Full text of American author and cardiologist James O’Keefe’s talk: Run for your life! At a comfortable pace, and not too far at TEDxUMKC conference.
Listen to the MP3 Audio here: Run for your life! At a comfortable pace, and not too far by James O’Keefe at TEDxUMKC
Great to be here. I’m a cardiologist, but before that, I was an exercise enthusiast. I’ve exercised, I bet, pretty much everyday of my life.
I had two grandfathers who were alcoholics. But for me, my way of coping with life is exercise. When I’m nervous, or anxious, or tired or, happy, or sad, or whatever, I exercise, if I have the time, and sometimes even when I don’t. You might have seen me in an airport, waiting for a flight, running up the down escalator with my backpack on, to kill 20 minutes.
But I always thought that exercise was the best thing for my heart, and I think it’s how I decided, at age 15, I wanted to be a cardiologist actually. But now that I am 56 [years old], and a lot of decades have gone by, I’ve started to have a few warning signs from my heart. A couple years ago I noticed this, and I got on a mission. I’m a research cardiologist, and I have a research fellow. And he and I have been working on this for the past couple years. And with the help of some of the brightest cardiologists from around the country, we had come to some startling new insights that seem to emerging about exercise.
This made me think twice about my lifestyle, and I’m worried I may have made a lethal mistake. I hope it’s not too late, but let me tell you the story.
So, as I said, I have been exercising for a long time. But if we go back 2,500 years, there was a guy named Pheidippides who ran the 26 miles from a battlefield near Marathon, Greece, into Athens to proclaim the news about a momentous victory over the Persians. When he arrived at the Emperor’s throne and said, “Victory is ours,” he abruptly collapsed and died.
Now, you may have heard that story before, but what you probably didn’t know is that Pheidippides was an accomplished runner. He’d been a Greek herald messenger his whole life. He ran a lot of miles everyday. I bet he was the fittest guy in Athens the day he died. That’s strange.
But now let’s go forward two millennia or more. When the Baby Boomers came of age, another boom happened: the running boom. If exercise was good for you as anybody could know, then more had to be better, and that was — the ultimate sort of test of running and endurance was a marathon. There was a physician who became famous back in the mid-70s by boldly proclaiming that if you could complete a marathon, you were immune to heart attack. This urban myth actually still holds sway with a lot of physicians.
One of my patients and friends is John. He is 68 now, but he’s been running for 45 years. As he puts it, if he hasn’t run 12 miles in a day, he felt like he was wimping out. When I saw him, he came into see me, and I said, John, let’s do a cardiac scan, a CT scan, simple, little, non-invasive, quick, high tech scan of your heart. Your arteries, I’m sure, will be soft and supple, clean and healthy. So that’s what a normal cardiac scan should look like: no calcium whatsoever in these arteries. His is over here; his score was 1,800. Anything above zero is abnormal, anything over 400 is severe; at 1,800, his arteries are harder than his bones! That can’t be good, and he didn’t have any other risk factors to speak of.
So in fact, people do die during marathons, but let’s be realistic. If you look at the latest data, the risk is minuscule: 1 in 100,000 participants. I’ve gotten to be friends with a guy named Amby Burfoot. Amby won the Boston Marathon in 1968. He is currently editor-in-chief and has been a long time editor at Large at Runner’s World Magazine.
In conversations we’ve had in recent months, he has challenged me. “If endurance extreme exercises are so bad, show me the bodies.” He’s got a good point; 1 in 100,000 is a pretty low risk. But I’m not so worried about that; running is supposed to add years to your life, and even life to your years. So, could it be shortening your life expectancy? I’m not worried about dropping into a risk, I am just trying to do the right thing, I’m a cardiologist, I’m in the business of finding out the ideal diet and lifestyle. And I’m coming to the conclusion that running marathons and extreme endurance athletics do not fit into that recipe.
So, that being said, let me be clear about this: there is no single step you can take in your life to ensure robust health and remarkable longevity than a habit of daily exercise. Okay, and this is a study of over 400,000 Chinese that was just published within last year. We published an editorial along with this afterwards, but they found vigorous exercise — this is all cause mortality reduction, the more reduction the better, and this is minutes of daily exercise, so 10, 20, 30 minutes of daily exercise. At 45 or 50, you get a point of further plateau, so further efforts and time do not appear to convey further improvements in life expectancy.
Down here is light to moderate exercise: walking, housework, day to day moving around; just get off your seat and move around. More is better there; it’s not quite as beneficial as vigorous exercise, but more is better. You can exercise all day it seems, without getting yourself in trouble if you keep it down.
So, one of my heroes, I love evolutionary medicine, I think if you look in the world of nature and into our deep past, you can find the template for ideal health, even in our modern world. Charles Darwin was wrong about one thing though: it’s not the survival of the fittest. In fact, it’s the survival of the moderately fit, OK? If the best you can do is walk one flight of stairs before you have to rest, things are not looking good. It could be a bumpy ride in the next few years.
On the other hand, if you can dance, or lightly swim, or you can even jog six miles an hour, that’s a ten minute mile, come on, that’s a pretty comfortable pace, right? Your mortality plummets, and if you, after warming up on a treadmill, can achieve a speed of 7 to 7.5 miles an hour, you are pretty much bulletproof, when you look at outcomes. And in fact, further attainments of peak fitness do not translate into further increases in life expectancy. It plateaus out. In fact, there’s even a little trend that it might even go up a little bit.
So, the important concept is that dose makes the poison. It’s true with a lot of things, all right? And if we could come up with a pill that gave all the benefits that we got from exercise, I’d be looking for work. In fact, exercise not only cuts your chance of premature death in half, but it reduces risk of heart disease, Alzheimer, osteoporosis, depression. It is an amazing drug. But just like any drug, there is an ideal dose range. If you don’t take enough of it, you don’t get the benefit. If you take too much of it, it could be harmful, maybe even fatal.
When you’re sitting here, listening, sitting around like most Americans do, doing nothing, your heart’s pumping, just idling along about a gallon a minute, about four, five liters a minute. If we went out, went for a run right now, and you ran hard, that would go up four, five or even six-fold. Five or six gallons a minute! That’s a workout, your heart is working hard, but that’s what it’s meant to do, intermittently. You know maybe a few minutes, 5, 10, maybe 30 minutes, maybe up to 60 minutes but by 60 minutes something starts happening: the stretch in the chambers starts overwhelming, the muscle’s ability to adapt, the catecholamine levels, the adrenaline levels rise, the free radicals blossom, and it starts burning the heart. It starts searing and inflaming the inside of your coronary arteries.
So we’re not really meant for these sustained levels of exercise for hours at a time. If you go to a marathon, and this has been done several times, you take a troponin level at the end of the marathon, over half of them will have elevated troponins. What’s a troponin? Troponin is a sacred chemical to us, cardiologists. When we see that a troponin goes up it means one thing: heart muscle has died. Normally, we hop into action because that generally means there’s a heart attack going on, we need to get a vessel open! In this case, these are little micro tears from the stretching and the searing, and it’s not a big deal if you do it once. These are little micro tears, they heal; a few days later it’s gone, the heart’s back down to normal size. But if you do this over and over again, and the chambers start dialing up, they get scarred, they get stiff, they get thickened.
If you look closely you can see these little white patches in these veteran extreme endurance athletes that accumulate and people who have been doing this for years and decades, their heart becomes older before it’s time. We’re asking too much of it, it’s overwhelming the heart’s capacities. This is a fascinating study done by a cardiologist that I know, and whose son is also a cardiologist. These two were both avid runners up in Minnesota. They did a study looking at the CT scans, like I’ve showed you of John’s, they looked at a group of marathoners who have been doing this for at least 25 years at least 25 marathons during that time compared to secondary controls. And you can see here they had 62% more plaque despite fewer risk factors.
People say, “That can’t be true.” In fact, a German cardiologist just replicated this study showing in 108 marathoners with similar findings. Hard to dismiss. Veteran endurance athletes also have about a five-fold increase risk of atrial fibrillation, a dangerous irregular heart rhythm. There is sort of an epidemic of this going on among runners because we’ve only been doing this for a few decades and it takes a while for this to develop. And even more worse, when we see this, as cardiologists, our pupils dilate, our heart rate goes up; this is ventricular tachycardia, this is a potentially life threatening rhythm. And we can see this from the scarring in the ventricle in some endurance athletes.
So “Born to Run” is a book that was published, a non-fiction book, published just in 2009. The hero of this story is a guy named Micah True. He dropped out of American culture, went down to live with the Tarahumara Indians in the northern part of Mexico in the Copper canyons. He was an epic runner, legendary for his ability to run long distances, hundred mile races. The Indians down there nicknamed him “Caballo Blanco”, the White Horse, for his ability, for his remarkable endurance.
So Micah True died, sadly, at 58 years of age, on a routine 12-mile training run in the wilderness of New Mexico, in March of this year. When they did the autopsy, they found an enlarged, thickened heart with scar tissues. The coroner said, “idiopathic cardiomyopathy.” But I’ve looked at that path report, and it reads like a description of the pathology we might expect to see in some extreme endurance athletes. My colleague who wrote some of these papers with me, Peter McCullough, has coined the term “pheidippides cardiomyopathy.” That’s what he had.
So there’s a couple papers that are coming out in the next two months, and we’re publishing a couple papers as well. They are going to change the thinking about exercise. This is one of them by Chip Lavie, one of my colleagues, and maybe my best friend. He’s down in Ochsner Clinic in New Orleans. So this was a look at 50,000 runners. I mean 50,000 people – 52,000 people followed for decades, on average 15 years but up to 30 years. And they compared the non-runners, about 14,000 to the runners — the runners of 14,000 and the non-runners of 38,000 and what they found was that runners did live longer, 19% longer.
But if we look closer, you’ll see that the runners, compared to non-runners here, the risk of death, the reference is one. If you ran more 25 miles per week, your benefits went away. You only got this 25% to 27% reduction in mortality rate. If you ran between 5 and 20 miles a week, ideally 10 to 15 miles a week, and when we looked at the running speed, sure enough if you ran too fast, over eight miles per hour, which is a 7.30 pace, the benefits went away.
Now they weren’t worse than the non-runners, but heck if you’re running that much, you would think you’d get some health benefits, but no, you have to back off to a six or seven mile an hour pace, which is about a ten mile an hour jog. And interestingly, how many days a week? Seven days a week if you’re running, the benefits go away. You need to run fewer days, two to five ideally.
So another study that’ll be published soon is this one from across the pond. The Copenhagen City Heart Study compared non-runners to runners and they found the same thing. The relationship appears much like that of alcohol. Mortality is lower in people reporting moderate jogging than in non-joggers or those undertaking extreme exercise. The moderate joggers got a 44% reduction in mortality, they lived six years longer, but it went away if you over did it.
So the truth is that exercise does confer powerful benefits, and the belief is “more is better”. But we’re learning that more is not better in this case. One of my good friends Meghan Newcomer is a triathlete from New York City. She grew up next door, she’s a dear family friend, she’s one of the top triathletes in the country. She did ten races last year, and she is 30. She won half of them. The other half she collapsed from heat exhaustion, dangerous heat exhaustion near the end of the race.
I told Meghan, “Meg, if you want to be in the real Olympics, which you very well could be, you just keep hammering away, maybe up your game a bit. But if you want to be alive and well for the 2052 Olympics, 40 years from now, you need to back and way off. Back your pace off and find some healthier exercise pattern.”
So there’s one last study that I want to tell you about. This is a study from last year that looked at mice. And they hammered these mice, they ran them to exhaustion, every day, for four months, and you know what? This replicated those same findings that we saw in Micah True, and these other findings that I have been telling you about. But what provides hope to me is that when they took these guys off their iron mouse training regiments, their hearts came back down to normal. The fibrosis even melted away, and their ventricular irritability and atrial fibrillation tendencies, all gone.
Well, I’m a man, not a mouse, but here’s hoping that maybe that works in humans too. Anyway, we’re not meant to run. We’re not born to run, I should say. We’re born to walk. We need to be walking more today. We need to be strolling, we need to be moving our body rather than sitting. Every chance you get, move, and do some high intensity interval training from time to time. But personally, I’ve found that what I do now is I’ve shorten my runs up. I go, when I run, I run a one and a half to, at the most, three miles, but typically about two miles. I take the pace down, and I walk with my wife, I play with the kids, and I stop in meadows or parks, and do some yoga.
When I’m swimming, rather than churning away, I go on my back, and I do some nice gentle backstroke. I watch the clouds sail overhead, and see the birds soaring in the sky, and I can feel my heart relaxing, healing, and getting better.
So all things in moderation is not a new concept. This was something that one of Phidippides’ contemporaries, the father of medicine said, 2,500 years ago, “The right amount of nourishment and exercise, not too much, not too little, is the safest way to health.”
So I’ve never presented in my 30 years as a cardiologist such controversial data. But the truth is, this is a U-shaped curve. The couch potatoes are using this as an excuse to continue their sedentary behavior. And then there’s the whole extreme exercisers, people like me, who don’t want to hear these myths. In fact, they kind of want to kill the messenger. I’ve been getting a lot of adverse comments about this research.
But you know what I’ve decided? It is that you need to snuggle in to the safety of the middle of the “U” curve when it comes to exercise. Or when it comes to anything else in life. And to me, I’ve decided that running too fast and too hard is only going to speed up my progress towards the finish line in my life. So I’ve decided to back it off, and hopefully, enjoy more sunrises and sunsets.