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Cardio fitness is a strong, consistent predictor of morbidity and mortality

490 points| wjb3 | 1 year ago |bjsm.bmj.com

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[+] keybored|1 year ago|reply
Some of my peers are deep into running. I don’t get it. Running is sometimes fun for me but most often painful.

Then I overheard one of them (the fittest) say to a budding runner that he [should] do mostly easy sessions. Okay what’s easy to him? He said that so slow that it can feel awkward and unnatural. What?

Then I searched around and found out about Zone 2 and how you should do most of your work in that zone when building aerobic fitness. And that it is characterized by being able to hold a conversation, although strained.

I searched around and found atheletes like amateur ultrarunners say the same thing.

Then it hit me. I’ve probably been jogging a lot in Zone 3. Or higher? Because the harder you go the more benefit, right? That seems to be the basic logic for everything.[1] Relatively short, painful sessions. Have I been conditioning myself to associate cardio with more pain than is necessary for the average session?

So maybe I should just go on the stationary bike today, do a “conversatitional” (talk to myself) pace and listen to my audiobook for an hour? And try to not let my groin fall asleep.

[1] With nuances like go-to-failure for hypertrophy in weightlifting and more back-off-a-little for strength training.

[+] danielbln|1 year ago|reply
I've been streak running (so running at least a mile per day with no exceptions, mostly 5ks during the week, 10-20k on weekends) for almost 8 years (2817 days). The single best tip I give to everyone is "slow down! run slow!"

Of course, almost no-one adheres to it unless they are already well practiced. It's just deeply ingrained in peoples heads that "only if it's hard or painful it must work". Then people check out of running because it feels like crap, which it does if you always push too hard.

In my opinion, three of the most important rules are:

- slow down! does it feel "too slow"? Great, that's the right speed for most runs

- small steps! feels awkward at first, but is sooo much more efficient and soo much better for your joints

- land on mid- or forefoot (that happens mostly automatically with small steps)

[+] bpizzi|1 year ago|reply
There's also value in spending some time in zone 5 [1]: this is where the heart is really trained as a muscle, and where the cardiovascular system is pushed to its limit (the famous vo2max: increasing vo2max is done in zone 5, for ex. with HIIT [2]).

Zone 2 is all about giving the mitochondries a chance to get better at providing a steady energy flow over a long time, mainly by optimizing for burning fat as fuel instead of glucose, avoiding lactate accumulation during the process [3].

In between, in zones 3 & 4, you get a little of both those ends of the spectrum, it's still helpful to a degree, but it's not really optimized: that why it's deemed preferable to spend the bulk of your training time in either your zone 2 or zone 5.

The ideal composition of a training period seems like 90% zone 2 and 10% zone 5, and going for more than 1h of zone 5 per week seems not that interesting. Also, mixing zone 2 and zone 5 in the same training session is not ideal, it's better to stay focused on one thing at at time.

[1] https://peterattiamd.com/category/exercise/high-intensity-zo...

[2] https://peterattiamd.com/category/exercise/vo2-max/

[3] https://peterattiamd.com/category/exercise/aerobic-zone-2-tr...

[+] wjnc|1 year ago|reply
A part of become a good runner is letting go of expectations. There is a lot of quasi meditative written on the topic, but even if that’s not your thing: even if you walk/jog/walk to retain a constant, middle to low heart rate you could easily have the same effort as a trained runner doing some great mileage. The humbling part is part of the experience. Stay away from anything with speed for the first thousand miles. It will only lead to injuries. The good thing is, both condition and speed will improve very fast and the happy run feeling isn’t based on speed or distance. It’s being outside, alone, in silence with sounds and weather while doing something actively (but not overly). Did I mention I miss running? (Alas I am now missing some necessary cartilage.)
[+] grantmuller|1 year ago|reply
I’ve been doing ultra marathons now for over a decade and the key is slow. Walk a lot at first if you have to. Some key resources getting started are Jeff Galloway and his run walk method. Once you build up to mostly running just mix in a few “strides” a week: pick two workouts and run 5x 30s at a “not quite sprint” speed. That’s it. Anything else you mix in (tempo, intervals, progressions, blah blah blah) is the last 10% and completely optional.

Your zone 2 speed will change over time. I do most of my training in zone 1 now, and that’s like a 9 minute per mile pace. When I started more than 15 years ago a 9 minute mile felt like death. Patience. This takes a lot of time.

[+] Dove|1 year ago|reply
I always hated running, but I had always been doing it for exercise. Perversely, this meant if I moved inefficiently and made the movement harder, I was doing better. I characterized running as "competitive suffering". No pain no gain, right? And like you, I always did more than felt good, and figured that meant I was doing it right.

But I don't think that way now. I want to enjoy moving. I want to move playfully and powerfully and efficiently. Exercise until it feels good, not until it feels bad. Love the body you have and take care of it and build it up, rather than hate-exercising to change it.

[+] bart_spoon|1 year ago|reply
I've recently come to the same realization. I've always considered myself a more short-distance athlete, having been a sprinter and played more "burst" sports in high-school like football. My wife is a more long-distance runner. I've never understood why people like her were able to run for miles and miles without stopping. I could maybe keep up with her for the first mile, maybe 2, but then I was toast.

It's only recently when I learned about Zone 2 training that I came to understand that my training approach has always been backwards. I have always indexed my pace on what has always been a "respectable" mile time, on the assumption that if I run at that pace over and over, eventually I'll be able to go for longer at that pace. And that kind of is true, but not ever to the extent I can keep up with my wife.

Now, I am attempting to approach my running from a "time spent running > speed", and I'm finding that I indeed can run for 40+ minutes straight with no stopping, at a much lower pace than what I had been, and that it is much easier to make progress by running slowly for 40 minutes and gradually increase my pace over time than it is to run quickly for as long as I can and gradually increase the distance.

[+] bo1024|1 year ago|reply
Yes, most of experienced runners' running is at a conversational pace, often literally (this is why running groups are popular).

To explain why harder isn't better: improvement in running comes only a little from muscular strength, so that mental model is bad.

Improvement is primarily based on aerobic development of the cardiovascular system. This is your body's ability to burn mostly-fat with oxygen, deliver the energy (ATP molecules) to muscles, and remove waste products. So you develop more capillaries, your heart gets literally stronger, and this fat-burning pathway gets more efficient.

Going too hard pushes into the anaerobic zone (burning sugar without oxygen). This is good training in some ways, but it can be counterproductive to aerobic development and, most important, it's too hard to do very much volume so the amount of stimulus is limited. By keeping it easy, you can do a higher volume of purely aerobic stimulus.

[+] anal_reactor|1 year ago|reply
When I was a kid I loved long-distance walking because it was "me-time". I have some introvert genes and I really needed to be on my own, away from people, and going for a walk was the only way I could achieve that.

Then I moved to a bike-friendly country and I started biking all the time. 30 minutes commute one way, 30 minutes back. I live right next to subway but god I hate public transport, and owning a car in this city is a massive headache.

Often I go for a small one-hour ride in the evening. I put on some music, start cycling, and thinking about things. I feel like I get into some kind of trance. When sitting at home I constantly feel "now what now what now what now what", but while cycling, I get into a rhythm and often; not always, but often; I get into a state where my thoughts kinda flow more easily, I can just think about something happy and focus on it, or maybe listen to the music. I live in a low-density area with biking lanes separated from most car traffic, so sometimes I get drunk or high and go cycling, which feels amazing - I have to focus and make it through one intersection, and after that the worst thing that can possibly happen is falling off the bike and getting a few bruises.

Sometimes I go for longer whole-day trips. When I reach the point of complete exhaustion the part of my brain that constantly worries about getting fired or possible WW3 shuts down and it's like being high but without drugs. I plan these trips so that I fight against the wind on my way "there" and then enjoy the help of the wind on my way back which becomes almost efforless. When I come home exhausted, the body experiences relaxation in ways impossible to achieve in other ways.

If you want advice, from my experience: 1. Stationary machines are a scam, 90% of pleasure comes from being outside. 2. Do exercise at a pace "I could keep on going like this forever" and then after an hour "oh not anymore" 3. Get something that keeps you entertained but doesn't require your attention. I don't recommend audiobooks because you need to keep actively listening. I recommend music or radio because if you zone out and stop listening, nothing bad happens. And sometimes try not having anything at all, just watch all the things around you.

[+] Aperocky|1 year ago|reply
This is absolutely true, when I started, I didn’t have a zone2 while running and running is just suffering.

But gradually I could hold a lower heart rate while running and now my zone 2 runs are actually faster than my fastest pace I could hold a year ago. Now I enjoy running more than cycling (though my fitness are still probably mostly derived by cycling).

[+] terhechte|1 year ago|reply
I watch all streaming shows on a rowing machine with not-so-high speed and not-so-high resistance. The show keeps me entertained and sometimes I even forget that I'm rowing. Previously I did that with an iPad 12.9" next to the machine, but I've just started watching shows on the Quest 3 and that's way better.
[+] ab71e5|1 year ago|reply
I've heard the same thing, but for cycling. However I wonder if that is not mostly for people who train much more than a normal person, like a pro or your ultra marathon friends.

I understood the idea was that by running / cycling mostly in zone 2, you can put in more distance / time as you can recover more easily. It would not be possible to bike 30 hours in a week in zone 3, you would trash yourself.

But for someone like me, biking like 6-8 hours a week, I could easily do a lot of higher intensity, recovery time is not a bottleneck, other obligations in life are. So I really wonder if that still applies if you're only running / biking a few hours per week?

[+] aqme28|1 year ago|reply
If you don’t like running, find an exercise you do enjoy. Running isn’t the only cardio out there. If you’re jumping through hoops to force yourself to enjoy it, try a few other activities. Me, I can only get myself to run if I’m engaged in sports.
[+] 01100011|1 year ago|reply
Are you carrying excess weight? I've been overweight most of my life. For a while in my 40s I hiked a lot and my BMI dropped into the normal range. When that happened, I became a runner. It felt amazing. I would run 5+ miles and felt like I could keep going forever. Once I put the weight back on(new relationship with someone who liked to eat), I couldn't run. It hurt and didn't feel good.

I don't know what the current research says, but I believe jogging is pretty hard on your joints vs running. I'd recommend hiking and fast walking as an alternative if you're looking to transition into running.

[+] samuell|1 year ago|reply
I love running and doing it consistently over ~10 years, always longing to get out again.

I'm the only one among my friends that do this, and I find this to be highly correlated with my running style: Really comfortable pace 7-10km through local forests, only (I tend to do more 10km more than 7km as I like it so much).

I learned this one time when I ran on a threadmill and realized the enormous difference between a slight variation in speed (from 11 to 9 km/h in my case, but the exact numbers don't matter), where I realized with this slight change I could go on indefinitely instead of being quickly exhausted.

[+] cycomanic|1 year ago|reply
Weird that people seem to assert that causality is not established? There are hundreds to thousands of studies that show that pretty much all markers for mortality and morbidity go down with excercise, i.e. put someone regulalrly on a treadmill for a couple of month and pretty much all health markers improve.

People implying that the study shows only correlation really don't seem to understand how we establish causality in science.

[+] lovecg|1 year ago|reply
There’s amusing statistics that show that if you’re out of shape and a smoker, you get a bigger bang for the buck from getting in shape first than quitting smoking. Disclaimer: not an endorsement of smoking.
[+] Aperocky|1 year ago|reply
Fortunately, this seems relatively simple to change (compared to other things with this magnitude of impact).

It was a transformative experience to go from 40 VO2max to 57 (as reported by Apple Watch, and losing 30lbs on the way) over the past 12 months. The best part about it is that I didn't even have to give up anything - the extra energy I gained from 90-120 minutes of aerobics per day also had the effect of making everything else more efficient.

[+] mvkel|1 year ago|reply
You should know that vo2 measurements that aren't performed via gas exchange or blood measurement are a complete guess.

The other thing is the denominator of vo2 is weight. So losing weight without working out at all will increase vo2

[+] jebarker|1 year ago|reply
40 to 57 is a huge increase in a year - kudos!
[+] johnfn|1 year ago|reply
What sort of workouts do you do? I've been trying to do the same thing, but I'm finding it difficult to get VO2max to go up consistently.
[+] 38|1 year ago|reply
2 hours a day is a ridiculous amount
[+] linux_devil|1 year ago|reply
Even if Vo2 is inaccurate on Apple watch , relative increase in your Vo2 is a positive metric. Kudos to you.
[+] sandspar|1 year ago|reply
That's a massive change! It's realistic for an untrained person to expect a 15% change in a year with exercise; you went up almost 50%. What subjective changes have you noticed in your day to day?
[+] purplerabbit|1 year ago|reply
that’s an amazing change. Could you elaborate on your training regimen?
[+] keybored|1 year ago|reply
Congrats. You’re an inspiration to me. :)
[+] throwaway2037|1 year ago|reply
I love these kinds of posts. They are ridiculous.

First:

    > Fortunately, this seems relatively simple to change
Second:

    > the extra energy I gained from 90-120 minutes of aerobics per day
Are you joking? You are asking average people to commit to 90-120 of c-v exercise per day? So, 7 days per week? This stuff is nonsense. Most people would quit after a week. I guess 99% of people could not sustain this for more than 3 months.
[+] busymom0|1 year ago|reply
Slightly related:

I have been engaging in powerlifting/weightlifting for over a decade. In my initial years, I was in the "just do weights, don't need cardio" camp. However, around 2018, I started doing cardio mostly to cut body weight as I wanted to hit my personal bests on squats, deadlifts, and bench at a lower body weight.

I personally experienced that my weights moved much better, especially when I was doing more volume work (higher reps) with cardio than without cardio. Cardio seemed to improve my working capacity and I felt more efficient at doing more reps.

So, I would recommend cardio even when one is trying to bulk up in weight and trying to get strong. Doesn't have to be crazy cardio either - just 10 - 15 minutes of zone 2 cardio 4 days a week might be good enough. You can also do types of cardio which work certain muscles - like stair master can be made to specifically target the quads and calves. Or rowing can be good for building the lats. Swimming is good too.

Personally, I either do intervals on the stair master or intervals on an echo bike (fan bike).

[+] weatherlite|1 year ago|reply
It's also absolutely amazing for mental health. It's a shame it isn't considered a first line of treatment for mental health because it's super effective (and free).
[+] Mathnerd314|1 year ago|reply
The relationship isn't linear, you can see in https://bjsm.bmj.com/content/54/20/1195#sec-16 that above 2200 MET-minutes/week there is increased cancer risk which outweighs the cardiovascular benefits. Now admittedly it is a very weak correlation, and MET measurement is imprecise, but I think it is safe to say that there are risks associated with over-exercising and while being in shape is good, being a ultra-marathon runner or other extreme fitness enthusiast is unhealthy long-term, and the risks start sooner than you might expect. (2200 MET-minutes/week is about 3 hours of 8mph running per week)
[+] MPSimmons|1 year ago|reply
The Apple watch has a decent cardio fitness monitor. The absolute values aren't precise (since it uses VO2Max estimates, which is really only accurate if you're doing a metabolic stress test), but it's good to keep an eye on trends.
[+] electrondood|1 year ago|reply
I was blown away at just how little exercise is required to significantly increase your lifespan: 20 minutes a day, 3 times a week. That's it.

The Copenhagen City Heart Study, published in the Journal of the American College of Cardiology in 2018 found that light jogging for 20 minutes a day, 3x a week reduces all-cause mortality by 78%.

That's insane.

[+] whateveracct|1 year ago|reply
I've been walking every day and lifting weights 2x a week. I feel good so far but the hard part is doing it for years and through seasons (both literal and figurative).
[+] squirrel6|1 year ago|reply
I’m going to plug Peter Attia, MD again here. In his podcast with Mike Joyner, MD (an exercise physiologist of Mayo Clinic) there is fairly detailed discussion of the literature on this topic.
[+] Fire-Dragon-DoL|1 year ago|reply
For people who misinterpreted the title like me, thinking that exercising is negative:

Conclusion

Our findings showed that high CRF is strongly associated with lower risk of premature mortality, incident chronic conditions (ie, hypertension, heart failure, stroke, atrial fibrillation, dementia and depression), and poor prognosis in those with existing chronic conditions. The consistency of the evidence across a variety of health outcomes demonstrates the importance of CRF and the need to incorporate this measure in routine clinical and public health practice. Future studies should focus on outcomes with limited evidence and where the certainty of the evidence was rated as very low by improving study quality.

[+] jimt1234|1 year ago|reply
Sorta related: My boomer mother is experiencing cognitive decline, probably the early stages of dementia. Her doctor said that as we age, blood vessels in the brain can get starved for blood and eventually dry up, making them useless. This is the biological explanation of her loss of memory and difficulty thinking. I asked if there's anything that can be done to at least slow this decline. She said the best medicine for the brain is physical exercise; it forces blood into the areas of the brain where blood vessels are at risk, prolonging its well-being.

BTW, I asked the doctor how much exercise is enough. Her response: If you smell the same when you're done exercising as when you started, it's not enough. I found that both humorous and helpful.

Disclaimer: I'm not a doctor or expert. If a loved-one is experiencing memory loss or difficulty thinking, see a doctor.

[+] perfectritone|1 year ago|reply
easy hack: maintain a garden in an area with poor soil. between clearing, aerating, digging, mulching and weeding you can get all of your cardio AND some fresh veggies!
[+] uptownfunk|1 year ago|reply
Regardless of what it is, if I don’t get my morning run in, I am a very unpleasant person to be around! Running has changed my life in all ways- I am much more calm, tolerant, positive, energetic. If the whole country did a mandated morning run, assuming you’re able, I really think this world would be a much better place!!

Start slow, 5 minutes, breathe, go slow, and enjoy the beautiful weather here this time of year.

[+] hyperthesis|1 year ago|reply
Can anyone give a sense of how much fitter 3.5 mL/kg/min is, in practical terms? e.g. distance cycled/how out of breath?

> For every 1-MET (3.5 mL/kg/min) higher level of CRF, we identified substantial reductions in the risk of all-cause, CVD and cancer mortality. We also identified significant reductions in the risk of incident hypertension, heart failure, stroke, atrial fibrillation and type 2 diabetes per higher MET.

> For most, a 1-MET higher level of CRF is attainable through a regular aerobic exercise programme. For example, in a large population-based observational study of over 90 000 participants, nearly 30% were able to increase their CRF by 1-MET (median follow-up was 6.3 years) without intervention.

[+] bhaney|1 year ago|reply
Sheesh, fine. I'll start jogging
[+] EcommerceFlow|1 year ago|reply
If anyone wants a shortcut to an extremely good workout, look into rowing (MAKE SURE you learn proper form!).

I focus on "maxing out" sets of 500m since it correlates well to basketball cardio, and I have infinite cardio even in my mid 30's.

[+] manoji|1 year ago|reply
I was surprised how much cardio fitness improves by just losing weight. After losing close to 10 kgs I was able to run a 5K consistently 3 times a week and reached a respectable level of fitness for playing basketball
[+] BenFranklin100|1 year ago|reply
I am disappointed by how poor primary care is in the developed world. It could easily be made better by including a VO2Max test and a DEXA scan every few years. On my own dime, I took both (cost was ~ $150 total from a private provider) and the DEXA scan revealed I carried too much visceral fat and my cardiovascular fitness was only average, things that never came up in my yearly physical. The same applies for basic strength testing, another predictor of morbidity and mortality.
[+] swatcoder|1 year ago|reply
For better or worse (worse), people don't go to the doctor for lifestyle analysis and rarely take lifestyle advice from their doctors.

They go to their doctors to know when to start medical interventions.

Even simple waist-to-hip ratio assessement would be a big win for identifying lifestyle concerns, but neither that nor the far more involved VO2Max and DEXA rests are going to become standard unless they becoming a gaiting condition for some celebrated drug or procedure.

And that's as much because of the patient's perspective of what they want from doctors as it is because of the doctors or broader establishment.

[+] giantg2|1 year ago|reply
"It could easily be made better by including a VO2Max test and a DEXA scan every few years."

Frankly, the vast majority of people don't need fancy tests. The thing is, the healthcare system is not about optimizing health or performance. It's mostly about fixing problems and heading off the most common ones in the easiest ways. If the goal was to optimize, it would be relatively easy for a trained individual to examine most people and tell them to lose weight and exercise more. Hell, you could blindfold the person and their advice would still be right like 80% of the time.

[+] refurb|1 year ago|reply
What would be the point of measuring VO2Max and a DEXA scan in a mostly sedentary, obese population?

"Excuse me sir, I have you VO2Max and DEXA scan results. It shows your cardiovascular fitness and body fat is problematic. But we already knew that since your BMI is 35 and you told me you don't exercise at all".

[+] eternauta3k|1 year ago|reply
What's the advantage of a VO2max test compared to e.g. measuring speed or power in your (standardized) intervals?
[+] s1artibartfast|1 year ago|reply
The highest impact diagnostic of all cause mortality is a scale. The next best is a mirror.

Most people have these at home and fail to take meaningful action based on the results.

[+] throwawaysleep|1 year ago|reply
Have to weight it against whether people are meaningfully willing to act on that information. Bluntly, I go to a Dr for meds. I have never been willing to make any lifestyle changes.
[+] ashconnor|1 year ago|reply
Pretty sure Dexa scans and VO2Max tests are HSA/FSA eligible.