Longevity and Healthy Aging: Two Competing Visions (Part 2 of 5)

Exercise as Intervention; or "the Most Powerful Medicine Available."

Exercise

Previously, for our first post in this series, we discussed the catastrophic effects of chronic diseases on American public health, and on our annual health expenditures. Experiencing a demographic shift, the USA has an aging population. The data is damning: Americans are NOT aging well (CDC, 2023: 1, 2023: 2).

                             Image Source USA CDC, 2023. Public Domain

We want solutions, not doom and gloom forecasts. We want to extend Healthspan across the Lifespan, and when necessary and possible, reverse or ameliorate the chronic diseases from which currently 6 of 10 American adults suffer (CDC, 2023: 1).

Our Four Experts in General Harmony

For these concerns, the “most powerful medicine available,” Sullivan (2016) declares, is “exercise medicine” which “has beneficial effects at every stratum of biological organization, from the molecular and cellular levels to the realm of neuropsychiatric health.”

Likewise, Luks (2022) declares that exercise “is the best medicine for your physical and emotional well-being” because it positively impacts “our weight, our glucose metabolism, our sleep, blood pressure, and the function of our immune system.”

“I used to prioritize nutrition over everything else,” Attia (2023) remarks, “but I now consider exercise to be the most potent longevity ‘drug’ in our arsenal, in terms of lifespan and healthspan.” Why? Because Attia (2023) has found that the “data are unambiguous: exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention.”

“The fitter you are, the healthier and longer you live,” Hyman (2023) declares, and so exercise is the “one simple intervention that can help reverse most of the hallmarks of aging."

The Research Behind the Consensus

We have strong consensus among our four medical doctors on the importance and centrality of Exercise to Healthspan and even Lifespan. Let us briefly review two major, large-scale studies which provide support for this consensus. The first concerns grip strength (which serves as a reliable proxy for overall strength); and the second concerns cardiorespiratory fitness (CRF).

Examining the data for over 460K participants, Esteban-Cornejo, et alia (2022: 10.1002/jcsm.12857) found that “lower grip-strength was associated with a higher risk of all-cause dementia incidence and mortality, independently of important confounding factors.”

The charts below show the results from three models. Model 1: Adjusted for Age, Sex, Ethnicity, and Deprivation.  Model 2: Adjusted for Health-related Conditions, including BMI and Co-Morbidities. Model 3: Adjusted for Lifestyle Behaviors (Diet; Smoking; etc). The top row shows the results for Dementia; the bottom row, for Mortality. For all models (1 to 3) for both negative outcomes (Dementia & Mortality), risk decreases as strength increases. (The dotted horizontal line indicates the baseline risk for people with poor grip strength — that is, poor general strength).

                        Source: Esteban-Cornejo, et alia (2022: 10.1002/jcsm.12857)

So “independently of important confounding factors,” being stronger lowers your risk for dementia and improves your chances of living longer.

Strength Matters

Strength matters. Particularly so for healthy aging, as confirmed by yet another recent study (2022: 10.1152/ajpcell.00365.2021) — this one a randomized controlled trial. For the public science exposition by lead researcher, Casper Søndenbroe, PhD, please see “Are you aged 40 or over? In that case, you need to do heavy weight training to keep fit” (Jul 15, 2022).

On the same, American Exile discussed the basics earlier in “Why Strength Training is Fundamental to Health and to Preventing Cognitive Decline” (Jul 9, 2022).

Cardiorespiratory Fitness Matters

Basic cardiorespiratory fitness also greatly matters — with no marathon running required. Examining “Cardiorespiratory Fitness and Mortality Risk Across the Spectra of Age, Race, and Sex” in a study size of over 750K people, Kokkinos, et alia (2022: 10.1016/j.jacc.2022.05.031) found that “relatively poor CRF [cardiorespiratory fitness] is a stronger predictor of mortality than any of the traditional risk factors examined regardless of age, sex, or race.”  

“Any of the traditional risk factors”: poor CRF is worse than smoking, believe it or not. Moreover, the study found that by achieving even moderate CRF, people could significantly reduce their risk — by “at least 50%” in most cases.

Build strength and improve CRF. But how? What exercises? When? How often? And how do we measure results?  

Exercise Prescriptions

For people new to, or getting back to, or intimidated by exercise, Luks (2022) provides the most accessible, immediately actionable, and friendly approach. For Luks (2022), a good exercise program has four pillars:

1. Resistance Training (strength)

2. Aerobic (cardiorespiratory fitness)

3. Balance & Mobility (coordination; strength; flexibility; and range of motion)

4. High Intensity Training (cardiorespiratory fitness)

He provides a basic but highly useful and actionable guide to getting started with all four. Longevity…Simplified (2022) has our highest recommendation for a general readership. Or, even to an expert audience for a case study in communication effectiveness. Truly outstanding. 

Beyond Beginnings

But people with more experience — such as recreational athletes, personal trainers, physical therapists, and so on — will want more. People who are performance-driven and work with data professionally, who want numbers, benchmarks, models and deep dives, will also want more. And medical professionals who share the interests of Sullivan, Luks, Attia, and Hyman will also want more.

When it comes to a discussion of exercise, Hyman (2023) does not advance upon Luks (2022) — politely put. We can safely drop Hyman (2023) from the remainder of this section. In contrast, Sullivan (2016) and Attia (2023) both strive diligently at designing exercise prescriptions.

For their exercise prescriptions, Sullivan (2016) and Attia (2023) offer two highly detailed but divergent approaches. Before describing their considerable differences, let’s focus on one key commonality.

Performance in the Arena of Life: Sullivan and Attia

Both Sullivan (2016) and Attia (2023) are concerned with what people need to do — and ideally, want to do — in real life. Consequently, exercise must result in greater functionality as well as extended Healthspan — and the ultimate performance metrics are not based on lab or gym results, but on the individual’s ability to safely and successfully complete needed and desired tasks.

Sullivan (2016) understands this as “performance in the Arena of Life”:

We’re talking about the ability to get out of bed, snatch a child from danger, lift a box overhead into a cupboard, pick up a heavy bag of groceries, leap for joy, play Frisbee with the dog, remodel the bathroom, row a boat across the fishing pond, or make love to our spouse.

All of these and other activities that “play out in the Arena of Life,” Sullivan (2016) declares, “involve expressions of strength, power, mobility, and balance” and none of them “involve running, biking, swimming or skiing for hours” or “feats of aerobic endurance.” So prioritize “strength, power, mobility, and balance.”

Sullivan (2016) is concerned that endurance training directly competes with strength training, not only in terms of time but also on the molecular level. For those lacking access to Sullivan’s tome, Andy Galpin, PhD, has an excellent discussion of this topic on the Huberman Lab podcast (25 Jan 2023) at 00:45:56.

Sullivan: Fight Sarcopenia

Likewise, Sullivan (2016) from his years of experience as an emergency room doctor knows firsthand the dangers of sarcopenia (muscle-wasting): “Muscle loss is endemic in older individuals, and it predicts frailty, illness, loss of independence, injury, and all-cause mortality.” In contrast, retaining lean muscle has considerable health benefits:

Healthy muscle is also a deep biological sink for carbohydrate and fat disposal, bristling with receptors sensitive to insulin signaling, and the most abundant secretory tissue, pound-for-pound, in the human body — your most massive ‘gland’.

So build strength, retain or increase lean muscle mass, and improve your CRF along the way. Biking, tennis, tai-chi, kick-boxing, walking your dog — all good. Be active. But your TRAINING is strength-training, and for Sullivan, barbells are the preferred toolkit with an emphasis on five major movements: squat, hip hinge (deadlift), press, pull, and loaded carry.

Sullivan (2016) to his considerable credit devotes three chapters, chapters 4 to 6, discussing alternatives to and hence the rationale for his Barbell Prescription. Chapters 7 to 13 comprise Sullivan (2016) and Andy Baker, SSC describing the Barbell Prescription framework. Obviously,  Sullivan (2016)  has thought about these concerns carefully and thoroughly, and provides for many people what would prove a hugely beneficial and readily actionable solution.

Are Barbells for Everyone?

Your author uses dumbbells and kettlebells instead of barbells for many major lifts, based on a previous mountain-biking injury which left one shoulder permanently subluxated. Your author can and does still lift heavy — but forcing symmetry of path as the barbell does on many movements is a recipe for injury. Certain barbell lifts presume an orthopedic normality which not all adults possess for various reasons.

Likewise, another possible criticism of Sullivan’s Barbell Prescription is that he undervalues the importance of working in the transverse plane — doing rotational exercises, in layperson’s speak. This is where suspension training (TRX, to many people), resistance-band training, and weighted tools like kettlebells, Indian clubs, and the Bulgarian bag can prove highly useful. As someone with years of on-again, off-again fight training, and as someone who is still taking boxing lessons after six decades on planet earth, your author has come to know that working in the transverse plane is not only essential to combat sports but also transfers readily to many daily life activities.

Roll your own CRF?

Moreover, for another possible criticism, although he recognizes the value of HIIT (High-Intensity Interval Training), Sullivan (2016) seems generally uninterested in programming for CRF. People are encouraged to do whatever they like — provided it does not interfere with their strength-training regime. This approach seems overly informal, but is perhaps well-suited to the busy adults who participate in his Greysteel Strength & Conditioning clinics. Sullivan knows better than your author who his clients are.

These remarks notwithstanding, Sullivan (2016) still provides the basis for strength training as it concerns Healthspan and longevity. Whether his Barbell Prescription is sufficient or appropriate for nearly all American adults over 40 is up for debate – but some form of resistance training certainly is required for improved Healthspan and perhaps an extended Lifespan. Strength training is essential.

Attia: Maintain Your Active Lifestyle

In contrast to Sullivan (2016), MD, PhD, the former emergency room doctor turned Professional Barbell Coach and personal trainer in his presumed retirement years, the Stanford and Hopkins educated MD turned investment banker and then returned to medical practice Attia (2023) deals with a rather more affluent clientele: “[My patients] feel supremely confident that they will still be snowboarding or kickboxing, or whatever else it is they enjoy doing now, when they’re in their seventies and eighties.”

Attia (2023) informs these Type A (and often enough, A-list) seekers of performance and longevity:

In order to do that, you will need to have a certain level of muscular strength and aerobic fitness at that age. But even right now, at age fifty-two (for example), your strength and your maximum volume of oxygen uptake (VO2 max) are already barely sufficient to do those things, and they are virtually certain to decline from here.

Attia (2023) also — like Sullivan (2016) — emphasizes that older adults need physical strength, cardiorespiratory fitness, and cognitive reserve simply to function:

The list [of daily activities] includes such basic tasks as preparing a meal for oneself, walking without assistance, bathing and grooming, using a phone, going to the grocery store, handling personal finances, and so on. ... [To] continue to live actively as we age, retaining even these minimal abilities, requires us to begin building a foundation of fitness and to maintain it diligently.

Again, all this strongly overlaps with what Sullivan (2016) refers to as your "Physiological 401K: saving strong muscle, hard bone, and full mobility for your retirement." But Attia (2023) pays greater attention to cardiorespiratory fitness (CRF) and cognitive reserve. He breaks exercise down as follows: “strength, stability, aerobic efficiency, and peak aerobic capacity.”

Set Goals for CRF as well as Strength

Since Attia (2023) holds that “increasing your limits in each of these areas is necessary if you are hoping to reach your limit of lifespan and healthspan,” his exercise prescription sets benchmarks for VO2 max as well as muscular strength, and includes ZONE 2 training as well as high-intensity work for CRF. This is similar to but a more intensely designed and quantified version of the “four pillars” recommended by Luks (2022).

Use Technology to Monitor Progress

Attia (2023) also heavily uses technology: fitness trackers, glucose monitors, DEXA body composition scans, blood testing well beyond the basic metabolic panel, and more. (We will discuss some aspects of this in the section on Bio-Hacking). He establishes both age-related and biological sex related fitness benchmarks for his clients, but also seems to heavily customize their fitness programs as per the individual client.

For strength and resistance training as programmed by Attia (2023), the barbell exercises endorsed by Sullivan (2016) are one valuable option in a larger toolkit. Attia (2023) also seems always to program for improving aerobic efficiency (some degree of cardio endurance) and increasing VO2 max.

In our upcoming post on Bio-Hacking, which follows our next post on Diet and Metabolic Health, we will discuss further how our experts recommend using technology to improve health outcomes.

Summing Up Exercise as Intervention

Although your author feels that the pioneering Sullivan (2016) is criminally undervalued, the last expert words for our discussion of exercise will go to Attia (2023), who expresses here nothing that Sullivan (2016) or Luks (2022) would disagree with:

Exercise has the greatest power to determine how you will live out the rest of your life. There are reams of data supporting the notion that even a fairly minimal amount of exercise can lengthen your life by several years. It delays the onset of chronic diseases, pretty much across the board, but it is also amazingly effective at extending and improving healthspan. Not only does it reverse physical decline, which I suppose is somewhat obvious, but it can slow or reverse cognitive decline as well.

Get moving. Get stronger. You will live better — and you will likely live longer.

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Necessary Disclaimer: American Exile does not offer medical advice, and none of our five posts in this series on Longevity should be understood as such.

Sources are cited in text. The four primary books discussed above: Sullivan (2016), The Barbell Prescription: Strength Training for Life After 40; Luks (2022), Longevity…Simplified. Living A Longer, Healthier Life Shouldn’t Be Complicated; Hyman (2023), Young Forever: The Secrets to Living Your Longest, Healthiest Life; and Attia (2023), Outlive: The Science & Art of Longevity.