and vitality of a “normal” 45-year-old.
The AP article
notwithstanding, the news on the benefits of exercise gets better all the time.
In a study published November 3, 1989 in the Journal
of the American Medical Association,
the research arm of the Cooper Clinic in Dallas, arguably the world leader in
preventive medicine, showed that people who exercise live longer.
The researchers followed 10,224 men and 3,120 women
who were given a preventive medical exam at the Cooper Clinic between 1970 and
1981, including a maximal treadmill test. After their exam, the men and women
were followed for an average of more than eight years. At the end of that time,
240 men and 43 women, all of whom were in good health when initially examined,
had died. The subjects were ranked based on their treadmill performance. The 20%
with the lowest treadmill times were classified as unfit; the top 20% were
classified as highly fit; and those in the middle were classified as moderately
fit. The results were striking.
The unfit men were 3.44 times as likely to die as the
highly fit men. The least fit women faired ever worse; they were 4.65 times more
likely to die than those in the best shape. Happily, the mortality rate of the
moderately fit men and women was also substantially less.
Clearly, fitness does affect aging. But there’s
more good news, especially for those interested in becoming highly fit.
A later study, published in The
New England Journal of Medicine on March 14, 2002, took another giant step, finding a direct connection
between fitness and mortality:
“A nearly linear reduction in mortality was observed as fitness levels
increased, and each increase of 1 MET in exercise capacity conferred a 12
percent improvement in survival,” Gary J. Balady, MD, wrote in an editorial
accompanying the report. As I related to my surgeon friend, fitness confers
powerful benefits.
Starting in 1987,
researchers from the Veterans Affairs Palo Alto Health Care System/Stanford
University studied 6,213 men (average age 59) referred for treadmill testing for
clinical reasons. They recorded the history and risk factors of each
participant. The subjects were then divided into those with documented
cardiovascular disease (3,679) and normal subjects (2,534). The exercise tests
consisted of walking on a treadmill for 8-12 minutes at gradually increasing
speed and incline to measure maximum exercise capacity. The subjects were then
followed for six years. Deaths during the study period were 1,256.
Peak exercise capacity
was measured in METS or metabolic equivalents. One MET is defined as the oxygen
uptake when a person is at rest. Two METS is oxygen uptake walking on a level
surface at less than 2 mph, five METS is oxygen uptake walking 4 mph, and eight
METS is the oxygen uptake running at six miles per hour.
The researchers found
that each 1-MET increase in exercise capacity resulted in a 12 % improvement in
survival. Participants whose exercise capacity was less than 5 MET were roughly
twice as likely to die as those with exercise capacity of more than 8 Met.
Absolute exercise
capacity measured in MET predicted risk of death better than percentage of age
predictions. What’s more - get this - in both healthy participants and those
with cardiovascular disease, peak exercise capacity was found to be a stronger
predictor of death than widely known risk factors such as hypertension,
diabetes, obesity, heart arrhythmia, high cholesterol, and even smoking.
In short, poor fitness
proved to be the deadliest risk factor of all.
"No matter how we
twisted it, exercise came out on top," lead author Jonathan Myers, a
professor of medicine at Stanford University, told the Washington Post.
And there’s more.
The Cooper Clinic led
the way in establishing the beneficial effect of cardio-respiratory fitness on
mortality. Now they’ve done the same with muscular fitness. In a study
published in the January 2004 issue of the Journal of Physical Activity
and Health, The Cooper Institute showed that individuals with moderate
and high levels of muscular fitness are at a lower risk for
mortality—regardless of cardio-respiratory fitness level.
The study involved
9,105 men and women, 20-82 years of age, who had completed at least one medical
examination at the Cooper Clinic in Dallas between 1981 and 1989. The exam
included a muscular assessment, based on sit-ups in one minute, one rep maximum
in the leg press and bench press, and a maximum treadmill test. A follow-up
through 1996 determined that 194 participants had died.
After adjusting for
age, health status, smoking, and cardio-respiratory fitness, the researchers
concluded that mortality rates were significantly lower for individuals with
moderate and high muscular fitness compared to those with low muscular fitness.
In addition, they found that those with high levels of strength had better
functional capacity and were healthier overall.
As always, the
researchers called for more studies to confirm their finding. Nevertheless, The
Cooper Institute UPDATE (summer 2005) reports that lead author Shannon
FitzGerald, PhD, believes that “resistance-training programs designed to
improve muscular fitness are important in order to lower the risk for death from
all causes.”
As we’ve seen,
numerous studies have demonstrated that exercise capacity is an independent
predictor of mortality. Normal fitness levels are well established for men of
all ages, but not for women. A report by Martha Gulati, MD, et al, published in The
New England Journal of Medicine (August 4, 2005), fills that gap by
developing normal values for women—and encourages doctors to wake up to the
prognostic power of fitness.
The Gulati et al study
involved 5,721 healthy women (without symptoms) and 4,471 with cardiovascular
symptoms. All of the women underwent a maximum stress test. Exercise capacity
was measured in metabolic equivalents (MET). Survival data was obtained for both
groups. Statistical analysis was used to estimate the mean MET achieved for body
mass and age. A nomogram (a graphic presentation) was then developed to estimate
the percentage of predicted exercise capacity achieved for all ages.
Using the nomogram and
survival data, the researchers found that the risk of death in both groups was
approximately twice as high for women whose exercise capacity was less than 85
percent of the age-predicted value as for those whose exercise capacity was at
least 85 percent of the predicted value.
Young women (under 55)
and older women (over 70) with poor exercise capacity had especially high
mortality rates. In all cases, extremely poor exercise capacity heralded
extremely poor outcome. The odds of women in very good physical condition living
to a ripe old age are far better than for women in very poor physical condition.
For both men and women
normal exercise capacity deceases with age. Interestingly, the difference in
predicted exercise capacity between men and women increases as age increases. In
other words, for reasons not explained, exercise capacity seems to decline at a
faster rate in women than in men.
Importantly, a
seemingly minor finding by Gulati et al was a major focus of an editorial in the
same issue on the clinical significance of the study. The
researchers classified women in the healthy group as sedentary or active on the
basis of their response to one question: Do you have a regular
(exercise) training program? “Although the validity of this question has
not been established,” Gulati and her colleagues wrote, “we have shown a
difference in achieved exercise capacity on the basis of activity status: the
more physically active women had a greater exercise capacity at all ages.
(Emphasis added.)
“Despite the
profoundly important prognostic information provided by simple clinical
assessment of fitness,” William E. Kraus, MD, and Pamela S. Douglas, MD, wrote
in the editorial, “ they are rarely used in the clinical setting and often
ignored in the exercise-testing laboratory. The article by Gulati et al
encourages us to rediscover the power of fitness.”
People who have visited
a doctor recently have probably been asked about their past and present smoking
habits. “Given the strong effect of fitness on the risk of death from
cardiovascular causes, and longevity, perhaps assessment of this variable should
also be made a routine component of all clinical assessments, by including a
simple question regarding exercise habits during each office visit,” Kraus and
Douglas wrote. “As has been learned from efforts to reduce smoking, unless
clinicians make it a regular practice to ask the relevant question and gather
data, they will fail to provide the consistent guidance and encouragement
essential to changing patients’ unhealthy lifestyle choices.”
“By confirming the
critical importance of fitness to health and longevity, [Gulati and his
colleagues] place a responsibility on clinicians to use this information for
their patients’ benefit,” the Journal editorial opines. “We
hope this report will provide a stimulus to reintroduce fitness assessments into
the routine clinical environment for both women and men.”
Amen!
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