FROM ENDURANCE TO CAPACITY –

A NEW APPROACH TO CARDIOPULMONARY FITNESS

Al Sears, MD

BEYOND “CARDIO” – A NEW APPROACH TO CARDIOPULMONARY

FITNESS

Al Sears, MD

The following potential conflict of interest relationships are germane to my presentation.

 Equipment: N/A

Speakers Bureau: N/A Stock Shareholder: N/A

Grant/Research Support: N/A Consultant: N/A

Status of FDA devices used for the material being presented:

NA/Non-Clinical     

Status of off-label use of devices, drugs or other materials that constitute the subject of this presentation  

NA/Non-Clinical

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Modern Exercise Advice Has Failed You

1. It doesn’t build functional strength

2. It won’t make your heart stronger

3. It won’t build your lung capacity

Modern Approaches to Fitness Don’t Work

1. Aerobics

2. Cardio

3. Weight training

The “big 3” create the wrong “adaptive response”. You need exercise, but what kind?

HARVARD ALUMNI HEALTH STUDIES

• 17,321 male alumni followed for 20 years

• High-intensity exercise was associated with a significant decrease in all-cause mortality

• No relationship between low-intensity exercise and death

Lee IM, Hsieh, CC, Paffenparger, RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA. 1995;273(15):1179-1184

.

Exercise Intensity and MortalityHarvard Health Study

Low Moderate High0.840000000000001

0.860000000000001

0.880000000000001

0.900000000000001

0.920000000000001

0.940000000000001

0.960000000000001

0.980000000000001

Rel

ativ

e R

isk

of D

eath

(%

)

Exercise Intensity

Lee IM, Hsieh, CC, Paffenparger, RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA. 1995;273(15):1179-1184

INTENSITY VS. DURATION

• 8896 recreation runners reported average exercise duration and intensity

• High intensity exercise associated with:Lower blood pressureLower triglyceridesLower CHOL/HDL ratiosLower BMIsLower waist, hip, and chest circumferences

• Exercise duration had no effect on these parameters

Williams P. Relationships of heart disease risk factors to exercise quantity and intensity. Arch Intern Med. 1998;158(3):237-245.

High-Intensity Exercise Improves Cardiac Function – Study Design

Patients with prior MI

(n = 29)

Control/no training(n = 8)

Low-intensity training*(n = 11)

High-intensity training**(n = 10)

*Low-intensity: HR @ 80% of gas exchange threshold (GET)**High-intensity: (HR @ GET – HR @ peak exercise)(40%) + HR @ GET

Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

High-Intensity Exercise Improves Peak O2 Uptake During Exercise

Control Low-intensity High-intensity0

50

100

150

200

250

Cha

nge

in p

eak

O2

upta

ke (

ml/

min

)

*P = 0.030

Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

High-Intensity Exercise Improves Ejection Fraction During Exercise

Control Low-intensity High-intensity0

0.5

1

1.5

2

2.5

3

3.5

Cha

nge

in e

ject

ion

frac

tion

(%)

*P = 0.024

Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

Low-Intensity Exercise Reduces Cardiac Function

Series1

-0.6

-0.4

-0.2

-2.22044604925031E-16

0.2

0.4

0.6

Low-intensityHigh-intensity

6-months 12-months

∆ R

est

to P

eak

LVE

F (

%)

Oberman, A, Fletcher F, Lee J, et al. Efficacy of high-intensity exercise training on left ventricular ejection fraction in men with coronary artery disease (the Training Level Comparison Study). Am J Cardiol. 1995 Oct 1;76(10):643-7.

So – What’s Going On?

Low-intensity durational exercise increases cardiac

endurance….at the expense of cardiac capacity

Endurance versus Capacity

Evolution– Humans did not evolve to engage in long-

duration, low-to-moderate intensity exercise

– Natural selection favored individuals who could sprint – not those who could run marathons!

– From an evolutionary perspective, traditional cardiovascular exercise in unnatural.

What’s wrong with endurance?

• Exercise causes adaptation of cardiac function

• The adaptations seen with traditional “cardio” exercise are:

• Increased cardiac endurance

• Increased cardiac efficiency

• BUT – the increased endurance/efficiency ONLY occurs in the narrow range of low-to-moderate output required by traditional cardiovascular exercise

The high cost of endurance …

• Endurance training requires significant physiological adaptations over a long duration, including:

Metabolism of waste products

Regulation of body temperature

Conservation of energy – in particular, conservation of enough energy to support repeated durational challenges

Deadly adaptations…

• The energy required to maintain the physiological processes required by endurance training comes at the expense of cardiac capacity

• The heart adapts with decreased capacity, resulting in a diminished cardiac reserve

• A reduction in cardiac reserve is a deadly adaptation

Endurance versus Capacity

Cardiac Reserve and Heart Failure

Normal Mild HF Moderate HF Severe HF Acute HF Cardiogenic Shock

0

1

2

3

4

5

6

Cardiac reserve

At rest

Maximal level

Car

diac

Pow

er O

utpu

t* (

w)

* Cardiac Power Output = (cardiac output)(arterial pressure)

Adapted from: Williams S, Barker D, Goldspink D, Tan L. A reappraisal of concepts in heart failure: central role of cardiac power reserve. Arch Med Sci 2005; 1(2) 65-74

Is high-intensity training anti-aging for your lungs?

It’s clear that cardiac capacity is vital

to healthy aging, but pulmonary capacity is another powerful predictor

of longevity

Framingham Heart Study

• Framingham researchers followed 5209 participants over 18 years

• Biggest finding: the risk of congestive heart failure rose as lung capacity fell

• Relationship was independent of: blood pressure, relative weight, pulse, smoking status, heart enlargement, ECG-LVH, blood glucose levels, and age

• Lung volume decreased BEFORE there was any clinical evidence of CHF

Are Your Lungs Dying?

32 37 42 47 52 57 62 67 72 7715

20

25

30

35

40

45

Men

Women

Age

Mea

n V

ital C

apac

ity (

dL)

Adapted from: Kannel WB, Seidman JM, Fercho W, Castelli WP. Vital Capacity and Congestive Heart Failure. The Framingham Study. Circulation. 1974;49(6):1160-1166.

Incidence of Congestive Heart Failure According to Vital Capacity

45 - 54 55 - 64 65 - 740

1

2

3

4

5

6

7

8

9

10

<4.54.5 - 5.15.2 - 5.7>5.7

Rat

e o

f C

HF

/100

0

Vital Capacity (L/height)

Age

Adapted from: Kannel WB, Seidman JM, Fercho W, Castelli WP. Vital Capacity and Congestive Heart Failure. The Framingham Study. Circulation. 1974;49(6):1160-1166.

Even Moderate Pulmonary Impairment Increases Risk of Death

5 yr 10 yr0.5

1

1.5

2

2.5

5th4th3rd2nd1st

Years Post Follow-Up

FEV (%)Quintile:

Rel

ati

ve

Ris

k o

f D

eath

(al

l ca

use

s)

Schunemann H, et al. Pulmonary function is a long-term predictor of mortality in the general population: 29-year follow-up of the Buffalo Health Study. Chest. 2000 Sep;118(3):656-64.

The Bottom Line

• Lung capacity decreases with age

• Decreased lung capacity increased risk of heart failure

• Even moderate, non-clinical decreases in lung capacity increase risk of death

• Lung capacity is a clear and powerful marker of aging.

Some Good News...

The age-related loss of pulmonary

function is manageable and

modifiable… if you engage in high-

intensity exercise

Pre- and Post-Intervention Pulmonary Function

RST ET Control2.85

2.9

2.95

3

3.05

3.1

3.15

3.2

3.25

3.3

Pre-intervention

Post-intervention

VO

2pea

k (L

/min

)

Exercise Group

Adapted from: Baily S, Wilkerson DiMenna F, Jones A. Influence of repeated sprint training on pulmonary O2 uptake and muscle deoxygenation kinetics in humans. J Appl Physiol. 2009 Jun;106(6):1875-87.

Building Younger Lungs

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 1000

10

20

30

40

50

60

People participating in high-intensity interval exercise

Average people

Max

O2 U

pta

ke (

ml/

Kg

min

)

Age

Adapted from: von Ardennne, M. Oxygen Multistep Therapy. Theime. 1990. p.31.

THE DATA ARE CLEAR

High-intensity exercise is the key to cardiopulmonary

health.

“Expert” advice that is killing your patients

• American Medical Association• Moderate intensity exercise for 30-minutes/day, at least 5

days/week

• American College of Sports Medicine• Moderate intensity exercise for 30-minutes/day, at least 5

days/week

• American Heart Association• Moderate intensity exercise for 30-minutes/day, at least 5

days/week

• National Institute of Health• “regular, moderate exercise”

High-Intensity Exercise and the Aging Patient

• Interval training is the most common type of high-intensity training, but...

• Interval training is not safe or effective for the typical deconditioned patient presenting to an anti-aging clinic.

The Solution

P.A.C.E

PROGRESSIVELY

ACCELERATING

CARDIOPULMONARY

EXERTION

Progressivity• Regular and consistent increases in the intensity of demands placed

on the cardiovascular system by making repeated changes in the same direction

• Analogous to inflating a balloon: the best way to fill a balloon to capacity is by gradually adding more air during each inflation

• Similar to muscle hypertrophy training where muscle capacity is increased by progressively adding small amounts of additional weight

• KEY POINT: In PACE, high-intensity is a relative term. This means that each individual will work towards their own unique level of maximum exertion. This makes PACE the safest form of exercise

Acceleration • Training to increase the speed at which the heart and lungs respond

to increases in demand

• The same exertion level/target heart rate will be reached more quickly throughout the training process

• Recovery back to resting heart rate/respiration also happens more quickly

• KEY POINT: most cardiac arrests occur when the heart is unable to respond to a sudden and dramatic increase in demand. Training for acceleration helps the heart to respond quickly to potentially life-threatening demands – reducing the risk of sudden cardiac death

PACE – The Twin Study

Female Fraternal Twins• 18-years old

• 24.5% body fat

• 16-weeks of training

PACE Twin

• Decreased body fat by14.5%

• Gained 9-lbs lean muscle

“Cardio” Twin• Decreased body fat by 5%

• Lost 2-lbs lean muscle

Case Study – Terri L.

• 55 year-old female• 250-lbs• 50% body fat• Elevated triglycerides• Low HDL

Terri L – Body Fat (%)

1 2 3 4 5 6 7 8 9 10 11 12 13 1420

25

30

35

40

45

50

55

Bod

y F

at (

%)

Months Post-Training

Terri L – Triglycerides

Baseline 3-months 6-months150

170

190

210

230

250

270

Trig

lyce

rides

(m

g/dL

)

Terri L – HDL

Baseline 3-months 6-months40

42

44

46

48

50

52

54

56

58

HD

L (m

g/dL

)

Terri L

Richard F

Sample PACE Log

Warm up:_______________

Exercise:_________________

Initial Sets

Set 1 Set 2 Set 3

Exertion Recovery Exertion Recovery Exertion Recovery

Additional (optional) Sets

Set 4 Set 5 Set 6

Exertion Recovery Exertion Recovery Exertion Recovery

What Makes a PACE Workout?

• Running• Rowing• Swimming• Bicycling• Jumping rope• Calisthenics

• Stair stepping• Elliptical• Circuit training• Hindu squats• Kettle bells

PACE – The Safest Exercise There Is!

• Interval training requires participants to exercise to an objective goal that does NOT consider the cardiopulmonary health of the participant. This type of high-intensity training may be dangerous for the average older adult

• In contrast, the progressivity component of PACE allows each individual to work to their own unique level of maximum exertion, making PACE a program that is fully-customized to the fitness level of every participant.

• The risk of durational exercise is illustrated by multiple reports1,2 of elevated creatinine kinase, myoglobin, and troponin among distance runners

1) Jassel D et al. Cardiac injury markers in non-elite marathon runners. Int J Sports Med. 2009 Feb;30(2):75-9.

2) Trivax J, et al. Acute Cardiac Effects of Marathon Running. J Appl Physiol. 2010 Feb 11.

PACE Trial

• My Wellness Research Foundation is currently conducting a longitudinal study to examine the efficacy of the PACE program

PACE Trial – Study Design

• 20 men and women (18+) with > 26% body fat• PACE-style exercise program supervised by an ACE-

certified trainer• Variables assessed include:

• Weight• Body fat & lean muscle mass• Cholesterol• Glucose and insulin• Testosterone• CRP and homocysteine

• VO2max and pulmonary function