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From The Desk Of Clarence Bass

"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, M.D., New England Journal of Medicine

Greater Fitness/Longer Life

Those of us who arenít satisfied with a moderate level of fitness can take heart from a study published March 14, 2002, in the New England Journal of Medicine. The researchers concluded that exercise capacity is perhaps the most powerful predictor of mortality. They found a direct relationship between greater fitness and longer survival.

Most previous studies have emphasized that the least fit have the most to gain from exercise, that the most striking reduction in mortality results when one becomes active and moves out of the poor fitness category. For example, as I related in The Lean Advantage 3, a study reported in 1989 by the Institute for Aerobic Fitness in Dallas highlighted that those in the high-fitness group were only slightly less likely to die than those in the medium-fitness groups. "Simply put, people who exercise even moderately tend to live longer," I wrote. Thatís still true, of course, but the new study shows that people benefit in proportion to their level of fitness.

As in other studies, the researchers found a "striking difference" in mortality rates between the least fit 25 percent and the next quintile of fitness. "This observation concurs with the consensus," the researchers wrote, "that the greatest health benefits are achieved by increasing physical activity among the least fit." They donít stress the desirability of becoming highly fit; they are more interested in persuading health professionals to put more effort into encouraging patients to exercise.

Emphasizing the benefits of being very fit, as shown by the study, is my idea. I believe itís appropriate, because the study also found "a nearly linear reduction in risk with increasing quintiles of fitness."

In my view, more people will continue exercising if they strive to be the best they can be.

As regular readers know, I believe the greatest satisfaction from exercise comes when we continually challenge ourselves to improve. Progress makes training a lot more fun and interesting; it motivates people to keep exercising.

See if you share my enthusiasm for the new study. Here are the details.

Issues and Study Design

According to the report, the majority of previous studies havenít clearly established whether exercise capacity predicts mortality equally well in patients with heart disease and normal people. The predictive power of exercise capacity in relation to other risk factors is also unclear. In addition, it hasnít been established whether absolute peak exercise capacity or percentage of age-predicted fitness is a stronger predictor of mortality risk. The purpose of the study was to clarify these issues.

Starting in 1987, researchers from the Veterans Affairs Palo Alto Health Care System/Stanford University studied 6213 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 (3679) and normal subjects (2534). The exercise test 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. During the study period, 1256 died.

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.

Exercise capacity based on percentage of age-predicted standards was also recorded.


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. Whatís more Ė 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.

Wake-up Call

A truly remarkable study, I think youíll agree. Exercise pays big dividends. Itís even more important than smoking in its impact on life span. Greater fitness means longer life. What could be a bigger dividend than that? Doctors who donít encourage their patients to exercise are missing the boat.

Gary J. Balady, M.D., summarized the message in the editorial which accompanied the report: "The data from the study compel the clinician to go beyond the identification of risk to the initiation of interventions, such as the prescription of increased physical activity and exercise, in order to modify risk, particularly in patients with low levels of fitness."

Yes, the fitter the better.

(My thanks to Paul Shipkin, M.D., for calling the study to my attention.)

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