Higher aerobic fitness linked to longevity and better quality of life

A new study from Cleveland clinic found that increased cardiorespiratory fitness (CRF) or aerobic fitness is associated with lower long-term all-cause mortality with no upper limit observed for the amount of exercise. Patients who demonstrated extreme CRF (≥2 SDs above the mean for age and sex) was at the lowest risk of adjusted all-cause mortality as compared to other performance groups.

People with poor aerobic fitness face the same likelihood of dying as that due to chronic diseases like diabetes, hypertension and cardiovascular disease note the researchers of this retrospective study published in the Journal of the American Medical Association Network Open.

This retrospective study recruited the largest reported cohort of 122 007 patients between Jan. 1, 1991, and Dec. 31, 2014, who underwent Exercise treadmill testing (ETT) at a tertiary care center. ETT eliminates the bias introduced due to self-reporting and is the most widely used method to measure the CRF.

Demographics and other co-morbidities were noted at the time of undergoing specified stress test under the supervision of exercise physiologist. Patients were classified into performance group by age- and sex-associated cutoffs as follows: elite (≥97.7th percentile), high (75th-97.6th percentile), above average (50th-74th percentile), below average (25th-49th percentile), and low (<25th percentile).

The mean age was 53.4years, and about 60% were male. As the performance level increased, the associated co-morbidities decreased except for hyperlipidemia (present in 30% of elite performers).

After multivariate analysis, it was seen that at any given point of time, patients in the elite group were 80% less likely to die as compared to patients with low CRF (elite vs. low: adjusted HR, 0.20; 95% CI, 0.16-0.24; P < .001). The survival benefit was more evident in older patients (70 and more) and those with hypertension. Long-term survival was adjusted for a patient’s age, sex, height, weight, BMI, medications, and comorbidities.

Hypertensive patients in the elite group were 30% less likely to suffer mortality as compared to those in the high-performance group (75th-97.6th percentile).

Patients with lowest aerobic fitness (<25th percentile) faced risks that were comparable or more than patients with chronic disease like CVD (24% more), diabetes (40% more) and smoking (40% more). 

These findings highlight the importance of aerobic fitness concerning prolonging life and improving the quality of life. This study reinforces the results of previous studies that have demonstrated the benefits of achieving CRF.

“Aerobic fitness is something that most patients can control. And we found in our study there is no limit to how much exercise is too much,” said Wael Jaber, M.D., Cleveland Clinic cardiologist and senior author of the study in a news release.  “Everyone should be encouraged to achieve and maintain high fitness levels.”

It also stresses the importance of continued high-level physical activity in older adults and the benefits of maintaining the highest aerobic fitness. Some recent studies have demonstrated an association between extreme high level of exercise and an increased incidence of atrial fibrillation, coronary artery calcification, myocardial fibrosis, and aortic dilation. However, it is not clear whether these findings are a simple physiological adaptation or because of cardiovascular pathology.

“We were particularly interested in the relationship between extremely high fitness and mortality,” said Kyle Mandsager, M.D., an electrophysiology fellow at Cleveland Clinic and the lead author of the study.  “This relationship has never been looked at using objectively measured fitness, and on such a large scale.”

The authors conclude, “Cardiorespiratory fitness is a modifiable indicator of long-term mortality, and health care professionals should encourage patients to achieve and maintain high levels of fitness.”

Full text

Cleveland clinic news release

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Do not use HRT solely for primary prevention of chronic diseases: USPSTF final recommendation

The US Preventive Services Task Force (USPSTF) recommends against the use of HRT in asymptomatic post-menopausal women solely for preventing chronic diseases in its final statement published yesterday in JAMA.

The recommendation holds good for estrogen alone or combined with progestin and upholds the previous 2012 statement.

The USPSTF statement does acknowledge few benefits of HRT in postmenopausal women such as reducing the risk of fractures and diabetes, but the potential harms outweigh the moderate benefits cited.

Combined use of estrogen and progestin is associated with increased risk of invasive breast cancer, coronary artery disease, venous thromboembolism, stroke, dementia, gallbladder disease, and urinary incontinence.

Use of estrogen alone predisposes the women to greater risk for thromboembolism, stroke, dementia, gallbladder disease, and urinary incontinence.

The recommendations were based on evidence from  Women's Health Initiative (WHI) trials, which were stopped early because of sufficient evidence of serious adverse effects in postmenopausal women.

The USPSTF statement is accompanied by an editorial by Cora E. Lewis, MD, MSPH, from the Division of Preventive Medicine at University of Alabama at Birmingham School of Medicine, and Melissa F. Wellons, MD, MHS, from the Division of Diabetes, Endocrinology and Metabolism at Vanderbilt University Medical Center in Nashville, Tennessee says that although the WHI trial was a observational study, till date no large sufficiently powered trials exist to recommend against the WHI conclusions.

The authors further asserted that these recommendations do not apply to “women who are considering hormone therapy for the management of menopausal symptoms, such as hot flashes or vaginal dryness. It also does not apply to women who have had premature menopause (primary ovarian insufficiency) or surgical menopause.”  

Also, the route of administration considered in the study is oral or transdermal and not creams and rings because those are not generally used for primary prevention of chronic conditions.

The editorial also mentions about the “timing hypothesis” put forward by the American Association of Clinical Endocrinologists/American College of Endocrinology in its July 2017 updated guidelines on menopause.

USPSTF statement stats that there is not sufficient evidence to support the “timing hypothesis” at present. It requires very large, sufficiently powered studies to evaluate the risk/benefit ratio in this specific age group.

At present, few women are on HRT, and physicians consider HRT only for the treatment of menopausal symptoms. Relatively healthy, younger menopausal women with severe climacteric symptoms may be prescribed HRT for symptoms relief and not for chronic disease prevention.

Full Text of  USPSTF guidance
 Editorial

‘All or none’ does not apply to walking, anything is better than nothing

Walking below recommended levels is also associated with lower all-cause mortality, even if the recommended goal is not met says the results of large prospective cohort study published online in in the American Journal of Preventive Medicine.

The current public health guidelines recommend >150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week; a goal met by only 50% of US adults.

Walking is the most common form of moderate- or vigorous-intensity physical activity (MVPA), and is known to be associated with lower incidence of cardiovascular disease, type 2 diabetes, and breast and colon cancers. But, its association with all-cause mortality has not been examined so far.

The study looked at data from 62,178 men (mean age 70.7 years) and 77,077 women (mean age 68.9 years), who were followed up for a period of 13 years from 1999–2012. The researchers studied the effect of moderate- or vigorous-intensity physical activity (MVPA) on all-cause mortality.

During the study period, 24,688 men and 18,933 women died.

The mean age of men was 71 years and 69 years for women, about 5.8% of men and 6.6% of women reported no MVPA when the study started. These ‘inactive’ individuals were 26% (HR=1.26) likely to die prematurely as compared to subjects who were active but not to the recommended level (only for <2 hours/week).

Meeting the minimum recommendation of walking one or two times per week was associated with 20% lower risk of mortality (HR=.77) which was at par with any MVPA.

Walking that extra mile than what was recommended did not add any extra benefit and the benefits were equivalent to meeting the requirements.

Walking one or two times per week as per the minimum recommendation also reduced the CVD and cancer mortality by 20% and 9% respectively.

All these results were adjusted by sex, baseline age, BMI, prevalent disease status, and leisure-time sitting.

Alpa Patel, PhD, the lead author and researcher at the American Cancer Society opines, “walking has been described as the “perfect exercise” because it is a simple action that is free, convenient, does not require any special equipment or training, and can be done at any age.”

The walking intensity in this study was not ‘power walk’ or ‘strolling in the garden’ but average walking that may make you slight breathless and you cover about a mile in 20 minutes. This constitutes moderate intensity activity.

In absolute figures not corrected for the confounders, it was seen that there was 4293 per 100,000 deaths for inactive participants vs  2851 for walking less than the recommended amount. That is 1442 fewer deaths per 100,000 than inactive participants.

And the number of deaths were further reduced to 2088 per 100,000 for those who met the walking guidelines.

A lot of people are now a day do a walking meeting instead of sitting meeting in the office. 

The authors conclude, “This study shows that engaging in walking is associated with increased longevity and has the potential to improve the public’s health significantly.”

Media: wisegeek. 

Abstract

Full Text

WHI Study: No increased all-cause mortality with menopausal hormone therapy

www.urmc.rochester.edu

Menopausal hormone therapy with conjugated equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) did not increase all-cause mortality and disease specific mortality in participants of Women’s Health Study(WHI) after nearly 2 decades of follow-up says the results of new data analysis published online in JAMA.

This study is specifically important because earlier studies have never looked into disease specific and all-cause mortality of women receiving hormone therapy. Menopausal hormone therapy is debated since decades, and the interest in prescribing HT waxes and wanes as new data is published.

The researchers analyzed data from two studies:  the first study was estrogen with progestin trial and the second was estrogen only trial published in JAMA in 2002 and 2004 respectively.

The researchers conducted an extended follow-up of women included in this trial for 18 years. The combined trial included 16,608 women with a uterus while the estrogen only trial included 10,739 women with a history of hysterectomy.

In the estrogen+ progesterone group, 8506 women were randomized to receive HT and 8102 were given placebo for a median of 5.6 years. In estrogen only group, 5310 women took estrogen and 5429 were placed on placebo for a median 7.2 years.

For the current analysis, the researchers pooled the data from these 2 studies, amounting to a total of 27,347 women, with ages between 50 to 79 years and 80.6% being white. These women were followed up for 18 years. There were 7489 deaths through December 31, 2014, including 1088 during the trial and 6401 since the trials ended.

All-cause mortality did not defer between the two study arms, it was 27.1% in the hormone therapy group vs 27.6% in the placebo group (hazard ratio [HR], 0.99 [95% CI, 0.94-1.03]) in the overall pooled cohort. The figures were similar for cardiovascular and cancer mortality.

The only difference in mortality was observed for breast cancer, with estrogen+ progesterone group facing a 44% increased risk relative to placebo while estrogen was protective against breast cancer and reduced the risk by 45%. 

Both the earlier trials were stopped early when it became clear that HT did not improve the CVD outcomes as for both trials the primary outcome was prevention of chronic diseases and not to gauge the effectiveness of HT in managing menopausal symptoms.

Hence, the results of the study are especially important as they reassure the physician and patient that HT can be safely used for management of menopausal symptoms with a positive risk/benefit profile.

At the same time, it should also be noted that HT increases risk of stroke and breast cancer and decreases risk of endometrial and uterine cancer and hip fractures.

Still, the results of the study cannot be applied in every situation and for all women. Women who are at high risk for blood clots and breast cancer, the added increased risk may outweigh the benefit of alleviating menopausal symptoms individually.

The article is accompanied by an editorial by Melissa McNeil, MD, MPH, from the University of Pittsburgh in Pennsylvania which highlights the complexity of the issue. She writes, "Although the long-term data on total and cause-specific cumulative mortality of pooled data for hormone users vs nonusers is both compelling and reassuring, several questions remain. Perhaps the most challenging question involves the issue of whether there is a difference in overall mortality by age and menopausal status at the time of initiation of hormone therapy."

"This reduction in mortality...thus remains suggestive but not definitive," Dr McNeil further added. 

"Other questions that remain include the optimal duration of hormone therapy and if an even earlier initiation of hormone therapy, such as within 2 years of the menopausal transition, would provide additional benefits."

So, the takeaway from the study results is: HRT can be prescribed to treat menopausal symptoms with a positive risk-benefit profile without increasing all cause, cardiovascular and cancer mortality. It however should not be prescribed for prevention of  CVD and other chronic conditions.

The authors have disclosed no relevant financial relationship.

Oophorectomy during premenopausal hysterectomy: Evaluating the prevalence

Nearly 1 in 3 women undergo oophorectomy during premenopausal hysterectomy in absence of appropriate indication, reports a study published ahead of print May 8, 2017 in North American Menopausal Society (NAMS) journal Menopause.  

Bilateral Oophorectomy before the age of menopause is associated with increased the risk of parkinsonism, cognitive impairment or dementia, and anxiety or depression. These women, particularly those who were below 45 years at the time of oophorectomy face 67% increase risk of all-cause mortality.

Analysis of data from Nurses’ Health Study also revealed that in 24 years follow up, women who were below 45 years at the time of surgery had 17% increased chances of non-fatal CHD.

In-fact, evidence suggests that at no age, oophorectomy shows any survival benefit.

The current study was a cross sectional analysis of data-base from California Office of Statewide Health Planning Development during a span of 6 years. (2008-2011).

Appropriate indications for oophorectomy with hysterectomy in the study were ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses.

A total of 57,776 benign premenopausal hysterectomies with oophorectomies were performed during the 6-year study period.

Out of these 57,776, 21,783 were found to be ‘inappropriate’ as no indication was found among the records.

Through the 6 years of study, the researchers observed a decreasing trend to perform oophorectomy with hysterectomy, but the percentage remain unchanged.

Women with Hispanic and African American ethnicity were more likely to undergo oophorectomy as compared to white women. (P < 0.001).

The authors concluded that, “the rate of inappropriate oophorectomy in California has not changed since the 2008 American College of Obstetricians and Gynecologists guidelines, and over one-third undergo oophorectomy without an appropriate indication documented”.

What does this mean for daily clinical practice?

Prophylactic Hysterectomy should only be done in cases were preponderance of evidence suggests that it will be beneficial to patient.

All patients should be counselled in detail before the surgery regarding the pros and cons of retaining the ovaries at the time of hysterectomy.

ACOG also recommends in favor of retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer.

In women with endometriosis, pelvic inflammatory disease, and chronic pelvic pain a decision should be taken after balancing the risk of reoperation vs the benefits of ovarian retention.

ACOG further recommends considering prophylactic salpingectomy in those women who are at population risk for ovarian cancer, and who opt for retention of ovaries.

‘Weekend warriors’ workout tied to longevity with low risk for CVD, cancer and all-cause mortality.

Courtesy: Pixabay

The standard recommendation by CDC[1] and American Heart Association[2] is 150 minutes of moderate or 75 minutes of vigorous physical activity per week for achieving health benefits for those aged 18 to 64 years. But, very few people can keep up with this routine and most of us just cram the workout of entire week into 1- 2 weekend sessions, 2-3 long runs or participating in our favorite sports like hiking, basketball or Zumba.

Courtesy: Pixabay

Well, although not ideal but, it reduces your risk of dying from cardiovascular, all cause and cancer by 30% according to a new study published in JAMA Internal Medicine online on January 9, 2017.[3] The study was conducted by researchers from the National Centre for Sport and Exercise Medicine–East Midlands at Loughborough University in the United Kingdom.

This study examined whether ‘weekend warriors’ also derive the same benefits as their more active, regularly hitting the gym counterparts.

Gary O’Donovan did a pooled analysis of 63 591 adult respondents (>40 years old) who answered a household based survey in England and Scotland. The survey was conducted between 1994 to 2012 and analyzed in 2016. The survey was prospectively linked to British National Health Service Central Registry which identified participants who died, including the cause of death.

For the purpose of analysis, the respondents very divided into 4 groups depending on their exercise pattern:  Those who  were inactive (reporting no moderate- or vigorous-intensity activities), insufficiently active (reporting <150 min/wk in moderate-intensity and <75 min/wk in vigorous-intensity activities), weekend warrior (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from 1 or 2 sessions), and regularly active (reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from ≥3 sessions). 

The mean age of the study participants was 58.6 years with nearly equal gender ratio. About 40,000 people did not exercise at all, 14000 were insufficiently active, 2500 were weekend warriors and 7000 people were regularly active.

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

A detailed analysis of ‘weekend warriors’ group showed that, men were more likely to work vigorously on weekends, mostly engaging in some sort of sports. Walking briskly was also very popular and reported by 30% of weekend warriors. Weekend warriors spent a total of 300 minutes exercising as compared to 450 minutes spent by those who are regular.

After adjustment for all confounders, as compared to inactive participants risk of all cause death for weekend warriors was 30% less (hazard ratio [HR], 0.70), risk of CVD was 40%( HR=0.60) less and cancer death was 18% less (HR= 0.82).

Similar pattern of risk reduction was found in insufficiently active people too, indicating any exercise is better than being totally inactive.

When analysis was run between inactive group and regular exercise group, the regularly active persons have a 35% decrease in all-cause mortality (HR=0.65),  41% lower CVD death(HR=0.59), and 21% lower cancer death(HR=0.79).

During the follow up period of 9 years, 8,800 people died, CVD being responsible for 2780 and cancer for 2500 deaths.

"These findings suggest that some physical activity in an isolated session, or low activity, is certainly better than no activity for reducing mortality risk," Hannah Arem and Loretta DiPietro, of George Washington University, wrote in a commentary accompanying the new study in the journal.

The study has its own limitations that it is dependent on self-reporting and assessed the activity level only once at the start of the study. The study also did not assess the risk of injury in the weekend warriors.

But, the encouraging new conclusion emerging from the study is for those who exercise less frequently is even 1-2 vigorous activity session per week have health benefits and can lower the mortality.

The recommendations by CDC for regular physical activity can be found here.

The recommendations by American Heart Association ( AHA)  for regular physical activity can be found here.

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[1] https://www.cdc.gov/physicalactivity/basics/adults/

[2] http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp#.WIPgqBsrK00

[3] http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596007