Category Archives: exercise

Which Exercise Is Best For Heart Health: Swimming or Walking?

Reader Pat asked the skeptical cardiologist the following question:

Which would be the better heart healthy choice? Walking briskly 3 x week or swimming for 45 minutes 2-3 x a week?

Swimming is an attractive alternative to walking or running for many of my patients with arthritis because it is a lot easier on the load-bearing joints of the lower extremities.

To my surprise there is at least one study (from Australia) comparing swimming and walking that was published in the journal Metabolism in 2010.

The investigators randomly assigned 116 sedentary women aged 50-70 years to swimming or walking. Participants completed 3 sessions per week of moderate-intensity exercise under supervision for 6 months then unsupervised for 6 months.

Compared with walking, swimming improved body weight, body fat distribution and insulin resistance in the short term (6 months).

At 12 months swimmers had lost 1.1 kg more than walkers and had lower bad cholesterol levels.

It should be noted that these differences barely reached significance .

Types of Activities And The Intensity of Exercise

My general recommendations on exercise (see here) give examples of different aerobic physical activities and intensities.

These activities are considered Moderate Intensity

  • Walking briskly (3 miles per hour or faster, but not race-walking)
  • Water aerobics
  • Bicycling slower than 10 miles per hour
  • Tennis (doubles)
  • Ballroom dancing
  • General gardening Vigorous Intensity

These types of exercise are considered Vigorous Exercise

  • Racewalking, jogging, or running
  • Swimming laps
  • Tennis (singles)
  • Aerobic dancing
  • Bicycling 10 miles per hour or faster
  • Jumping rope
  • Heavy gardening (continuous digging or hoeing, with heart rate increases)
  • Hiking uphill or with a heavy backpack

As a rule of thumb, consider 1 minute of vigorous exercise equivalent to 2 minutes of moderate exercise and shoot for 150 minutes per week of moderate exercise or 75 minutes of vigorous exercise.

Of course one can swim laps at peak intensity or at a very slow, leisurely pace so swimming laps doesn’t always qualify as “vigorous” exercise. Likewise one can play singles tennis languorously and be at a moderate or lower intensity of exercise.

It is entirely possible that the swimmers were working at a higher intensity during their sessions than the walkers and that could be the explanation for the differences seen between the two groups.

Ultimately, the best type of  exercise for heart health is the one you can do and  (hopefully) enjoy on a regular basis.

Antilanguorously Yours,

-ACP

N.B. Speaking of swimming. A year ago I wrote about longevity and featured Eugene, a 98 year old who could swim the length of a swimming pool underwater. Eugene turns 100 in 2 days.

Mitigating Sarcopenia In The Elderly: Resistance Training Is A Powerful Potion

While researching afib-detection apps recently, the skeptical cardiologist stumbled across an article with the title “Resistance training – an underutilized drug available in everybody’s medicine cabinet”

This brief post from the British Journal of Sports Medicine blog nicely presents the rationale for using strength training to improve the overall health of the elderly. I have reblogged it below.

Americans spend billions on useless supplements and vitamins in their search for better health but exercise is a superior drug, being free  and without drug-related side effects

I’ve spent a lot of time on this blog emphasizing the importance of aerobic exercise for cardiovascular health but I also am a believer in strength and flexibility training for overall health and longevity.

As we age we suffer more and more from sarcopenia-a gradual decrease in muscle mass.

Scientific reviews note that loss of muscle mass and muscle strengh is quite common in individuals over age 65 and is associated with increased dependence, frailty and mortality

Specific information on progressive resistance training for the elderly is sparse but I found this amusing and helpful video on a Canadian site that provides some guidance for beginners.

 

And below is the referenced blog post:

Resistance training – an underutilised drug available in everybody’s medicine cabinet

By Dr Yorgi Mavros @dryorgimavros

As we get older we begin to lose muscle mass, approximately 1% every year. But more importantly, the decline in muscle strength declines at a rate 3-times greater [1]. The consequences of this decline in strength are significant, with lower muscle strength being associated with an increased risk dementia[2], needing care, and mortality[3]. But should we accept this as our fate, or is there anything we can do prevent, reverse or at least slow this age-related decline?

In 1990, a type of exercise called progressive resistance training, commonly known as strength training, was introduced to 9 nonagenerians living in a nursing home, specifically to treat the loss of muscle mass and strength, and the functional consequences of disability [4]. After just 8 weeks, these older adults saw average strength gains of 174%, with 2 individuals no longer needing a cane to walk. In addition, one out of the three individuals who could not stand from a chair, was now able to stand up independently. Just take a moment to think about the results of that study. If I told you there was a medicine that you or a loved one could take, and it could make either of you strong enough to now get out of a chair, would you take it?

What if you or a loved one had a hip fracture, and I told you that same medicine could help reduce the risk of mortality by 81%, and the risk of going in to a nursing home by 84%, as was shown in this study [5]. Currently, the only way to take this medicine is by lifting weights, or pushing against resistance.

A recent study from Britain, [6] showed an association between adults who participated in 2 days per week of strength training and a 20% reduction in mortality from any cause, and a 43% reduction in cancer mortality. Data from the Women’s Health Study in the US published at a similar time were very similar, with women reporting up to 145 minutes per week of strength training having a 19-27% reduced risk of mortality  from any cause [7].

So where does the benefit of strength training come from? First and foremost, it is anabolic in nature (meaning that it can stimulate muscle growth) making it the only type of exercise that can address the age-associated decline in muscle mass and strength. Within our laboratory at the University of Sydney, we have shown that we can use this type of exercise to improve cognitive function in adults who have subjective complaints about their memory [8]. What’s important though, is that there was a direct relationship between strength gains and improvements in cognition, and so maximizing strength gains should be a key focus if you want to maximize your benefit [9]. This type of exercise has even been taken into hospitals and used in adults with kidney failure undergoing haemodialysis, where it was shown to reduce inflammation, and improve muscle strength and body composition [10].

Other laboratories around the world have also used strength training to increase bone strength in postmenopausal women [11], help manage blood sugar levels in adults with type 2 diabetes [12], as well as to counteract the catabolic side effects of androgen-deprivation therapy for men with prostate cancer [13]. Not to mention its benefits to sleep [14], depression  [15] and recovery from a heart attack  [16].

So it is no surprise to see that the  Australian [17] and UK [18] public health guidelines for physical activity recommend we take part in activities such as strength training 2-to-3 days per week. Unfortunately however, these recommendations lack detail and guidance on intensity and frequency.

A key theme in all the randomized controlled studies discussed above, is that not only were exercises performed at least 2 days per week, but they were fully supervised, used machine and/or free weights, and were done at a high intensity, which is commonly set to 80% of an individual’s peak strength. It is for this reason I like to focus on the guidelines put forward by The American College of Sports Medicine (ACSM) [19]. The ACSM advises that everyone, including older adults do at least 2 days of progressive resistance training, which is to be performed at a moderate (5 – 6) to high/hard (7 – 8) intensity on a scale of 0 to 10, involving the major muscle groups of the body. So if you are looking to maximise the benefit from your time in the gym, or looking to make a positive change to your lifestyle, remember that there is medicine you can take; Try lifting some weights or doing other forms of strength training, 3 days a week, and importantly, make sure it feels moderate to hard. Not only will it add years to your life, but life to your years.


Since college I have regularly done weight training 3 times per week As I get  dangerously close to age 65 and joining the ranks of the “elderly” I have ramped up the intensity of my workouts, working hard to forestall the sarcopenia that will ultimately be my fate.

Antisarcopenically Yours,

-ACP

***************************

Video credit: Produced for the University of British Columbia’s (UBC) Department of Physical Therapy, the Aging, Mobility, and Cognitive Neuroscience Laboratory, the Centre for Hip Health and Mobility and the Brain Research Centre at Vancouver Coastal Health and UBC
hiphealth.ca/news/preventing-dementia

 

What Should Your Maximal Exercise Heart Rate Be?: The Importance Of Using The Right Age-Predicted HRmax Formula

A reader who runs 5Ks posted a question recently which indicated concern that his heart rate during intense exercise was much higher than his age-predicted heart rate.  He writes

I’m 65, exhaustion HRmax is 188, HRave for 5k is usually 152-154 and interval HRmax is usually 175-179 depending on how hard I push”

He wondered if he should be concerned about being a “high-beater.”

This prompted the skeptical cardiologist to examine the literature on age-predicted maximal heart rate which led to the shocking discovery that the wrong formula is being utilized by most exercise trainers and hospitals.

First , some background.

The peak heart rate achieved with maximal exertion or HRmax has long been known to decline with aging for reasons that are unclear.

The HR achieved with exercise divided by the HRmax x 100 (percentage HRmax) is widely used in clinical medicine and physiology as a basis for prescribing exercise intensity in cardiac rehab programs, disease prevention programs and fitness clinics.

During stress tests we seek to have patients exercise at least until  their heart rate gets to at 85% of HRmax.

The Traditional Formula For HRmax

The formula that is widely used for HRmax is

HRmax = 220-age

It appears to have originated from flawed studies in the early 1970s. These studies included subjects with cardiovascular disease, smokers and patients on cardiac medications.

The Improved HRmax Formula

Tanaka, et al in 2001 performed a meta-analysis of previous data on HRmax along with accumulating data in their own lab. This was the first study to examine healthy, unmedicated, nonsmokers. In addition each subject achieved a verified maximal level of effort as documented by metabolic stress testing.

Their analysis obtained the regression equation (which I term the Tanaka equation)

HRmax = 208-(0.7 x age) 

Below is the graph of the laboratory measurements from which the regression equation was obtained.

Relation between maximal heart rate (HRmax) and age obtained from the prospective, laboratory-based study.(Tanaka, et al)

This graph shows how  inaccurate the traditional equation is, especially in older  individuals like my reader:

Regression lines depicting the relation between maximal heart rate (HRmax) and age obtained from the results derived from our equation (208 − 0.7 × age) (solid linewith 95% confidence interval), as compared with the results derived from the traditional 220 − age equation (dashed line). Maximal heart rates predicted by traditional and current equations, as well as the differences between the two equations, are shown in the table format at the top.(from Tanaka, et al)

The traditional equation in comparison to the Tanaka equation  overestimates HRmaxin young adults, intersects with the present equation at age 40 years and then increasingly underestimates HRmaxwith further increases in age. For example, at age 70 years, the difference between the two equations is ∼10 beats/min. Considering the wide range of individual subject values around the regression line for HRmax(SD ∼10 beats/min), the underestimation of HRmaxcould be >20 beats/min for some older adults.

There are likely lots of perfectly healthy individuals in their sixties and seventies then who have heart rates at maximal exertion that exceed by 10 to 20 beats per minute the HR max predicted by the traditional formula.

This is due to a combination of the inaccuracy of the traditional formula and the wide variation in normal HR max at any given age (standard deviation (SD) of approximately 10 beats/min.)

Thus, my reader at age 65 would have a HRmax predicted by the Tanaka equation as

208-0.7 x 65=162

If we allow for a 10 BPM range of normality above and below 162 BPM we reach 172 BPM which gets close to  but doesn’t reach the reader’s 188 BPM.

If you examine the scatterplot of the Tanaka data you can see that several of the points for age 65 reach into the 180s so chances are my reader is still within normal limits

The Bottom Line on HRmax

The widely used traditional formula for predicting HR max is inaccurate.

Athletes, trainers, physicians and hospitals should switch to using the superior Tanaka HR max formula.

Individuals should keep in mind that there is a wide range of HR response to exercise in normals and variations of 10 BPM above and below the predicted response are common and of no concern.

Chronotropically Yours

-ACP

Addendum. The 220-age formula is so heavily etched into my brain that I used 220 instead of 208 when I initially calculated the predicted max HR for my reader. this has been corrected.Thanks to Chris Sivewright for pointing this out.

Exercise As Medicine: Preventing Age-Related Decline in Cardiac Stiffness

As we age our hearts and arteries become stiffer. This cardiovascular stiffening plays a key role in hypertension, atrial fibrillation, and heart failure in older individuals (1).

Age-related cardiac stiffening is worse in those who are sedentary compared to those who exercise regularly (2).

Recent studies strongly suggest that regular exercise can prevent or minimize these age-related changes, thereby hopefully reducing the high rate of heart failure, hypertension and atrial fibrillation in the elderly.

In my post on fitness as a vital sign I briefly mentioned a fascinating study from 2014 which looked at 102 healthy seniors (age>64 years) and stratified them into 1 of 4 groups based on their lifelong histories of endurance exercise training.

Consider which of these 4 categories you fall into:

Sedentary subject-exercised no more than once per week during the prior 25 years.

Casual exercisers-engaged in 2-3 sessions per week

Committed exercisers-performed 4-5 sessions per week

Competitive “Masters level” athletes-trained 6-7 times per week

Exercise sessions were defined as periods of “dynamic activity lasting at least 30 minutes.”

The participants had sophisticated measures of their exercise capacity (max VO2), the size and mass of their left ventricles (cardiac MRI) and the stiffness of their left ventricles (invasive pressure/volume curves to calculate LV compliance and distensibility.)

This graph shows the key finding of the study: a markedly different pressure/volume curve in the sedentary and casual exercisers (blue and red dots) versus the committed or master exercisers. The two curves on the left correspond to a very stiff heart, similar to curves found in patients with heart failure.

The far right curve of competitive exercisers resembles that of a young heart.

The black triangle curve of the committed exerciser is in between these extremes

F5.large-3

The study concludes:

“low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes”

It would appear we need at least 4-5 30 minute exercise session per week to forestall the age-related stiffening of the heart and lower our chances of getting heart failure, hypertension and atrial fibrillation.

Since this was an observational study there is always a chance that lack of exercise is not the causes of poor cardiac stiffness.  It is conceivable that those of us with stiffer hearts tend to be more sedentary because of the poor cardiac function.

Can You Reverse The Age-Related Changes In Cardiac Stiffness?

If you have already reached middle age there is still hope for you as these same investigators recently published a study showing that cardiac stiffness can be improved with exercise. These findings imply that lack of exercise is the cause of worsening cardiac stiffness with aging.

This study identified 61 sedentary men in their mid-fifties and randomly assigned them to either 2 years of exercise training or attention control (a combination of yoga, balance, and strength training 3 times per week for 2 years) and measured their LV stiffness and max VO2 before and after intervention.

Max VO2 increased by 18% and LV stiffness declined from .072 to .051 in the exercise group but did not change in the control group.

The exercise training arm of this study involved a mixture of continuous moderate-intensity aerobic exercise combined with high intensity training. The high intensity portion of the program involved exercising at 90-95% of HR maximum for 4 minutes followed by a 3 minute active recovery period, repeated 4 times.

Over a period of 6 months under the guidance of exercise physiologists the participants had their exercise levels gradually increased. After 6 months they were training 5-6 hours per week, including 2 of the “high intensity interval” session and 1 long (>/= 1 hour) and one 30-minute base pace session each week.

By the sixth month, participants were training 5 to 6 hours per week, including 2 interval sessions, and 1 long (at least an hour) and one 30-minute base pace session each week.

How Much Exercise Do We Need To Minimize Cardiac Aging?

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

 

screen-shot-2016-10-01-at-10-18-34-am

 

 

 

 

 

These guidelines suggest that if you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires at least  150 minutes/week.

Based on these recent studies on exercise and cardiac stiffness and the bulk of scientific literature on the overall health benefits of exercise I would advise for all individuals with or without heart disease

-If you are sedentary, become a committed exerciser.

-Committed exercise means some form of dynamic exercise 4-5 times per week

-If you are already a committed exerciser at moderate intensity levels consider adding to your routine one or two sessions of high intensity interval exercise.

-High intensity exercise will require you to get your heart rate up to 90-95% of your maximum 

-Predicted maximal HR=220 -age.  For a 60 year old this equals 160 BPM. 90% of 160 equals 144 BPM. 

Compliantly Yours,

-ACP

 

 

 

 

Urban Cycling, Part 2: Hit and Run Drivers and Bike Helmets

A doctor colleague of the skeptical cardiologist was riding his bike on a quiet road here in St. Louis recently when he suddenly awoke in a hospital bed. His friend who was riding in front of him heard a crash, turned and saw a black car making a U-turn and speeding off. Fortunately, the good doctor, suffered only the concussion and multiple bruised ribs and will live to ride again

He is in his seventies and I asked him if he would, indeed, climb onto the saddle of a two-wheeled vehicle in the future and he indicated yes, but never again on roads shared with cars.

I also inquired as to the state of his bike helmet post-trauma: it was shattered into multiple pieces.

In a previous post I pondered the question: Does cycling to work make you more or less likely to die?

cycling to work for many individuals would provide the daily physical activity that is recommended for cardiovascular benefits. However, cycling in general, and urban cycling in particular, carries a significant risk of trauma and death from accidents and possibly greater exposure to urban pollutants.

In the Netherlands cycling to work likely makes you less likely to die.

One study quantified the impact on all-cause mortality if 500,000  people made a  transition from car to bicycle for short trips on a daily basis in the Netherlands and concluded

For individuals who shift from car to bicycle, we estimated that beneficial effects of increased physical activity are substantially larger (3–14 months gained) than the potential mortality effect of increased inhaled air pollution doses (0.8–40 days lost) and the increase in traffic accidents (5–9 days lost). Societal benefits are even larger because of a modest reduction in air pollution and greenhouse gas emissions and traffic accidents.

In St. Louis, however, I suspect my longevity would be substantially reduced by cycling the 15 miles of heavily trafficked roads from University City to St. Lukes Hospital in Chesterfield. I would be cheek to jowl with SUVs, pick-up trucks, and mini-vans full of distracted, texting and chatting commuters.

Should  Bike Helmets Be Mandated?

Like most people I know, my colleague wears a bike helmet religiously when cycling. He, like many who have shared their bike accident stories with me, believes the bike helmet saved his life. I certainly can’t refute that possibility but it is impossible to know with certainty.

I’ve posted my analysis of the wisdom of mandating bike helmets here and even after hearing the good doctor’s story,  I still refuse to wear one.

Typical skeptical cardiologist bike riding garb. No helmet but safari (not bee-keeper) hat because sun is not his facial friend.

A commonly cited statistic is that bike helmets reduce serious head injuries by 85% and brain injuries by 88%.  This comes from an observational  study  published in 1989 which has serious limitations and has never been reproduced. For an exhaustive critique of these data see here.

I think a fair summary is in this British Medical Journal editorial which is behind a paywall but can be reviewed as a PDF here (bmj-june-2013.pdfbicycle helmets and the law).

 

Larry Husten, a journalist, who writes an excellent cardiology blog at cardiobrief.org apparently agrees with me and has recently written about “The Unintended Consequences of Bike Helmets.”

I encourage everyone to read his post which can be found here.

Here is his main point:

I am opposed to public health campaigns that focus on helmets, thereby implanting in people’s minds the dangers of cycling. Instead, in my view, the public health agenda regarding cycling should be to promote the far greater health benefits of cycling. The overarching goal of any public health campaign should be to dramatically increase cycling in the US, thereby encouraging physical activity and helping to reduce obesity and diabetes.  In tiny Denmark, by way of example, one expert, Lars Bo Andersen, PhD, of Western Copenhagen University of Applied Sciences, reports that “26 persons were killed in the whole country in cycle accidents last year, but more than 6000 deaths were avoided due to the huge amount of physical activity this behavior is a result of.”

Circuitously Yours,

-ACP

Speaking of Holland, the skeptical cardiologist will be visiting this hotbed of cycling, tulips and dikes in July.

I’ll be staying in Haarlem but wandering around the country researching cycling, assisted suicide and the Dutch dairy industry which may be responsible for the Dutch having gone from being among the shortest people in Europe to being the tallest in the world.

Nonskeptical Musical Thoughts On Dick Dale and the Dead While Running For Longevity

Since determining that running would lower my cardiovascular risk and that it was actually good for my wonky knees (running is associated with a lower risk of ostearthritis or hip replacement, see here), I’ve been trying to do it regularly.

It has become therapeutic in many ways, aiding sleep and reducing stress levels. And, unlike my bike riding adventures, I have yet to fall and injure myself running and I don’t get dirty looks for not wearing a helmet.

I’ve even contemplated running 5 kilometers,  although not as part of any formal exhibition: just a personal , private goal. To this end I have for the first time recently run 4 kilometers.

Listening to music during these longer runs greatly helps the time pass and sometimes I am able to find songs which fit my running cadence, albeit not through any systematic analysis but through mere serendipity. I let my entire musical collection (nicely streamed by Apple music) be my running playlist and this ranges from the Talking Heads to Thelonius Monk to Bach.

This morning’s run (the second time I reached 4K) I was aided by two songs: one by the king of surf guitar, the other by the kings of psychedelic jam rock.

Dick Dale and Miserlou

Although, Dick Dale was huge in the early sixties, he did not register on my musical radar until  I watched Pulp Fiction and in its dazzling opening scene and  was jolted by Dale’s staccato machine gun guitar riffs alternating with his plaintive trumpet solo on  “Miserlou“.

I immediately strapped on my Strat and began trying to emulate his unique playing style.

Here’s Dick and the Del-Tones performing their version for the movie “A Swinging’ Affair”

This version contains none of the rhythmic power and electrifying guitar attack of the single and the band appears to be on tranquilizers. To make matters worse, Dick  doesn’t play that magical melodic moaning trumpet solo which contrasts so brilliantly with the pile-driving reverb-drenched guitar riffs on the original version.

You can see some of the power of the left-handed Dale in this live performance of Miserlou from 1995 but alas, no trumpet solo.

Dick Dale, remarkably, is still touring and playing well at age 80.

As fortune would have it the beats per
minute of this song is 173 which fits my preferred running speed stride cadence perfectly.

The Other One (Not Cryptical Envelopment)

The next song to aid me on my run was a live performance from the Grateful Dead’s 1972 European Tour  which is 36 minutes long.

I was slow to revere the Dead but when I first listened to their live album Europe ’72 I was hooked. Instead of studying in college, I spent way too many hours playing Sugar Magnolia (and Blue Sky, et al..)  thereafter.

The Other One highlights their free and wild improvisational style. While running I could focus on what Keith Godchaux was doing on the piano and that takes me to a psychic place in which I feel no pain.

Please excuse my hubris but I am convinced that I could have done a good job as the Dead keyboardist.  It’s probably a good thing I never got that gig, however, as it carries a very high mortality rate (not to mention that I’m a much better cardiologist than keyboardist.)

As Billboard pointed out in its obituary on the last keyboardist, Vince Welnick (who committed suicide by slitting his throat at age 55 in 2006):

Welnick was the last in a long line of Grateful Dead keyboardists, several of whom died prematurely, leading some of the group’s fans to conclude that the position came with a curse.

Welnick had replaced Brent Mydland, who died of a drug overdose in 1990. Mydland succeeded Keith Godchaux, who died in a car crash shortly after leaving the band. And Godchaux had replaced the band’s original keyboard player, Ron “Pigpen” McKernan, who died at 27 in 1973.

Last week a very good Grateful Dead documentary (Long Strange Trip) was released on Netflix. I’ve been somewhat mesmerized by what I’ve watched so far.  For example, at one point, Phil Lesh reveals that Jerry Garcia asked him to join the band as their bassist even though he had never played the instrument. (If only he had asked me!)

Strangetrippingly Yours

-ACP

N.B. Miserlou is a very old folk song with a scale that sounds exotic to Western ears: the double harmonic scale

per Wikipedia

The song’s oriental melody has been so popular for so long that many people, from Morocco to Iraq, claim it to be a folk song from their own country. In fact, in the realm of Middle Eastern music, the song is a very simplistic one, since it is little more than going up and down the Hijaz Kar or double harmonic scale (E-F-G#-A-B-C-D#). It still remains a well known Greek, Klezmer, and Arab folk song.

 

 

 

Longevity: Lifespan, Healthspan and Swimming Underwater At Age 98

img_7056
Eugene and Naomi.

The skeptical cardiologist has a few nonagenarian patients who seemingly defy the ravages of aging and remain vibrant and active into their late 90’s.

Eugene, for example, still ballroom
dances regularly with his wife, Naomi and swims underwater significant distances.

In this video, recorded when he was 97, you can see him swim the length of a swimming pool underwater

As life expectancy at birth has increased  from 35 years in 1900 to over 80 years now, we see more and more individuals reaching their nineties. Ongoing research seeks to further extend our lifespan.

But just as important as increasing lifespan is increasing healthspan, the portion of the life span during which function is sufficient to maintain autonomy, control, independence, productivity and well-being.

Eugene is an example of someone with a long lifespan and healthspan and this is what we truly seek, the combination of living well and living long.

Peter Attila writes that lifespan is driven by how long one can avoid the onset of diseases caused by atherosclerosis such heart attacks and strokes (see my  discussions on subclinical atherosclerosis here), cancer and neurodegenerative disease.

Healthspan,  Attila writes, is about preserving three elements of life as long as possible:

  1. Brain—namely, how long can you preserve cognition and executive function

  2. Body—specifically, how long can you maintain muscle mass, functional strength, flexibility, and freedom from pain

  3. “Spirit”—how robust is your social support network and your sense of purpose.

Problems with the body result in frailty, recognized as a major cause of disability and related falls, hospitalizations and death in the elderly.

The single best tool for warding off frailty appears to be physical exercise.

img_7051
Eugene and Noami tripping the light fantastic in our exam room

So, if you want to life a long life with lots of quality years at the
end of that life be like Eugene: swim and dance with your loved ones. Keep moving, stretch and exercise in some manner regularly.

Gerontologically Yours,

-ACP

Should Fitness Be A Vital Sign?

The skeptical cardiologist routinely probes his patients’ activity and exercise levels and encourages them to engage in 150 minutes of moderate exercise weekly. However, I’m somewhat skeptical of the benefit of treating such assessments as a vital sign (like blood pressure or heart rate)  as a recent AHA scientific statement suggests.

I can only envision still another item  on a chart checklist that will have to be recorded in the EHR or already over-worked physicians will have their payments withheld.

The AHA statement suggests that ideally we should be measuring  our patients’ fitness by obtaining  maximal oxygen consumption (VO2 max) utilizing an expensive and rarely utilized cardiopulmonary exercise test. Failing that we should consider doing a treadmill stress test. Failing that, rather than utilizing my simple question to patients: “How active have you been?”,  the statement recommends doctors utilize some sort of formal questionnaire to estimate their patients’ cardiorespiratory fitness (CRF) such as the one at World Fitness Level.

I went online to take this CRF estimator (based on this paper) and I remain skeptical.

The online site and  a free smartphone app both ask the following questions:

  • Country and City
  • Ethnicity
  • Highest Level of Education
  • Gender/Age/Height/Weight
  • Resting and Maximal Pulse
  • How often do you exercise?
  • How long is your workout each time? (over/under 30 minutes)
  • How hard do you train? (I had to choose between “I go all out”or “Little hard breathing and sweating”)

 

screen-shot-2016-12-03-at-11-33-13-amWhen you have finished answering the questions you are given an estimate of your fitness age. When I did this online a few days ago and answered truthfully I got the result to the right: I had the fitness of a 41 year old with an estimated VO2 max of 49 ! (interestingly this estimate corresponds exactly with VO2 max derived from a recent stress test I completed.)

I used the app (which unlike the online version did not ask me my waistline measurement) and changed a few parameters:

  • I increased my resting heart rate or pulse  from 60 to 68 beats per minute (BPM)
  • I increased my maximal heart rate from what I know is 158 BPM to what the app calculated (173 BPM, which makes no sense)
  • I switched from exercising 2-3 times per week  and longer than 30 minutes  at “all out” level to the lowest level for all 3 questions.

The change was dramatic and depressing: I went from 39 years old to 67 years old in the bat of an eyelid!img_8073

 

 

 

The app and online site direct you to a non-profit site where you can get information on a 7 week program to increase your fitness level. I haven’t checked this out.

I’ll be trying out this CRF estimator on my patients: assessing whether it adds anything to my usual line of questioning on activity and fitness.

I encourage you to give the CRF estimator a try. Let me know in the comments how you feel it works for you. Does it motivate you to exercise more knowing that, for example, your fitness age is substantially higher than your chronological age?

Running For Longevity: From A-Punk to Aba Daba Honeymoon

About two years ago I wrote about a study that found that any amount of leisure-time running was associated with a lower risk of cardiovascular disease which  made me reconsider my usual advice to patients on exercise:

As part of a prospective longitudinal cohort study at the Cooper Clinic in Dallas, Texas, Lee, et al. looked at data from a group of 55,137 adults on whom they had information on running or jogging activity during the previous 3 months.
Those individuals who described themselves as having done any running in the last 3 months had a 30% lower risk of all-cause mortality and a 45% lower cardiovascular mortality.

Amazingly, it didn’t matter how much you ran.

Those who ran <51 minutes per week did just as well as those who ran >176 minutes per week.

At the time I felt the study was not definitive, but food for thought. Evidently, it got me thinking so much that I began running regularly (despite my previous dislike of running).

Music and the Tempo of Running

During my runs I listen to music on my iPhone, either through Apple Music or songs that I have purchased.

Today, after deciding Leonard Cohen’s Live in Dublin (although awesome, and one of the best live albums I’ve ever heard) was not motivating enough, I hit the first song on my iPhone: A-punk by Vampire Weekend.

A-Punk is one of my favorite songs released in the last decade. It’s very upbeat.. perfect for a running accompaniment. The opening guitar riff is simple, fast and catchy. It’s simple enough that I can play it on guitar but, so fast that my fingers fatigue quickly.  The bridge portion features a wonderfully fast and complicated bass line with punchy drums and an overlying synth flute melody. You can watch a video of it here:

As I ran I realized that the tempo of A-Punk was perfectly suited to my preferred running speed of 6.1 MPH. You’re probably wondering what the tempo of A-Punk is. It’s likely that the only time song tempo comes up in general conversation is when talking about CPR and the need to compress the sternum at 100 beats per minute, the alleged tempo of The Bee Gees Stayin’ Alive (it’s actually 104 BPM.)

A-Punk’s tempo turned out to be 175 BPM. If you are not inclined to count the actual beats in a minute to determine the tempo of a song, you can enter the song into this site to get the number or download a smart phone app for the purpose.

Oddly enough, the next song on my alphabetical listing of songs, Hoagy Carmichael’s version of Aba Daba Honeymoon, also had a screen-shot-2016-10-02-at-8-45-44-amtempo (174 BPM) perfectly suited to my running speed. (The song after that was my old band Whistling Cadaver attempting to play the medley at the end of Abbey Road at our 30 year high school reunion in 2002-not good for running to, but immensely entertaining).

Monetizing Music For Running

Having observed that the tempo of certain songs matched perfectly to my running tempo, I wondered if there were any advantages to selecting such songs. Would I run faster or longer or with less discomfort or less injuries?

The web site run2rhythm would certainly like me to believe that screen-shot-2016-10-02-at-9-45-42-amrunning to the right tempo song will improve my performance. This site claims that “the wrong musical playlists can be detrimental to your training as they will not provide any synchronization between the body, the music and the mind. The body is almost always out of sync with the music.”

screen-shot-2016-10-02-at-9-03-39-amRun2rhythm provides a chart of the BPM that corresponds to different running speeds and sells playlists starting at $3.99 corresponding to specific tempos. These are playlists by unknown artists created for run2rhythm and the samples were not inspiring to me.

Here’s an example:screen-shot-2016-10-02-at-9-05-39-am

 

 

Is Music a Legal Drug For Athletes?

It turns out that there is a body of scientific literature related to music and exercise, and the vast majority of it seems to come from one man,  Dr Costas Karageorghis at Brunel University in London, an expert on the effects of music on exercise.  In his 2010 book, Inside Sport Psychology, he claims that listening to music while running can boost performance by up to 15%.

In media articles on the topic he is often quoted as saying “Music is a legal drug for athletes.”

However, in a 2012 review article he is more circumspect, concluding:

Music is now rarely viewed in a manner akin to the ‘vitamin model’ described by Sloboda (2008) wherein one can ascribe immutable effects to a specific musical selection for all listeners and at all times. The beneficial consequences of music use stem from an interaction between elements of the musical stimulus itself and factors relating to the traits and experiences of the listener, and aspects of the exercise environment and task. In particular, the role of music is dependent on when it is introduced in relation to the task and the intensity of the exercise undertaken. In closing, the evidence presented in this review demonstrates that music has a consistent and measurable effect on the psychological state and behaviour of exercise participants

Creating Your Own Tempo Playlist

The research on music and exercise suggests that songs with inspirational themes (apparently, “Gonna Fly Now,” the Rocky theme, is the most popular workout song of all time) are more effective performance enhancers. Also, self-selection of songs works better.

For me, running while listening allows me to focus on nuances of instrumentation, timing  and lyrics that otherwise I would not pay attention to. It is essential, then, to have songs that are worthy of such close listening.

I wondered if anyone has compiled lists of songs of a certain BPM that were originals and good songs.  Sure enough, the folks at jog.fm have exactly such a function.  My search for songs with tempo of 175 BPM yielded A-Punk and hundreds of other songs, screen-shot-2016-10-02-at-10-10-58-amincluding some I like (thumbs down for Footloose and Wonderwall (which is really 1/2 of 175 BPM or  88 BPM), thumbs up for Dancing With Myself).

You will note that my preferred tempo of 175 BPM corresponds to a much faster running speed than my preferred 6.1 MPH. This may have to do with my short legs or my running style. It makes sense to count the number of steps you take per minute at your optimal speed rather than rely on charts or averages.

Achieving the Right Dose of Exercise

Whatever you listen to while running, walking, cycling or hopping, hopefully it will assist you to achieve the dose of exercise per week that results in improved cardiovascular outcomes.

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

screen-shot-2016-10-01-at-10-18-34-am
If you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires 150 minutes/week.

As a result of switching to running, I’ve cut down my total exercise time per week by half leaving me more time to create music!

Readers – feel free to share your favorite workout songs and let me know what tempo works best for you.

Synchronously Yours,

-ACP

Yikes! This is a silly video. I’m not sure I can run to the song anymore.

 

 

Walking To Público: Leeks and Life Extension

Last weekend the skeptical cardiologist and his Eternal Fiancee’ walked to Público, a restaurant in the Delmar loop that was recently named the best new restaurant in St. Louis by Sauce magazine.

Walking (instead of driving) to restaurants is a great way for us to get aerobic exercise into our hectic days, which we know makes us feel better and which may also be improving the quality and quantity of our years.

A presentation at the 2015 European Society of Cardiology meetings which was widely picked up by various media outlets with the headline “25 Minutes Of Daily Walking Adds 7 Years To Your Life”  touches on this.

The author of that study, a British cardiologist, was quoted as saying:

‘Exercise buys you three to seven additional years of life. It is an anti-depressant, it improves cognitive function and there is now evidence that it may retard the onset of dementia.’

and

“we may never avoid becoming completely old, but we may delay the time we become old. We may look younger when we’re 70 and may live into our 90s.

Health Benefits of Neighborhood Walkability 

We moved to University City from the western suburbs of St. Louis for, among many reasons, the opportunity to do more walking around our neighborhood for errands, recreation, dining out and entertainment.

Researchers have studied how such factors can influence lifestyle.

A study in Ghent, Belgium investigated whether neighborhood walkability (higher residential density, land use mix, street connectivity) was positively associated with physical activity in Belgian adults.

Twenty-four neighborhoods were selected, stratified on GIS-based walkability and neighborhood SES. In total, 1200 adults (aged 20-65 years; 50 per neighborhood) completed the International Physical Activity Questionnaire and wore an accelerometer for seven days.
Living in a high-walkable neighborhood was associated with more accelerometer-based minutes of moderate-to-vigorous physical activity (38.6 vs. 31.8 min/day, p<0.001), transportational walking and cycling, recreational walking, and less motorized transport (all p<0.05).

This study confirmed previous similar studies in Australia and the United States, demonstrating that the design of your neighborhood strongly influences how much you drive a car versus walk.

Measuring Your Neighborhoods Walkability

Walkability has been defined as “the extent to which the built environment is walking friendly.”
Walkscore.com is a website (which my friend, and legendary New York City flaneur, David Alquist, made me aware of), which attempts to quantify walkability.
Enter your zip code or address and the site will use its patented methodology to give you a Walk Score for your neighborhood.
Walk Score measures the walkability of any address using a patented system. For each address, Walk Score analyzes hundreds of walking routes to nearby amenities. Points are awarded based on the distance to amenities in each category. Amenities within a 5 minute walk (.25 miles) are given maximum points. A decay function is used to give points to more distant amenities, with no points given after a 30 minute walk.
Walk Score also measures pedestrian friendliness by analyzing population density and road metrics such as block length and intersection density. Data sources include Google, Education.com, Open Street Map, the U.S. Census, Localeze, and places added by the Walk Score user community.
Walk Score® Description
90–100 Walker’s Paradise
Daily errands do not require a car.
70–89 Very Walkable
Most errands can be accomplished on foot.
50–69 Somewhat Walkable
Some errands can be accomplished on foot.
25–49 Car-Dependent
Most errands require a car.
0–24 Car-Dependent
Almost all errands require a car.
 Benefits Of High Walk Score Neighborhoods
According to Walk Score, there are numerous benefits of living in a high Walk Score neighborhood:
Health: The average resident of a walkable neighborhood weighs 6-10 pounds less than someone who lives in a sprawling neighborhood.1
Cities with good public transit and access to amenities promote happiness.2
Environment: 82% of CO2 emissions are from burning fossil fuels.3 Your feet are zero-pollution transportation machines.
Finances: Cars are the second largest household expense in the U.S.4 One point of Walk Score is worth up to $3,000 of value for your property.5Read the research report.
Communities: Studies show that for every 10 minutes a person spends in a daily car commute, time spent in community activities falls by 10%.6

Park Slope, New York City Versus University City

Screen Shot 2016-01-17 at 7.57.47 AM Screen Shot 2016-01-17 at 7.56.48 AMDespite my perception that our new neighborhood allows us much more opportunity to engage in pleasant walking for recreation and transportation, the Walk Score for our zip code is only 54, putting us in the somewhat walkable category.

David’s neighborhood of Park Slope, on the other hand, has a score of 97, one of the best places in the world for walkability.

Obviously, the Walk Score is not a perfect measure of true walkability but it’s a start at looking at the issue.

Publico and the Leeks

After walking 1.1 miles (2250 steps) to Público, the Eternal Fiancee’ and I felt really good about sampling some of their awesome Latin-inspired dishes.
leeksI could not resist ordering the Leeks (aji rocoto, arbol, crema, blis roe),the national emblem of my birthplace, Wales.

The leeks were great; I concur with what this reviewer wrote:

“A simple order of leeks arrived as a work of art, decorated with bright roe and surrounded by crema that demanded to be licked from the plate. ”

Walking home from Público, we passed the chain that the Eternal Fiancee’ unsuccessfully tried to hurdle a few weeks earlier after a run to the Delmar Loop. Although the fall that resulted from that failure resulted in severe elbow and back injuries, we are still convinced that using our feet for transportation is healthier in the long run.

For 2016 I encourage all my patients to walk more and eat more leeks!

Happy MLK day,

-ACP

If you’d like to read a good, in-depth article from Slate about Walk score, see here.

And if you’d like to visit Público here is there info:

6679 Delmar Blvd.

University City, MO 63130

Map & Directions

314.833.5780