Even In Your 20s, Fitness Cuts Risk For Later Heart Disease, Major Study Finds

(Elaine Thompson/AP)

(Elaine Thompson/AP)

Feeling a bit bloated and sluggish after Thanksgiving weekend? A major study just out in the journal JAMA Internal Medicine offers an added nudge to get back on the exercise wagon. How fit you are even in your 20s, the study finds, can dramatically affect your risk of heart disease and death well into middle age.

So dramatically, in fact, that every minute matters.

Imagine you’re doing a stress test on a treadmill. Every two minutes, the machine makes you go faster and at a steeper incline. The first few minutes are no sweat — you’re walking, then trotting, then jogging — but soon you start to suck air, and finally hit the point that you can bear no more. (Or you may reach the 18-minute maximum, if you’re superhuman.)

Say you did that test in your 20s. Now fast-forward 25 years. The study found that every extra minute you could last on the treadmill meant you were at a 15 percent lower risk of death over that quarter-century, and at a 12 percent lower risk of harmful effects of heart disease, including stroke and heart attack.

“That’s a lot,” I found myself saying in a phone interview with the study’s two lead authors, Dr. Ravi V. Shah, of Harvard Medical School and Beth Israel Deaconess Medical Center, and Dr. Venk Murthy of the University of Michigan.

“We were surprised too,” Dr. Shah said.

“Two, three, four, five minute differences are not uncommon,” Dr. Murthy said. “That adds up. That’s 15 percent per minute — it’s pretty substantial.”

Though, of course, it must be noted that the overall risk of heart disease and death are relatively low in such a young population. Among the 4,872 people in the study, 273 died, but 200 of those deaths had no relation to heart disease. And just 4 percent of the study’s subjects had a “cardiovascular event” like a heart attack.

Still, the results cast new light on just how much fitness matters for heart health — even in our 20s, when many of us can still get away with a sleepless all-nighter or an all-weekend TV binge.

This new research is the first large study to examine people in their 20s onward over such a long period, the lead authors say, and underscores the importance of starting good fitness habits early — not just in later years, when the health price of inactivity is already well known.

The study also found that the heart benefits of fitness held true independent of weight and other heart risk factors. That suggests, Dr. Shah said, that “being fit is important for everyone, not just for people who are trying to lose or maintain weight.”

The study — an epic endeavor that began back in the mid-1980s and was led by four universities, including Harvard and Johns Hopkins — also suggests that early trajectory matters. That is, typical as it may be, it is not a good idea to let your fitness decline in your 20s.

Nearly 2,500 of the subjects underwent a second treadmill test just seven years after the first. For every minute less that they could last compared with their first test, their risk of death in the coming years went up by 21 percent, and their risk of heart disease by 20 percent.

And one other, particularly fascinating finding: Fitness as reflected by treadmill performance did not seem to matter for an accepted measure of heart health, the accumulation of calcium deposits in the arteries that supply the heart. Continue reading

Most States Don’t Require CPR Training For High Schoolers — Should They?

(Ken Schwarz/Flickr)

(Ken Schwarz/Flickr)

By Marina Renton
CommonHealth intern

I walked into health class one day to find slack-jawed mannequin heads atop foam torsos lined up in rows on the classroom floor. Interspersed among the adult mannequins were infant dummies — fully formed, but equally eerie.

That macabre scene began the first aid unit of 11th-grade health, which included the memorable experience of giving the mannequins chest compressions to the rhythm of “Stayin’ Alive,” using both hands for the adults and only two fingers for the infants.

I learned cardiopulmonary resuscitation at a Massachusetts public high school, but it wasn’t a legally mandated part of the curriculum. Twenty-one states — including Washington, Texas, Alabama and Iowa — have passed laws that make CPR training a high school graduation requirement. Massachusetts is not one of them.

Someone ‘has to take up the torch and really advocate for it.’

– Dr. Farrah Mateen

But maybe it should be. A commentary just out in the Mayo Clinic Proceedings argues that the potential benefits of requiring CPR training in high school — from saving lives to getting a taste of selfless service — are so great that every state should do it.

Why don’t they? The answer isn’t that states are necessarily facing resistance to the laws. It’s that the laws just aren’t a priority, says commentary co-author Dr. Farrah Mateen, an assistant professor of neurology at Harvard Medical School and a neurologist at Massachusetts General Hospital.

In other states, legislation has been advanced by champions of the cause, Mateen said. Continue reading

‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem


When Dartmouth economics professor Jonathan Skinner was speaking recently at the University of Texas about the “cowboy doctor” problem, an audience member objected: “You have a problem with cowboys?”

Well, actually, we all have a problem with cowboys — when they’re doctors. Including the Texans. New research written up in a National Bureau of Economic Research paper finds that “cowboy” doctors — who deviate from professional guidelines, often providing more aggressive care than is recommended — are responsible for a surprisingly big portion of America’s skyrocketing health costs. The paper concludes that “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.”

Whoa, Nelly. That means cowboy doctors are a half-a-trillion-dollar problem. But mightn’t they also be good? Wouldn’t many of us want a go-for-broke maverick when we’re in dire medical straits? I asked Prof. Skinner, who’s also a researcher at the Dartmouth Atlas of Health Care, to elaborate. Our conversation, lightly edited:

So how would you define a cowboy doctor?

Cowboys go it alone. They have developed their own rules and they don’t necessarily adapt those rules to what the clinical evidence would suggest. So if you actually talked to what we term a ‘cowboy doctor,’ he or she would say, ‘I get good results with this procedure for this type of patient.’ That’s why we found it so interesting: they go beyond what the professional guidelines recommend. And it’s not as if they were out there before the professional guidelines got there. Sometimes pioneers are doing things that the guidelines haven’t figured out yet. But we found no suggestion that subsequent guidelines were consistent with what these physicians were actually doing.

So is it stubbornness, then?

I don’t know if it’s stubbornness but it’s individuality. It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.

This graph shows 64  hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows  that in regions with a larger share of “cowboys,”  risk-adjusted end-of-life Medicare spending is higher.(Courtesy Jonathan Skinner)

This graph shows 64 hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows that in regions with a larger share of “cowboys,” risk-adjusted end-of-life Medicare spending is higher. (Courtesy)

Yes, the extent of the variation in medical practice is striking. But I was most struck in your paper by how big a piece of the health-cost problem this could be. Can you quantify that?

We were surprised, too. What we show is that the opinions of these physicians — in particular, opinions that are outside of the clinical guidelines — explain as much as 17 percent of total variation in health care spending, which is, roughly speaking, 3 percent of GDP.

Wow. What is that in billions?

The association we found suggests it’s almost half a trillion dollars.

Can you give me a concrete example of how a cowboy doctor could drive up costs? Continue reading

WSJ: Everything You Need To Know About New Cholesterol Guidelines

It’s so very disconcerting when deeply entrenched health wisdom is suddenly flipped on its head. But that’s the way it often goes in this arena.

The Comedian/flickr

The Comedian/flickr

So, with such widespread confusion over the new guidelines on cholesterol and statins, cholesterol-lowering drugs, I was relieved to see that veteran health reporter (and my former colleague) Ron Winslow at The Wall Street Journal offered a just-the-facts-ma’am Q & A on exactly what you need to know about the new guidelines. It’s got everything from LDLs to the new risk calculator — which was down when I checked this morning. (What’s going on with all the bugs in our critcal health care sites??)

Here’s a snippet from Winslow:

The new tack recommended by the American Heart Association and the American College of Cardiology is to prescribe moderate to high doses of cholesterol-lowering drugs called statins to patients who fall into one of four risk groups regardless of their LDL status. Here is a look at the implications:

Q. Why get rid of the LDL targets?

A. The targets lack strong scientific evidence. The expert panel that developed the guidelines concluded that by focusing on an individual patient’s overall risk rather than a relatively arbitrary set of LDL targets, the strategy to prevent heart attacks and strokes will be more effective and more personally tailored to the needs and preferences of each patient.

Q. What should patients do in response?

A. Patients already on cholesterol-lowering medication should ask their doctors at their next appointment whether they are on the most appropriate therapy to reduce their heart-attack and stroke risk, says Neil Stone, a cardiologist at Northwestern University who headed the panel that wrote the cholesterol guideline.

For people not on cholesterol drugs, a new risk calculator is available online. If you have a 7.5% chance of having a heart attack over the next 10 years, you are a candidate for treatment with a statin no matter your LDL level under the new guidelines.

Q. I have no heart problems and my LDL was 90 in a recent cholesterol test. Is it possible I should be on a statin anyway? Continue reading

Don’t Miss: Why Mass. Needs Law On Screening Newborn Oxygen Levels


When a pediatric cardiologist tells me we need a law requiring hospitals to screen newborns’ oxygen levels to detect potentially dangerous heart defects, I listen.

Cardiologist and author Darshak Sanghavi writes on WBUR’s Cognoscenti today that the Massachusetts legislature held a hearing last week on making “pulse oximetry tests” for newborns mandatory in the state — as several other states have already done. He writes:

The results have been dramatic. Hours after the law was passed in New Jersey, for example, it saved a newborn’s life.

But Massachusetts, a leader in health care innovation, and home to some of the nation’s best health care centers, hasn’t followed suit. Instead, the state Department of Public Health decided earlier this year the screening shouldn’t be mandatory. They reasoned that doctors and hospitals would do the right thing on their own.

But that’s an incorrect assumption. According to a state-sponsored 2012 survey of Massachusetts birthing facilities, only one-quarter were performing the screening, even though the federal recommendation had been out for almost a year.

Read the full post on Cognoscenti: A Simple Test. Newborn Lives Saved. What’s The Holdup?

Get To Know Your Likely Killer: ‘Tangled History’ Of Heart Disease

(Wikimedia Commons)

(Wikimedia Commons)

Chances are, heart disease is going to get you. It’s eternally America’s number one killer, estimated to cause about 600,000 deaths a year.

If you want to get a better grasp on your likeliest executioner, don’t miss this fascinating piece, titled “A Cardiac Conundrum,” in the latest Harvard Magazine. It features Dr. David Jones, a Harvard professor of the culture of medicine, and his recent book, “Broken Hearts: The Tangled History of Cardiac Care.

Jones discusses the shaky evidence base for many of the most common heart disease treatments, from bypass surgery to angioplasty and stents.

…“Patients are wildly enthusiastic about these treatments,” he says. “There’ve been focus groups with prospective patients who have stunningly exaggerated expectations of efficacy. Some believed that angioplasty would extend their life expectancy by 10 years! Angioplasty can save the lives of heart-attack patients. But for patients with stable coronary disease, who comprise a large share of angioplasty patients? It has not been shown to extend life expectancy by a day, let alone 10 years—and it’s done a million times a year in this country.” Jones adds wryly, “If anyone does come up with a treatment that can extend anyone’s life expectancy by 10 years, let me know where I can invest.”

“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.”

And another key passage: Continue reading

Why To Exercise Today: At 73, Zelda Runs Her Fifteenth Tufts 10K

In honor of Monday’s race, a Boston institution that is now in its 36th year and draws thousands of women every fall, we offer a bit of inspiration today from Zelda Jacobson Schwartz. She will be running her fifteenth Tufts Health Plan10K For Women at the age of 73. We may not all be able to run for miles in our seventies — or our twenties, for that matter — but we can all draw strength from the memorable wisdom she shares: “It’s okay to be at the back of the pack. It’s thrilling just to be there,” and “The miracle is not that we finished, but that we had the courage to start.”

By Zelda Jacobson Schwartz
Guest contributor

73-year-old Zelda Schwartz is running her 15th Tufts 10K

When people ask me why I am running my 15th Tufts Health Plan 10K for Women as a 73-year-old, I answer: “Because I’m so lucky I can!”

I started running when I was 40 at the same time I gave up smoking, not realizing I’d be giving up a dreadful addiction for a really marvelous one that would form the structure of each of my days.

I ran for many years as a ”master” (age 40-49). During those early years, I ran two “Bonnie Bell 10Ks”; my proudest moment came in 1982 when I clocked a time of 44 minutes. Now, 30 years later, that race is called the Tufts Health Plan 10K for Women and I’m called a “veteran” (age 70-79), and I will need an hour more as I walk most of it. Continue reading

To Watch The Boston Marathon Responsibly, Watch This Video First

I hate to be a spoiler. After all, for me at least, one of the great joys of watching from the Boston Marathon sidelines as the heroically suffering runners pass by is the sheer “better you than me” schadenfreude. I admire the runners and revel in the pure, not-running passivity of being a spectator at the same time.

So it’s with deep chagrin that I report that recent research by Dr. Aaron Baggish of Massachusetts General Hospital and others suggests that we spectators can’t be quite so passive anymore, because when nearby crowd members or runners know CPR and rush to the aid of a collapsed runner, they really can save lives. (And I don’t want to think about how many collapses may be caused by heat now predicted to rise into the eighties on Monday.)  In a January paper in The New England Journal of Medicine, Dr. Baggish and colleagues write:

The strongest predictors of survival of cardiac arrest were initiation of bystander-administered cardiopulmonary resuscitation (CPR) (P=0.01 by Fisher’s exact test) and an underlying diagnosis other than hypertrophic cardiomyopathy (P = 0.01 by Fisher’s exact test).

Of course, as Dr. Baggish points out, that’s good news because it suggests action could help: broader CPR training. There are even special Marathon-oriented training sessions this weekend. If you don’t have time to take a course, the video above offers the basics of the relatively new dogma on “Hands-only” CPR, and just to review my favorite tip, if you need to do CPR on someone, the best beat comes from Queen’s “Another One Bites the Dust” (but maybe you shouldn’t sing it aloud to the patient…)

Follow-Up On Cool-Downs: What To Do And Why You Really Should

A triathlete cools down

My boss, chief John Davidow, tells me I ruined his life with this post on the danger zone after exercise, written in the wake of Kara Kennedy’s recent death. Used to be, he’d play his boisterous morning game of basketball, then assume that his body was cooling itself down naturally as he shaved. Now he still shaves right after playing, but as he does, he worries that he’ll drop dead from a heart attack with a white beard of cream still on his face.

Now, I’d rather not have “life-ruining” appear on my next performance review. Also, I don’t want John to die with a foamy face. And I figure if he’s left with concerns, probably so are many others. So I asked Dr. Aaron Baggish of Massachusetts General Hospital for a follow-up conversation to help clear up exactly what constitutes an adequate cool-down and why it’s so important. He’s an expert on the effects of exercise on the heart and cardiovascular system. (Also himself a competitive runner, and the cardiologist for the Boston Marathon.) His conversation with John, edited and distilled:

John: So are you kidding me? Do I really have to warm up and cool down?

‘Tell them to wait. It’s much better they all jog with you than have to wait while they’re calling the ambulance.’

Aaron: I’m not kidding you. The issue is this: That we know, and have known probably for 30 or 35 years, that routine physical exercise reduces your risk of heart trouble. That story is very clear. But it comes at a price: If you’re going to run into trouble, it’s going to be while or after you’re exercising. If you’re going to exercise — and you should — you have to know how to do it right: You have to let your body warm up and cool down. Your body doesn’t like sudden changes.

So why do I see studies saying, ‘Oh, don’t bother stretching’? Continue reading

Why To Exercise Today: ‘The Delights Of The Healthiest Elixir’

Dr. John Mandrola, a cardiologist in Louisville, surely understands the mechanics of how exercise helps the heart. But in this lovely recent post on his “Dr. John M” blog, he also writes about the effects of exercise on the metaphorical heart — what I would call the glory of it.

‘Fess up, hard exercisers: sometimes, you feel something akin to ecstasy, don’t you? Here, he tries to capture that:


Yes I am a little giddy.

I just finished riding my bike in mud and grass. There were many other people — nice ones, with good hearts (and legs). People trying to be — almost “normal.”

It was just a Wednesday cyclocross practice.

Did I say there was an orangy sunset, a cool autumn breeze and happy animals buzzing around too? The dogs and squirrels seemed to look at us with envy.

An aging cardiologist, a realtor, a litigator, a new Dad got to duel with high-schoolers. The omega and the alpha. “Go bike, Go.!” Word has it there was even a philosophy major in attendance. Lest you think we cyclists are witless, or Conservative.

So why can’t I convince my patients of the wonders of what their body could do? They don’t have to ride in mud, or slog through an Ironman, or calcify their coronaries by running like Forest Gump. All they have to do is something that makes them sweat — every day that they eat. Something fun.

No pills; just the sweet elixir of trying hard, moving fast, being alive. Check the p-value on that!