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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)

Prestigious Medical Journal Highlights
 Predictive Power of Fitness

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.

Case for Exercise Grows Stronger

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.

Cooper Clinic Leads the Way on Fitness and Longevity

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.

Muscular Fitness and Mortality

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.”

New Study Encourages Routine Exercise History

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.”


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