Essential Exercise

Did I lie to you?

TLDR

• Exercise is non-negotiable if you’re serious about healthspan. It’s the most powerful intervention that we know of, beating medicine, nutrition and sleep.

• Exercise improves our quality of life by protecting our physical abilities and enhancing our mood.

• It also acts directly on almost every system of the body, reducing our risk of cardiovascular disease, cancer, metabolic illnesses like diabetes and neurodegenerative illnesses, like dementia, and more.

• For healthspan, exercise is ideally multi-dimensional, encompassing strength training and cardio training at both high intensity and low-medium intensity. This post will help you to understand these 3 types of training and how to get the required dose. You can skim by scrolling through the charts.

• In a nutshell, endeavour to lift heavy stuff, get your heart rate up and clock up some distance every week.

• Women should be sure to incorporate some strength training. As we tend to have a lower baseline than men to begin with, the negative and serious consequences of losing muscle mass and strength can impact us earlier and more severely .

• Don’t freak out if it sounds like a lot. Some light strength training and low-medium cardio is a good way to start. Go get at it!

Opportunity into action

In the last edition of Extend, we looked at VO2 max as a measure of fitness.

To follow up, let’s take action to improve our fitness, which is of course to EXERCISE. 

Exercise is a huge topic and covers much more than improving our VO2 max. I’m starting out with a basic overview of strength and cardio-respiratory training.

Some principles

• I’m on record as saying that improving our healthspan can be ‘rewarding and joyful’. What I didn’t say was that getting the level of exercise you need will mean some physical discomfort and prioritising time that you might feel you don’t have. Was that a lie of omission? Sorry? Now you know.

• You have to exercise if you’re serious about healthspan. There’s no way around it. Even if you eat well. Even if you’re pretty trim. Even if you’ve had an injury. Even you’ve never liked it or think you’re too old to start. Exercise you must. 

• The best time to start is now.

• For healthspan, exercise has to be multi-dimensional. You’re not training for a single activity, you’re training to achieve a wide range of physical and cognitive benefits to enable your life and fend off the chronic diseases of ageing. 

What are the healthspan benefits of exercise?

My friends, they are too many to list. Here’s a summary of some of the key areas:

• Physical fitness is the single best predictor of healthspan and longevity. Improved fitness reduces the risk of all cause mortality (our risk of dying from all non-accidental causes) at every level. Let’s look at a chart again:

Kokinos et al. There’s an almost 5-fold greater risk of all cause mortality between the highest and lowest fitness groups. ‘Least fit’ carries greater risk than any other traditional risk factor including age, diabetes, smoking, chronic kidney disease, hypertension, atrial fibrillation, obesity, prior cardiovascular disease, and cancer.

• Physical ability - to use our bodies across every dimension of physical activity, from the basics of being able to sit, stand and walk unaided through to high performance sport or adventures. Exercise can be the difference between living an active life and descending down a slide to frailty.  

• Mood - exercise releases a raft of mood enhancing hormones (endorphins, serotonin, dopamine, oxytocin and more) which improve your enjoyment of life, increase resilience to stress, and reduce the risk of potentially debilitating or life threatening mental illness.

• Injury prevention and recovery - Injuries are where we can fall off the horse when it comes to healthspan. Some of us never get back on, triggering a downward spiral where one injury alters the course of our life much more than we appreciate at the time. Studies have shown that muscle mass and strength can decline by 10-15% within as little as 2-4 weeks of inactivity. 

• Cardiorespiratory health - higher capacity, lower resting heart rate, lower blood pressure, reduced risk of heart attack, stroke and other cardiovasuclar illnesses.

• Metabolic function - improved ability to use fat and glucose as energy, better mitochondrial function (healthier cells, good for everything, including lower risk of cancer), higher ratio of muscle to fat, lower risk of weight gain and obesity, lower risks of metabolic illnesses like diabetes.

• Brain health - improved cognitive function, including better protection of learning capabilities and memory, and lower risk of neurodegenerative diseases such as dementia. Exercise stimulates a better brain through a variety of pathways, including improved blood flow to the brain, production of new brain cells, function and survival of brain cells and brain plasticity.

• Sleep quality - as we will later explore, sleep is essential to healthspan, particularly to the brain’s ability to repair itself and memory. Exercise helps to regulate sleep patterns and promotes a higher quality of sleep.

I could go on, but by now you’re convinced, right?

Types of exercise

This post is an intro to two of the main pillars of exercise identified in the Healthspan Framework - Strength Training and Cardio Training, with the latter divided into low-medium intensity and high intensity. The idea is to give you a picture of what covering most of your bases could look like. Exercise is a broad church and there is no single correct program.¹

I don’t go much into mobility (comprising aspects such as stability, balance, flexibility, agility) in this post, but rest assured that the exercise we discuss will help improve those dimensions too. Here we go!

Strength training

As you might recall, strength is one of the most significant indicators of longevity, arguably as indicative as VO2 max.

Sarcopenia, the age-related loss of muscle mass and strength, begins in your mid-thirties. On average, women aren’t as strong as men to begin with and the consequences of muscle and strength deterioration can therefore hit us earlier and harder. Hormonal changes in menopause further accelerate the decline. The chart below shows grip strength, a reliable proxy for overall strength, for men and women by age.

Grip strength refers to how well and securely you can grasp an object. It's a proxy for muscle strength and can indicate overall health status. Dennison, E., Sayer, A. & Cooper, C. Epidemiology of sarcopenia and insight into possible therapeutic targets. Nat Rev Rheumatol 13, 340–347 (2017). https://doi.org/10.1038/nrrheum.2017.60

Loss of muscle mass and strength is associated with both falls and osteoporosis, which also disproportionately affect women. This is a dangerous cocktail. I was shocked to learn that between 15-35% of over-65 year olds who suffer a broken hip or thigh are dead within a year.²  Muscle and bone strength is harder to gain as we age and is easily lost with inactivity. The best time to start strength training is now. Plan to keep it up for life.  

Peter Attia notes a couple of helpful strength tests / goals which you can try and train towards:

• Grip strength is a proxy for overall body strength and is also key to being able to do stuff with our hands. Try hanging from a bar and timing how long you can bear your bodyweight. A woman of 40 should aim to hang for at least 90 seconds

• How much can you carry in your hands and walk around with? You can work towards being able to carry at least 75% of your bodyweight (half in each hand) while walking around for at least 1 minute.

Cardio training: low-medium intensity

Low to medium intensity cardio provides the foundation for most of the physical activity that we do in daily life. Over millennia, humans evolved to spend several hours per day in moderate physical activity, with strenuous effort required occasionally, and we remain genetically adapted to this pattern.³  

In low to moderate cardio, we are relying mostly on our aerobic metabolism and our type 1 ‘slow twitch’ muscle fibres. Fun fact - women can be a closer match to men in endurance sports because we have a higher proportion of slow twitch fibres in our muscles.

Cardio training - high intensity

By now, you’ve picked up that max cardio output measured by VO2 max, is perhaps the single most important indicator for longevity. Untrained, VO2 max declines on average 10-15% per decade from your thirties. High intensity training is the most effective way to push your VO2 max up, including for the approximately 20% of people who don’t see a VO2 max improvement at moderate intensity.⁴ 

Don’t freak out

Well done if you’ve made it this far. 3 different types of training can feel like a lot, don’t let it overwhelm you. Some important things to know:

• If you’re new to exercise or returning after a long break, start with some light strength training and low-moderate cardio, before building up to more

• The exercise program that is best for your healthspan is one that you enjoy and can sustain long term. Every form of exercise can deliver you some healthspan benefits

• If you don’t yet love exercise, trust that you will grow to love it. Your biology will take care of it

• In the coming weeks, I’m going to share how I’m getting on with this exercise program myself. Spoiler alert, I’m not doing all of it yet!

• I’m also going to be looking at ways to measure more aspects of our baseline fitness.

Good luck!

xx

Toni

1. This recommendation largely conforms to the protocol recommended by Dr Peter Attia in ‘Outlive’, complemented by things I’ve drawn from the work of Dr Rhonda Patrick, Dr Stacy Sims and others.

2. Attia, Outlive.

3. O'Keefe JH, O'Keefe EL, Eckert R, Lavie CJ. Training Strategies to Optimize Cardiovascular Durability and Life Expectancy. Mo Med. 2023 Mar-Apr;120(2):155-162. PMID: 37091937; PMCID: PMC10121111.

4. I found this talk and others by Dr Rhonda Patrick instructive on the benefits of high intensity cardio. I also found useful: Wen D, Utesch T, Wu J, Robertson S, Liu J, Hu G, Chen H. Effects of different protocols of high intensity interval training for VO₂max improvements in adults: A meta-analysis of randomised controlled trials. J Sci Med Sport. 2019 Aug;22(8):941-947. doi: 10.1016/j.jsams.2019.01.013. Epub 2019 Jan 29. PMID: 30733142.