1. FROM ENDURANCE TO CAPACITY – A NEW APPROACH TO CARDIOPULMONARY FITNESS Al Sears, MD

2. B EYOND “C ARDIO ” – A N EW A PPROACH TO C ARDIOPULMONARY F ITNESS Al Sears, MD The following potential conflict of interest relationships are germane to my presentation. Equipment: N/A Speakers Bureau: N/A Stock Shareholder: N/A Grant/Research Support: N/A Consultant: N/A Status of FDA devices used for the material being presented: NA/Non-Clinical Status of off-label use of devices, drugs or other materials that constitute the subject of this presentation NA/Non-Clinical

3. Modern Exercise Advice Has Failed You 1.It doesn’t build functional strength 2.It won’t make your heart stronger 3.It won’t build your lung capacity

4. Modern Approaches to Fitness Don’t Work 1.Aerobics 2.Cardio 3.Weight training The “big 3” create the wrong “adaptive response”. You need exercise, but what kind?

5. HARVARD ALUMNI HEALTH STUDIES 17,321 male alumni followed for 20 years High-intensity exercise was associated with a significant decrease in all-cause mortality No relationship between low-intensity exercise and death Lee IM, Hsieh, CC, Paffenparger, RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA. 1995;273(15):1179-1184.

6. Exercise Intensity and Mortality Harvard Health Study Relative Risk of Death (%) Exercise Intensity Lee IM, Hsieh, CC, Paffenparger, RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA. 1995;273(15):1179-1184

7. INTENSITY VS. DURATION 8896 recreation runners reported average exercise duration and intensity High intensity exercise associated with: Lower blood pressure Lower triglycerides Lower CHOL/HDL ratios Lower BMIs Lower waist, hip, and chest circumferences Exercise duration had no effect on these parameters Williams P. Relationships of heart disease risk factors to exercise quantity and intensity. Arch Intern Med. 1998;158(3):237-245.

8. High-Intensity Exercise Improves Cardiac Function – Study Design Patients with prior MI (n = 29) Control/no training (n = 8) Low-intensity training* (n = 11) High-intensity training** (n = 10) *Low-intensity: HR @ 80% of gas exchange threshold (GET) **High-intensity: (HR @ GET – HR @ peak exercise)(40%) + HR @ GET Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

9. High-Intensity Exercise Improves Peak O 2 Uptake During Exercise Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

10. High-Intensity Exercise Improves Ejection Fraction During Exercise Change in ejection fraction (%) * P = 0.024 Adachi H, Koike A, Obayashi T, et al. Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction? Eur Heart J. 1996 Oct;17(10):1511-21.

11. Low-Intensity Exercise Reduces Cardiac Function 6-months12-months ∆ Rest to Peak LVEF (%) Oberman, A, Fletcher F, Lee J, et al. Efficacy of high-intensity exercise training on left ventricular ejection fraction in men with coronary artery disease (the Training Level Comparison Study). Am J Cardiol. 1995 Oct 1;76(10):643-7.

12. So – What’s Going On? Low-intensity durational exercise increases cardiac endurance….at the expense of cardiac capacity

13. Endurance versus Capacity Evolution –Humans did not evolve to engage in long- duration, low-to-moderate intensity exercise –Natural selection favored individuals who could sprint – not those who could run marathons! –From an evolutionary perspective, traditional cardiovascular exercise in unnatural.

14. What’s wrong with endurance? Exercise causes adaptation of cardiac function The adaptations seen with traditional “cardio” exercise are: Increased cardiac endurance Increased cardiac efficiency BUT – the increased endurance/efficiency ONLY occurs in the narrow range of low-to-moderate output required by traditional cardiovascular exercise

15. The high cost of endurance … Endurance training requires significant physiological adaptations over a long duration, including:  Metabolism of waste products  Regulation of body temperature  Conservation of energy – in particular, conservation of enough energy to support repeated durational challenges

16. Deadly adaptations… The energy required to maintain the physiological processes required by endurance training comes at the expense of cardiac capacity The heart adapts with decreased capacity, resulting in a diminished cardiac reserve A reduction in cardiac reserve is a deadly adaptation

17. Endurance versus Capacity

18. Cardiac Reserve and Heart Failure Maximal level Cardiac Power Output* (w) * Cardiac Power Output = (cardiac output)(arterial pressure) Adapted from: Williams S, Barker D, Goldspink D, Tan L. A reappraisal of concepts in heart failure: central role of cardiac power reserve. Arch Med Sci 2005; 1(2) 65-74

19. Is high-intensity training anti- aging for your lungs? It’s clear that cardiac capacity is vital to healthy aging, but pulmonary capacity is another powerful predictor of longevity

20. Framingham Heart Study Framingham researchers followed 5209 participants over 18 years Biggest finding: the risk of congestive heart failure rose as lung capacity fell Relationship was independent of: blood pressure, relative weight, pulse, smoking status, heart enlargement, ECG-LVH, blood glucose levels, and age Lung volume decreased BEFORE there was any clinical evidence of CHF

21. Are Your Lungs Dying? Age Mean Vital Capacity (dL) Adapted from: Kannel WB, Seidman JM, Fercho W, Castelli WP. Vital Capacity and Congestive Heart Failure. The Framingham Study. Circulation. 1974;49(6):1160-1166.

22. Incidence of Congestive Heart Failure According to Vital Capacity Rate of CHF/1000 Vital Capacity (L/height) Age Adapted from: Kannel WB, Seidman JM, Fercho W, Castelli WP. Vital Capacity and Congestive Heart Failure. The Framingham Study. Circulation. 1974;49(6):1160-1166.

23. Even Moderate Pulmonary Impairment Increases Risk of Death Years Post Follow-Up FEV (%) Quintile: Relative Risk of Death (all causes) Schunemann H, et al. Pulmonary function is a long-term predictor of mortality in the general population: 29-year follow-up of the Buffalo Health Study. Chest. 2000 Sep;118(3):656-64.

24. The Bottom Line Lung capacity decreases with age Decreased lung capacity  increased risk of heart failure Even moderate, non-clinical decreases in lung capacity increase risk of death Lung capacity is a clear and powerful marker of aging.

25. Some Good News... The age-related loss of pulmonary function is manageable and modifiable… if you engage in high- intensity exercise

26. Pre- and Post-Intervention Pulmonary Function VO 2peak (L/min) Exercise Group Adapted from: Baily S, Wilkerson DiMenna F, Jones A. Influence of repeated sprint training on pulmonary O2 uptake and muscle deoxygenation kinetics in humans. J Appl Physiol. 2009 Jun;106(6):1875-87.

27. Building Younger Lungs Max O 2 Uptake (ml/Kg min) Age Adapted from: von Ardennne, M. Oxygen Multistep Therapy. Theime. 1990. p.31.

28. THE DATA ARE CLEAR High-intensity exercise is the key to cardiopulmonary health.

29. “Expert” advice that is killing your patients American Medical Association Moderate intensity exercise for 30-minutes/day, at least 5 days/week American College of Sports Medicine Moderate intensity exercise for 30-minutes/day, at least 5 days/week American Heart Association Moderate intensity exercise for 30-minutes/day, at least 5 days/week National Institute of Health “regular, moderate exercise”

30. High-Intensity Exercise and the Aging Patient Interval training is the most common type of high-intensity training, but... Interval training is not safe or effective for the typical deconditioned patient presenting to an anti-aging clinic.

31. The Solution P.A.C.EPROGRESSIVELYACCELERATINGCARDIOPULMONARYEXERTION

32. Progressivity Regular and consistent increases in the intensity of demands placed on the cardiovascular system by making repeated changes in the same direction Analogous to inflating a balloon: the best way to fill a balloon to capacity is by gradually adding more air during each inflation Similar to muscle hypertrophy training where muscle capacity is increased by progressively adding small amounts of additional weight KEY POINT: In PACE, high-intensity is a relative term. This means that each individual will work towards their own unique level of maximum exertion. This makes PACE the safest form of exercise

33. Acceleration Training to increase the speed at which the heart and lungs respond to increases in demand The same exertion level/target heart rate will be reached more quickly throughout the training process Recovery back to resting heart rate/respiration also happens more quickly KEY POINT: most cardiac arrests occur when the heart is unable to respond to a sudden and dramatic increase in demand. Training for acceleration helps the heart to respond quickly to potentially life- threatening demands – reducing the risk of sudden cardiac death

34. PACE – The Twin Study Female Fraternal Twins 18-years old 24.5% body fat 16-weeks of training PACE Twin Decreased body fat by14.5% Gained 9-lbs lean muscle “Cardio” Twin Decreased body fat by 5% Lost 2-lbs lean muscle

35. Case Study – Terri L. 55 year-old female 250-lbs 50% body fat Elevated triglycerides Low HDL

36. Terri L – Body Fat (%) Body Fat (%) Months Post-Training

37. Terri L – Triglycerides Triglycerides (mg/dL)

38. Terri L – HDL HDL (mg/dL)

39. Terri L

40. Richard F

41. Sample PACE Log Warm up:_______________ Exercise:_________________ Initial Sets Set 1Set 2Set 3 ExertionRecoveryExertionRecoveryExertionRecovery Additional (optional) Sets Set 4Set 5Set 6 ExertionRecoveryExertionRecoveryExertionRecovery

42. What Makes a PACE Workout? Running Rowing Swimming Bicycling Jumping rope Calisthenics Stair stepping Elliptical Circuit training Hindu squats Kettle bells

43. PACE – The Safest Exercise There Is! Interval training requires participants to exercise to an objective goal that does NOT consider the cardiopulmonary health of the participant. This type of high-intensity training may be dangerous for the average older adult In contrast, the progressivity component of PACE allows each individual to work to their own unique level of maximum exertion, making PACE a program that is fully-customized to the fitness level of every participant. The risk of durational exercise is illustrated by multiple reports 1,2 of elevated creatinine kinase, myoglobin, and troponin among distance runners 1) Jassel D et al. Cardiac injury markers in non-elite marathon runners. Int J Sports Med. 2009 Feb;30(2):75-9. 2) Trivax J, et al. Acute Cardiac Effects of Marathon Running. J Appl Physiol. 2010 Feb 11.

44. PACE Trial My Wellness Research Foundation is currently conducting a longitudinal study to examine the efficacy of the PACE program

45. PACE Trial – Study Design 20 men and women (18+) with > 26% body fat PACE-style exercise program supervised by an ACE- certified trainer Variables assessed include: Weight Body fat & lean muscle mass Cholesterol Glucose and insulin Testosterone CRP and homocysteine VO2 max and pulmonary function