The Exercise Sweet Spot

 

The eyes of the world are on Milan-Cortina in Italy (pictured above, the Duomo, symbol of the city of Milan). The world’s best athletes are competing in some of the toughest sports in the Winter Olympics. As we watch the events, we know there is a difference in the energy a speed skater expends racing around a track compared to the average person walking on a treadmill. What is that difference and how can it be quantified?  Is there an optimal amount of time spent in our favorite exercises to maximize the benefit? Is there an exercise sweet spot?

 

Exercise is quantified using the metabolic equivalent (MET). The MET is the energy cost of doing any activity such as walking, running, playing a sport or doing household chores. One MET is the energy used just sitting and doing nothing. An activity that costs 4 METS is four times as strenuous as sitting still. Light activity is considered less than 3 METs, moderate activity is 3 to 6 METs and vigorous activity is greater than 6 METs. The higher the METs, the more exercise energy is required and the more calories burned. The table below displays the METs of some common activities and sports: 

Activity/Sport	METs
General bicycling	7.0
Bicycling 14-16 MPH	10.0
Jogging 2.6-3.7 MPH	3.3
Running 4 MPH	6.5
Marathon Running	13.0
Walking the dog	3.0
Walking 2.8-3.4 MPH	3.8
Swimming laps	5.8
Tennis- singles	8.0
Tennis- doubles	4.5
Free weights	6.0
Squats/Pushups	3.0
Exercise classes	5.5
Yoga	2.3
Zumba	6.0
Pilates	2.8
Snow blower	2.5
Snow shoveling	5.0-7.5
Mowing lawn, power mower	5.0
Mowing lawn, hand mower	6.0

 

How does this compare to the energy required for some Olympic sports?

 

Winter Olympic Sports	METs
Ice dancing	14.0
Speed skating	13.8
Cross country skiing	15.0
Biathlon	12.8
Downhill skiing	8.0
Slalom skiing	9.3

 

As we can see, winter sports are very high energy. Also keep in mind that these METs are for the average exerciser. Olympic competitors are working at an even higher rate. The website https://pacompendium.com/adult-compendiun/ has a list of many more activities and sports.

 

What is the optimal number of METs per week? What is a good amount of exercise? It is well known that the largest benefit of exercise occurs when going from doing nothing to doing a moderate amount of physical activity. People doing 150 minutes of moderate exercise per week lower their risk for heart disease and death by 14% compared to people who are sedentary. It is also well known that increasing the exercise volume doesn’t give much more benefit; the mortality benefit plateaus. In other words, exercising more and more doesn’t mean that you will live longer and longer. Mortality isn’t the only thing that reaches a plateau, heart disease, respiratory disease and cancer all hit a limit. Does this relationship hold for various types of exercise? A new study examined this question. The study followed 111,000 participants for 30 years. The study found a similar relationship for multiple different types of activities including walking, jogging, running, bicycling, swimming, tennis, rowing and weight training. All of these exercises lowered the risk of dying and all plateaued as the volume went up. The study used MET hours per week to quantify exercise volume. MET hours per week is derived by multiplying the MET associated with an activity by the hours per week engaged in doing the activity. For example, walking 3 MPH (3.8 MET) for 2 hours each week yields 7.6 MET hours per week. With some exercises (jogging, swimming), mortality actually went up as the volume of exercise per week increased. Is there an exercise “sweet spot”? It turns out that exercising about 5 MET hours per week for any activity in the study gives the maximum mortality benefit. The 5 MET hours per week is not hard to achieve. The time needed to reach the sweet spot for each activity is:

Walking                      90 minutes/week

Jogging                       45 minutes/week

Running                      30 minutes/week

Bicycling                    50 minutes/week

Swimming                  45 minutes/week

Tennis                         45 minutes/week

Rowing                       60 minutes/week

Weight training           90 minutes/week

 

Of course, there may be other reasons to exercise above this rate (for example, to lose weight, to keep in shape, to train for a competition, to control blood pressure, to improve diabetes, to reduce the risk for rhythm problems, etc), but the additional work load won’t reduce the risk of dying further. In addition, engaging in different types of exercises gives additional health benefits. 

 

Why is there an exercise plateau? Why doesn’t mortality continue to decline with more activity? Most studies have shown that elite athletes live longer than the general population. On the other hand, studies have shown that high volume exercisers do experience cardiac abnormalities. Men who do high volume training (50 MET hours/week) have a higher burden of heart artery calcium than nonathletes. Higher coronary calcium levels are consistently found in avid exercisers. Calcium is associated with heart artery blockage and this could certainly limit life span. Similarly, high blood levels of troponin are found in athletes after exercise. Troponin is a measure of damage to the heart muscle and elevations are diagnostic of acute heart attacks. More than 80% of marathoners have troponin concentrations that are above normal cut offs. Troponin in athletes could be a normal physiologic finding or it could be due to transient damage of the heart from over exercising. Lastly, fibrosis or scarring of the heart muscle has been found in endurance athletes. Fibrosis is associated with malignant arrhythmias. No one really knows why these phenomena happen in high volume exercisers or its significance, but it could explain why there is a plateau. 

 

Next, we’ll make use of our MET knowledge and tackle a favorite winter sport, snow shoveling. Shoveling snow exerts a significant workload on the heart. This begs the question, at what age should you stop shoveling snow?  One expert says to stop at age 65. Another expert, citing a study showing that 85% of adults over 50 years of age already have atherosclerosis, says to stop at age 45! Clearly the recommendation must be individualized. If you have known heart disease or do not regularly do an equivalent amount of exercise (for example running at 4 MPH, 6.5 METs; snow shoveling 5.0-7.5 METs) then put down the shovel. If you regularly run on a treadmill at 4 MPH without difficulty at home or in the gym, then go for it. The same thought process should occur during the summer with lawn mowing (power mower 5 METs, hand mower 6 METs).

 

Once you are done with snow shoveling, put on fire, sit back and enjoy the Winter Olympics. Now you can appreciate the difference in energy expenditure between competing in an Olympic speed skating event (13.8 METs plus) versus walking on a treadmill (3.8 METs). However, if your goal is to live longer and not winning an Olympic medal, you can still hit your exercise sweet spot by walking only 13 minutes per day.

 

How to Do CPR in Space (and How to Prevent Sudden Cardiac Arrest on Earth)

                                                    Photo courtesy of Nick Nikolaides
 

Becoming an astronaut is a highly selective process. Only the best, the fittest, are chosen to be astronauts and to go on missions. In 2024, 8,00 people applied to become an astronaut, only 10 were chosen. To be selected, the candidates have to be in perfect physical health. There are vision and height requirements, they need to have excellent heart health and no high blood pressure. Once chosen, the process continues. Astronauts go through one of year of intensive physical training including wilderness survival, underwater training and learning to cope with low gravity. Despite being in tip top shape and low risk, it is still possible that an astronaut could suffer sudden cardiac arrest (SCA) while in space. If that happens, could they be resuscitated? How would cardiopulmonary resuscitation (CPR) be performed in zero gravity? How can astronauts (and those of us on Earth) lower our risk for SCA?

 

Sudden cardiac arrest is a common problem and is often the first manifestation of heart disease. It is an abnormal heart rhythm most often caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart).  When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death.  Sudden cardiac arrest affects more than 300,000 people in the US each year with a death rate of about 90%. Treatment of SCA involves prompt initiation of CPR and performing defibrillation. Defibrillation is an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED). Cardiologists can determine which patients are at high risk for SCA including those with prior heart attack, previous SCA, congestive heart failure and low ejection fraction (below 30%). However, these high-risk patients only account for a small proportion of the SCA total (about 10% of the total number of arrests). In contrast, the majority of SCA occurs in asymptomatic, low-risk people in the general population (more than 50% of the total). It is very hard to predict, or prevent, these events in the general population. 

 

By any measure, astronauts would fall into a low-risk category. Still, the risk is not zero and SCA could occur while on a mission. If SCA happened in space, how would CPR be performed? Traditional CPR relies on gravity to be effective and weightlessness poses a problem. NASA recommends that a rescuer stand behind a victim, wrap their arms around the person (in a bear hug) and squeeze (almost like the Heimlich maneuver, but applying continuous compressions to the chest not the abdomen).  The rescuer and the victim can be moved to a room with medical equipment and the victim strapped down. The rescuer then does compressions in a handstand position, with hands on the patient’s chest and legs braced against a wall. This method can’t provide the compression depth that is recommended, so it would not be as effective as CPR on Earth. One way around this would be to use a LUCAS automated chest compression system, a machine used in emergency medicine with a plunger that automatically does chest compressions to the right depth and at the right rate. Current space vehicles do not have this device (due to size and weight considerations) but do have AEDs.

 

If you are an astronaut or a low-risk citizen of Earth, what can you do to lower the risk for SCA? Over the past twenty years, the incidence of SCA has gone down, but there is room for improvement in preventing it. The CARES (Cardiac Arrest Registry to Enhance Survival) network is a national registry tracking SCA. It currently covers about 40 states. CARES showed that from 2021 to 2024, overall survival improved from 9% to 11%, public AED use increased from 10% to 13%, but bystander CPR remained steady at 41%. However, we can do better. A large study of SCA was published this year covering 500,000 participants, average age 56 and 50% were women. The study showed that the American Heart Association’s Life’s Essential Eight were strongly related to risk for SCA. The eight risk factors are:

Diet- high in fat, low in fruit and vegetable intake

Activity- sedentary lifestyle

Smoking

Sleep- less than seven hours per night

Obesity- high body mass index (BMI), high waist circumference

High Cholesterol

Diabetes

High Blood Pressure

In addition, the study found several novel risk factors for SCA. These are depression, social isolation, low educational level, increased arm fat, reduced grip strength (a marker of frailty) and air pollution. The study concluded that SCA could be reduced by 40% to 60% if these risk factors were controlled or eliminated.

 

With this information, we can now respond to SCA anywhere in the universe and begin to prevent its occurrence. So, if you are planning on being a space tourist (or if you want to reduce your risk for SCA here on Earth), work on controlling these risk factors. And maybe bring your own LUCAS device on board, just in case.

 

Talking Turkey

 

It's November and Thanksgiving is on the horizon. On Thanksgiving Day, questions abound. Whose house are we going to? How is the traffic? What are we bringing for dinner? Which station is airing the football game? The question from mothers and grandmothers in kitchens all across America, “Are you hungry?". The other question Americans will be asking on Thanksgiving is, "What is my cardiologist eating today?". According to the National Turkey Federation, about 88% of Americans eat turkey on Thanksgiving, consuming 46 million turkeys each year on that day. Is your cardiologist eating turkey or tofurkey, a plant-based substitute for turkey made from tofu or wheat protein served at a vegetarian or vegan Thanksgiving gathering? Let’s carve into those big questions, “What is hunger? What is on the cardiologist’s dinner table?” 

Why are you so hungry? As the obesity epidemic rages on, one out of eight people worldwide had obesity in 2022 with the number continuing to rise, more and more research is being dedicated to understanding hunger. Researchers have identified three distinct mechanisms of hunger. The first type of hunger is called homeostatic hunger. This is a very basic system which involves the brain (specifically an old part of the brain called the hypothalamus) and the gut. There are feedback mechanisms between the brain and the stomach that regulate hunger and satiety (when we have enough food). An empty stomach and low blood sugar triggers secretion of an appetite hormone. The hormone and nerve signals are relayed to the brain where the hypothalamus conveys to the person that they need to eat, they are hungry. With food intake, the stomach enlarges, another signal is sent to the brain and the hunger sensation is suppressed. In addition, when the stomach is full, the gastrointestinal tract secretes different hormones (including glucagon-like peptide 1, GLP-1) which leads to satiety. Homeostatic hunger is tightly regulated providing a balance between hunger and satiety. There is no excess calorie intake. On the other hand, hedonic hunger is not stimulated by the lack of food or energy. Hedonic hunger is driven by pleasure, not an empty stomach. Various hunger triggers (anger, fear, depression, lifestyle, psychology, emotions) stimulate the reward centers in the brain, leading to consumption of high fat, high sugar, energy dense foods subsequently resulting in weight gain, diabetes and heart disease. The reward centers are targeted by food advertisers who prey on eating related thoughts and desires. In 2009, the Power of Food Scale (PFS) was developed. It quantifies the psychological effect of hedonic hunger. It can assess a person’s susceptibility to food in a world where food is plentiful. Currently, the PFS is purely a research tool, but we do know this. People with high PFS scores are more likely to eat for pleasure, while those with low PFS scores don’t have the same reward center activation. Homeostatic hunger is a survival instinct driven by the need for food and energy. Hedonic hunger is more complex and more prevalent in a society where tasty food is easy to obtain and calories are consumed irrespective of the physical needs of the body. The third type of hunger is microbiota driven hunger. Bacteria that normally reside in the gastrointestinal tract influence hunger. The gut bacteria break down food producing metabolites such as short chain fatty acids. These fatty acids decrease hedonic hunger by inhibiting the brain reward center. In addition, the metabolites can activate hunger stimulating hormones as well as hunger inhibiting hormones (such as GLP-1). As we can see, GLP-1 is a key hormone. One of the ways GLP-1 agonists (for example, Ozempic, Mounjaro, Wegovy, Zepbound) promote weight loss is by mimicking the effect of GLP-1 subsequently suppressing hunger. 

 

What is your cardiologist eating on Thanksgiving? To answer that question we turn to a survey conducted by the American College of Cardiology in 2024. The group polled 166 U.S. cardiologists and tabulated their answers. About 41% of cardiologists recommend a whole food plant-based diet for their patients. However, only 8% of cardiologists follow a plant-based protein diet. So, with 92% probability, your cardiologist is having turkey on Thanksgiving. Prior to Thanksgiving dinner is your cardiologist going out for a run or sitting on the couch, watching football and smoking a cigarette? 91% of cardiologists recommend exercise to their patients but only 69% meet physical activity guidelines. In addition, 92% of cardiologists avoid tobacco (8% of heart doctors smoked in 2024? Really?). 

 

On Thanksgiving Day, start with a turkey trot. Then feed your homeostatic hunger. Join the 88% of Americans and 92% of cardiologists enjoying a turkey dinner. Try to deny that hedonic hunger! Then on Black Friday you can go back to your whole food, plant-based diet.

 

Guarding Against Syncope

 

Changing of the guard ceremonies take place in many countries, including the United States (Arlington Cemetery), the United Kingdom (Buckingham Palace), China (Tiananmen Square), Greece (Syntagma Square), Canada (Parliament Hill), India (palace of the President) and Monaco (the Prince’s Palace). Typically, these ceremonies involve military personnel with one group switching place with another and taking over the protection of a significant national monument. The guard changes are elaborate, precisely choreographed and viewed by tourists. Many times, the soldiers stand motionless for hours in the hot sun. Sometimes, they pass out. Passing out, fainting, blacking out or losing consciousness is called syncope. What causes syncope and how can it be diagnosed efficiently?

 

Syncope is an abrupt and transient loss of consciousness due to lack of blood flow to the brain followed by a quick recovery. Syncope must be distinguished from seizure, low blood sugar, drug or alcohol intoxication or psychiatric conditions all of which may cause a person to pass out but are not due to lack of brain blood flow. Syncope is extremely common, accounting for 3% to 6% of all emergency room visits. In people over 45 years of age, 25% have reported an event. The incidence of syncope has three peaks, ages 20, 60 and 80. Women are more likely than men to pass out. 

 

The causes of syncope can be divided into nonlife-threatening processes and severe, potentially life-limiting diseases. Benign causes include the following. 

Vasovagal syncope: passing out due to an unpleasant stimulus (pain, sight of blood, stress, medical procedure)

Situational syncope: passing out after coughing, sneezing, swallowing, urinating

Orthostatic hypotension: passing out after standing, blood pressure falls on standing

Dehydration

Even though these causes usually are not life-threatening, there is significant morbidity such as falls and fractures.

Potentially life-threatening etiologies include:

Bradyarrhythmias: slow heart rate (heart rate less than 40 beats per minute or no heart beat for 3 or more seconds) or heart block (electric pathway between upper and lower chambers disrupted).

Tachyarrhythmias: ventricular tachycardia (irregular heart rhythm from the lower chambers)

Heart attack

Blood clot in the lungs

Structural heart disease, obstruction to the blood flow from the lower chamber: thickened heart muscle or blockage in the aortic valve  

The prognosis in cardiac related syncope is much worse than the other types. With vasovagal syncope, the prognosis is the same as the general population. In both groups, 60% are alive 15 years after the event. In patients with a cardiac cause, only 20% are alive at 15 years. Therefore, it is important to determine whether the cause of syncope is due to a heart related issue.

 

Syncope is a symptom and finding an accurate diagnosis is imperative. However, trying to determine the cause of a syncopal episode is notoriously difficult. Even in the best of circumstances a diagnosis can be attributed in only about 50% of cases. There are many diagnostic tests that can be ordered including, CT scan, MRI, ambulatory external monitor (one to three days or one to four weeks), implantable cardiac monitor, stress test, catheterization, ultrasound of the neck arteries, electrophysiology study, tilt table test. One or more of these tests may be appropriate in the right situation, but not every patient with syncope needs multiple tests.  The items with the greatest diagnostic yield are the history, the physical exam, an electrocardiogram (EKG) and an echocardiogram (ultrasound of the heart). These should be done on all patients and further tests can be ordered as needed.  The history, the circumstances surrounding the event, is the key.

If the syncope occurs:

With an unpleasant stimulus (for example, a needle stick), think vasovagal.

With coughing, swallowing, urinating, defecating, think situational.

In any position (especially while sitting or lying down), think cardiac.

With standing up, think orthostatic hypotension.

With nausea, sweating or flushing, think vasovagal.

With palpitations or chest pain, think cardiac.

With history of heart disease or male or older age, think cardiac.

With blood pressure drop on standing, think orthostatic hypotension.

With associated head or facial trauma, think cardiac.

With normal physical exam, EKG and echocardiogram (structural heart disease less likely), think noncardiac cause.

After evaluating these four items, a risk assessment can be made, further testing ordered tailored to the situation and appropriate treatment begun.

 

So, if you find yourself watching a changing of the guard in the hot mid-day sun and you pass out, take it seriously. Head to the nearest emergency room immediately, even if you are low risk and even if you feel perfectly normal after recovering.  

The Chaos of Atrial Fibrillation

 

Chaos is defined as a state of disorder, disarray, a lack of organization. Atrial fibrillation (Afib) is a disorganized, chaotic heart rhythm. Chaos theory is a branch of science and mathematics that seeks to find connections and repetitive patterns in chaotic systems (for example weather patterns, stock market trends, or understanding complex medical systems). It seeks to bring order to the chaos. This review will try to bring some order to the chaotic world of Afib. 

 

During normal heart rhythm, the atria (the upper chambers of the heart) beat smoothly and rhythmically. In Afib, the atria fibrillate and beat chaotically, like a bag of squirming worms. Afib is triggered by extra beats (premature atrial contractions) that arise in the pulmonary veins (there are 4 pulmonary veins bringing blood from the lungs into the left atrium). The extra beats start the rhythm, then multiple electrical wavelets travel in a random, chaotic way through the atria. The wavelets disrupt the normal, organized contraction of the atria, leading to disorganization and “squirmy atria”.

 

Afib is the most common arrhythmia encountered in cardiology. About 3 to 6 million people in the US currently have Afib and that number is expected to rise in the coming years (to about 12 million by 2030). The prevalence of Afib rises with age. About 1% to 3% of 60-year-olds have Afib while 10% to 11% of 80-year-olds have it. Afib causes serious medical problems, increasing the risk for stroke by 5 times, the risk for congestive heart failure by 3 times and the risk of death by 2 times. 

 

Risk factors for developing Afib include: high blood pressure, valvular heart disease, congestive heart failure, heart attack, sedentary lifestyle, obesity, alcohol, smoking, sleep apnea, and thyroid disease. However, it is not just the old and the sick who have Afib. Famous people who have had Afib include: George HW Bush, Dick Cheney, Tony Blair, Barry Manilow, Elton John, Roger Moore (aka, James Bond), Kareem Abdul-Jabbar, Larry Bird, Jerry West, Billie Jean King, Mark Spitz, and Mario Lemieux.  The athletes on this list might be surprising, but there are many Olympic athletes who have had Afib. In fact, studies have shown that high volume exercisers, professional and amateur, are prone to Afib. Elite, Olympic rowers are seven times more likely to develop Afib compared to the average person. 

 

Afib is diagnosed on an electrocardiogram (EKG) or on a rhythm strip. Often, Afib is fleeting and short- and long-term monitors have been developed to try to catch Afib. An example of a short-term monitor is a Holter monitor, which assesses the heart’s rhythm for one to three days. An event monitor is a patch that provides more long-term evaluation and is worn for one to four weeks. Wearable devices (such as an Apple watch) can detect Afib and the detection algorithms are getting better and better. Still, wearable devices are only about 70% accurate in determining Afib. The diagnosis must be confirmed by a medical-grade device. 

 

The treatment for Afib occurs on several levels. Almost everyone is put on a blood thinner to prevent blood clots and strokes. If the heart rate is fast, beta blockers (such as metoprolol) or calcium channel blockers (for example diltiazem) are used to slow the heart rate. If appropriate, cardioversion is recommended. Cardioversion is performed with the patient under light anesthesia. An electric shock is given via pads placed on the chest. This resets the heart rhythm and, in many cases, returns the patient to normal sinus rhythm. In addition, antiarrhythmic agents may be employed (for example, amiodarone, sotalol or flecainide). Antiarrhythmics are powerful medications with many side effects. In addition, they are only moderately effective. The best agent, amiodarone, can only keep a patient in normal rhythm 60% of the time. What else can be done to bring order to Afib?

 

Catheter ablation is an invasive procedure to try to cure Afib. Cardiologists who specialize in arrhythmias (electrophysiologists) place a catheter around each of the four pulmonary veins and create a scar (using radiofrequency or pulsed field energy). The scar acts as an electrical barrier, preventing the wavelets in the pulmonary veins from escaping and precipitating Afib in the atria. The ablationists can eliminate Afib about 80% of the time; so let’s call them the chaos crushers. What can the average person do to avoid Afib and an ablation? Several lifestyle modifications can be initiated to prevent Afib. Being sedentary is a huge risk factor for Afib. Moderate exercise will decrease the risk substantially. If obese (BMI > 27), losing 10% or more of body weight almost cures Afib. Treating sleep apnea decreases the risk of Afib by 40%. Lastly, stopping or cutting back on alcohol consumption lowers the risk of Afib.

 

Life can be chaotic. Your heart rhythm doesn’t have to be.  Take care of the factors that you can control. See your doctor and treat any medical issues that might lead to Afib (bring blood pressure down or treat sleep apnea, for example). Initiate the lifestyle changes noted earlier to decrease the risk of Afib. This is the theory on how to control the chaos king of cardiology, Afib.

  

Wheel of Four Chambers

Pat Oceanridge: Welcome to our fun new game show, Wheel of Four Chambers. We have with us today three prominent cardiologists who will try to guess our mystery phrases pertaining to a concept in cardiology. First up is Dr Robert Bruce from Rochester New York. He developed the stress test protocol that is used the world over. Next is Dr Hein Wellens from Holland, a master of the heart’s electrical system. Lastly, we have Dr Andreas Gruentzig from Switzerland, the father of cardiac angioplasty.

Pat Oceanridge: Doctors, here is the first phrase: 

            S_ _ _ n T_ _ _ s_ nd S_ _ ps P_ r _ _y

Dr Bruce: It is Seven Thousand Steps Per Day. 

Pat Oceanridge: Correct. Would you care to elaborate? 

Dr Bruce: Certainly. We don’t necessarily need to take 10,000 step per day to lower cardiac risk. In fact, 10,000 steps was a catch phrase made up in 1964 by a Japanese manufacturer of pedometers to sell more units. Good quality research shows us that fewer steps are needed for good health. A review of studies showed that the benefits of walking leveled off at around 5000 to 7000 steps per day. Compared to 2000 steps per day, taking 7000 steps per day lowered the risk of dying by 47%, decreased heart disease by 25%, lowered the risk of cancer by 6%, decreased type 2 diabetes by 14%, decreased dementia by 38% and reduced the chance of falling by 28%. Even walking 4000 steps per day (compared to 2000 steps) improved health outcomes. Another large review found that even increasing the step count from 2000 steps to 2500 steps per day lowered mortality by 8% and cardiac disease by 11%. This study also noted that the benefit leveled off at 7000 to 8000 steps per day. The bottom line is that the more steps taken per day, the better the benefit and the optimal number of steps is between 4000 and 7000 steps per day. 

Pat Oceanridge: Very good. Here is our next phrase: O_ _ L _ gg _d S _ _ _ d

Dr Wellens: I would guess One Legged Stand

Pat Oceanridge: Excellent. Can you explain?

Dr Wellens: It is well known that muscle mass, muscle strength and balance all decline as we get older. Men will lose 33% and women 26% of their muscle mass between 60 and 90 years of age. Muscle strength goes down linearly with each decade as well. It is also well known that with loss of muscle mass, muscle strength and worsening balance, the risk for falls increases and the risk of dying goes up. For example, people with low muscle mass are 86% more likely to die compared to people with higher muscle mass. The same is true for muscle strength. We know how to measure cardiac fitness (using the stress test). We don’t have a standardized way to measure non-cardiac fitness (muscle mass, strength and balance). One way is the one-legged stand. It is easy to do, it doesn’t require special equipment and it tests both muscle strength and balance. The test is simple: stand on one leg without holding onto anything. If you can do this for 10 seconds or more, then you pass the test. As expected, the ability to pass the 10 second one-legged stand decreases with aging. It reaches 50/50 at around age 70 (ie, 50% of 70-year-olds can stand on one leg for 10 seconds or more). It turns out that the risk of dying for those who cannot do a 10 second leg stand is 3.8 times higher than those who can.

Pat Oceanridge: A great discussion. Here is the next phrase: S _ tt _ _ g T_ R _ s _ _ g

Dr Greuntzig: I know! I know! Sitting To Rising. Another easy test that measures non-cardiac fitness is the sitting to rising test. This test assesses all the main components discussed earlier: muscle mass, muscle strength and balance. The test is easy: sit on the floor and try to rise using the minimum amount of support that you need, then sit back down again.  A score of 5 is given for sitting or rising without any support. One point is subtracted if you need to use a hand, arm, knee or side of leg to help you. How does sitting and rising translate into a longer life? In people aged 46 to 75 years old, the lower the sitting to rising score, the higher the mortality. Those with low scores have a 5 to 6 times higher risk of dying compared to those with higher scores. It may also be a factor in longevity on the Blue Zone Japanese island of Okinawa. On the island people sit on the floor to eat and to socialize, sitting and rising multiple times through the day, thus maintaining strength and balance late in life.

Pat Oceanridge: The next phrase is: D _ m _ n _ _ a

Dr Bruce: The phrase looks familiar, but I’m having trouble coming up with the answer. Oh, wait. Dementia!

Pat Ocenridge: Yes! Would you care to enlighten us on what is new in the world of diagnosing and delaying Alzheimer’s disease?

Dr Bruce: It takes at least 20 years for Alzheimer’s disease to manifest. Over that 20 years, amyloid and other proteins (tau proteins) accumulate in the brain and initiate inflammation. A major milestone is the development of a very accurate blood test to predict Alzheimer’s disease. The blood test is called p-Tau217 and it tracks brain pathology. In people who don’t have dementia or even mild cognitive impairment, p-Tau217 can predict the development of Alzheimer’s disease years into the future. In addition, the blood test will go down with intervention (for example starting an exercise program) so it can be used to track the disease. As p-Tau217 levels go down, dementia progression is slowed. We are not yet sure who should get the blood test, but in the future p-Tau217 may be used to predict and track Alzheimer’s disease much like cholesterol levels are used in heart disease today.

Once high-risk cases are identified (abnormal p-Tau217, family history of Alzheimer’s, genetic variant in apolipoproteinE4) dementia can be delayed. Life style modifications can be made (exercise, weight loss, following a Mediterranean diet, smoking cessation, avoiding excess alcohol, reducing ultraprocessed foods) and treating chronic diseases (high blood pressure, diabetes, hearing and vision loss) can slow the progression. What about brain boosting supplements? Most research has shown that these supplements don’t have the benefit that they claim in advertisements. However, there are new approaches which seem promising. For example, taking a multivitamin pill may help with cognition in older adults. Music may be helpful as well. It has been reported that people who play a musical instrument (especially keyboard or woodwind) have better working memory and executive function than those who aren’t musical.

Pat Oceanridge: Here is our last phrase: Sh _ n _  l _ s

Dr Wellens: I just had a case. It is Shingles. Shingles is very painful and can have long -term consequences; it is not fun to get. It is caused by a virus, varicella-zoster, that also causes chicken pox. If you had chickenpox as a child, the virus can live in your nerve cells for years. Later in life, with stress or with a weakened immune system, the virus is activated. It causes a rash and severe pain in the skin attached to the nerve. Fortunately, there is a vaccine which can help prevent shingles called Shingrix. One side benefit from the vaccine is that it reduces the risk for dementia. People who received the vaccine are 20% less likely to develop dementia. The vaccine decreases inflammation along the brain blood vessels caused by the virus and boosts the immune system, causing it to remove harmful proteins such as amyloid. So it may be worth getting the vaccine for a couple of reasons.

Pat Oceanridge: That is it for our installment of Wheel of Four Chambers. I’d like to thank our esteemed guests for playing and enlightening us.

Processing The French Paradox

 

The French love their food. The world loves French food as well with French cuisine often voted among the best on the planet. French dishes, however, with their emphasis on sauces and cheeses, are high in saturated fat and cholesterol. Despite this, the French have a low incidence of heart disease. This is the French paradox: why is there a low rate of heart artery disease despite a dietary pattern heavy in saturated fat? Many theories and much research has tried to explain this paradox. One theory is that the French drink more red wine than other cultures and that the wine helps protect against heart disease. However, this is likely not the case as we are discovering that alcohol, even red wine, is not heart healthy. Could the types of food used in French cuisine provide the answer?

In 2010, a new classification of foods was presented. The NOVA classification categorizes foods not based on their nutrients, but on the degree of processing that they undergo prior to consumption. It turns out that processing is really important. There are four groups in the classification. Group 1 foods are unprocessed or minimally processed and no substances are added to the original food. Examples include fresh fruit, vegetables, nuts, eggs, and pasta. Group 2 includes ingredients used in cooking such as sugar, oil, butter and salt. Group 3 foods are processed. Foods from Group1 and Group 2 are altered, usually using preservation techniques like canning, freezing, smoking, curing or pickling. Group 4 foods are ultraprocessed containing artificial ingredients, additives, emulsifiers, colorings and flavorings. Ultraprocessed foods are made in laboratories with little or no whole foods included in their make-up.  Ultraprocessed foods are meant to replace fresh meals. Examples include sugar sweetened beverages, processed meat (example, hot dogs, sausages), sweet snacks and deserts, frozen dishes, canned soups, frozen pizzas, chicken nuggets and ice cream. Other, somewhat surprising, items are yogurt, diary-based desserts, bread and cold cereal. How can you tell if something is ultraprocessed? If you can’t make the food item with ingredients in your home kitchen, then it is likely ultraprocessed. 

Ultraprocessed foods are extremely common. In the US and the United Kingdom more than 50% of calories come from these foods. On the other end of the spectrum, about 20% of energy is from ultraprocessed items in Italy and Greece. It has been shown that the greater the consumption of ultraprocessed products, the greater the risk for death, cardiovascular disease and stroke. Those with the highest intake of ultraprocessed foods have a 17% increase risk for cardiac disease mortality. The detrimental health effects are directly related to the amount consumed. If more than 40% of calories come from ultraprocessed foods, then adverse outcomes occur. Eating <30% does not worsen health outcomes. In the 30-40% range there doesn’t seem to be much harm. Consuming about 40% of calories from ultraprocessed foods equates to about 10 servings per day, while 20% is about 3-4 servings per day. In addition to adverse cardiac events, those whom consume > 40% have an increase in blood sugar and about 24% increased risk of diabetes. Also, since ultraprocessed foods are energy dense, there is an increase in weight associated with increased usage. These foods are designed to be addictive, causing you to consume more and more. The more calories that are eaten, the more weight gained. Lastly, high consumption of ultraprocessed foods increase the risk of cognitive decline, dementia and Parkinson’s disease, but it doesn’t seem to increase the risk for cancer. The bottom line is that eating a single, ultraprocessed item alone is not bad for you, but eating multiple servings each day is not good for overall health. The dose matters. Not all ultraprocessed foods are harmful. The two leading items that cause the most harm are sugar or artificially sweetened beverages and processed meats. Most of the other ultraprocessed foods seem to be neutral in terms of their adverse effects. Some ultraprocessed foods, such as breads, cold cereals and yogurt, actually decrease the risk of cardiovascular disease.

A recent study found that 39% of Americans believe that processed foods are not healthy. However, processing is not necessarily all bad. Processing prevents food from going bad, allows it to be transported and makes certain items available that are not in season. Some processed foods even decrease cardiac risk. The key is knowing which ultraprocessed foods to avoid and to keep consumption relatively low.

It is certainly possible that the type of food in the French diet could account for the French paradox. French cuisine emphasizes whole foods such as fresh fruits, vegetables and olive oil and is low in ultraprocessed food.  In fact, the French consumption of ultraprocessed foods is about 30%, putting them in the lower risk category. So, to decrease your risk for cardiovascular disease, diabetes and other adverse health outcomes, be like the French and focus on eating whole foods, while eliminating sugar sweetened beverages and processed meats.