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“Do you come from Liverpool?”

Paul Alper writes:

Because I used to live in Trondheim, I have a special interest in this NYT article about exercise results in Trondheim, Norway.

Obviously, even without reading the article in any detail, the headline claim that

The Secret to Longevity? 4-Minute Bursts of Intense Exercise May Help

can be misleading and is subject to many caveats.

The essential claims:

Such studies [of exercise and mortality], however, are dauntingly complicated and expensive, one reason they are rarely done. They may also be limited, since over the course of a typical experiment [of short duration], few adults may die. This is providential for those who enroll in the study but problematic for the scientists hoping to study mortality; with scant deaths, they cannot tell if exercise is having a meaningful impact on life spans.

However, exercise scientists at the Norwegian University of Science and Technology in Trondheim, Norway, almost 10 years ago, began planning the study that would be published in October in The BMJ.

More than 1,500 of the Norwegian men and women accepted. These volunteers were, in general, healthier than most 70-year-olds. Some had heart disease, cancer or other conditions, but most regularly walked or otherwise remained active. Few were obese. All agreed to start and continue to exercise more regularly during the upcoming five years.

Via random assignment, they were put into three groups: the control group which “agreed to follow standard activity guidelines and walk or otherwise remain in motion for half an hour most days,” the moderate group which exercises “moderately for longer sessions of 50 minutes twice a weekend” and the third group “which started a program of twice-weekly high-intensity interval training, or H.I.I.T., during which they cycled or jogged at a strenuous pace for four minutes, followed by four minutes of rest, with that sequence repeated four times.”
Note that those in the control group were allowed to indulge in interval training if they felt like it.

Almost everyone kept up their assigned exercise routines for five years [!!], an eternity in science, returning periodically to the lab for check-ins, tests and supervised group workouts.

The results:

The men and women in the high-intensity-intervals group were about 2 percent less likely to have died than those in the control group, and 3 percent less likely to die than anyone in the longer, moderate-exercise group. People in the moderate group were, in fact, more likely to have passed away than people in the control group [!!].

In essence, says Dorthe Stensvold, a researcher at the Norwegian University of Science and Technology who led the new study, intense training — which was part of the routines of both the interval and control groups — provided slightly better protection against premature death than moderate workouts alone.

Here can be found the BMJ article itself. A closer look at the BMJ article is puzzling because of the term non-significant which appears in the BMJ article itself and not in the NYT.

Conclusion

This study suggests that combined MICT and HIIT has no effect on all cause mortality compared with recommended physical activity levels. However, we observed a lower all cause mortality trend after HIIT compared with controls and MICT.

Discussion

The Generation 100 study is a long and large randomised controlled trial of exercise in a general population of older adults (70-77 years). This study found no differences in all cause mortality between a combined exercise group (MICT and HIIT) and a group that followed Norwegian guidelines for physical activity (control group). We observed a non-significant 1.7% absolute risk reduction in all cause mortality in the HIIT group compared with control group, and a non-significant 2.9% absolute risk reduction in all cause mortality in the HIIT group compared with MICT group. Furthermore, physical activity levels in the control group were stable throughout the study, with control participants performing more activities as HIIT compared with MICT participants, suggesting a physical activity level in control participants between that of MICT and HIIT.

As it happens, I [Alper] lived in Trondheim back before North Sea oil transformed the country. The Norwegian University of Science and Technology in Trondheim, Norway did not exist but was called the NTH, incorrectly translated as the Norwegian Technical High School. Back then and as it is today, exercise was the nation’s religion and the motto of the country was

It doesn’t matter whether you win or lose. The important thing is to beat Sweden.

To give you a taste of what the country was like in the 1960s, while I was on a walk, a little kid stopped me and said, “Do you come from Liverpool?”

Dude should have his own blog.

26 Comments

  1. As an exercise & nutrition enthusiast, I would not have taken this study so seriously b/c I have come across so many contradictory perspectives on the value of moderate vs. high intensity exercise regimes. I do engage in high intensity & low intensity aerobic exercise every week. High intensity once or twice a week only. I think people who want to improve their health research their exercise options and adjust accordingly to their energy levels.

    I’m a bit vexed by what is meant by moderate exercise, i.e, 50 minutes twice on weekend.

    Moderate exercise, typically, is most often characterized as walking 120-150 minutes a week. So the control group fulfilled that I gather.
    Moderate, also includes strength training 2 or 3 times a week, by most fitness experts.

    I strongly believe that what you eat is even more critical for longevity [not longetivity]. The Fat you East is the Fat you wear, a contributor to heart disease, metabolic syndrome, cancer, diabetes, etc. It would have been valuable to have also taken information on their diets.

    Dean Ornish, Bill Clinton’s former doctor, revolutionized treatment of cardiovascular disease. Actually reversing several disease states through diet and exercise recommendation. There is also the famouls Michael Greger, who is the author of How Not to Die. Worth reading. In short, animal & dairy fats are implicated in diseases mentioned. Plant based diets seem to be better health sustaining options.

    • Brent Hutto says:

      Sameera,

      I believe the quote material is using “Moderate” as a level of intensity. Most often an intensity categorized as “Moderate” is cited as the range from 3-6 METs.

      Walking may need to be at a fairly brisk pace to achieve that usually-cited minimum of 3 METs for reasonably fit individuals, although severely deconditioned or very obese individuals may achieve 3 METs or more while walking more slowly.

      The recommendation you refer to was promulgated beginning in the late 90’s or early 00’s. Although the details vary depending on who is making the recommendation it started as something like “30 or more minutes of MVPA on 5 or more days per week” which was believed to accrue general health benefits at the population level. Then it kind of morphed into 150 minutes per week of Moderate PA (3-6 METs) or 75 minutes per week of Vigorous PA (6+ METs) or any equivalent combination.

      There have also been a plethora of somewhat confusing additional qualifications concerning the need (or not) for the PA to occur is bouts of 10 minutes or 8 minutes in a 10 minute period or whatever. So it all definitely is confusing the general public and not entirely clear to practitioners in the field!

      • Thanks Brent,

        I see the intervention protocol in the article:

        ‘Intervention Participants were randomised to two sessions weekly of high intensity interval training at about 90% of peak heart rate (HIIT, n=400), moderate intensity continuous training at about 70% of peak heart rate (MICT, n=387), or to follow the national guidelines for physical activity (n=780; control group); all for five years.

        ————

        The percentages of the peak heart rates given astonish me. To achieve 90% of peak heart rate, for example, demonstrates a very high level of fitness. For older participants, I would not have recommended 90% for the participants that had disease conditions too.

        I have been watching exercise gurus on You Tube for the last 5 months at least. Each has his or her guidance for audiences. Some of these videos has corrected some of my exercise routines to date. It’s kinda fun to watch all these hunks too. LOL just kidding.

        High Intensity exercise should be approached with great caution b/c it is so easy to overdue. All in all, I approach exercise from the perspective of a physical therapist. It helps.

        Frankly, I haven’t found an exercise regime that really addresses the needs of older adults all that well. I was actually thinking of exploring the possibility of featuring one. I say this b/c so many of current regimes are just modifications of regimes for much younger ages.

        Yes, the exercise recommendations

        • Eeeekk! Sorry ‘overdo’ not ‘overdue’. And cut ‘Yes, the exercise recommendations’.

        • Brent Hutto says:

          I don’t know what my true peak heart rate is (never have done a max exertion test) but using the 220-age approximation I will say this. For me, getting to 90% of that heart rate even briefly feels so unpleasant I have to think anyone who repeatedly cycles up to that level for 4 minutes at a stretch is a very motivated individual indeed! The study we’re talking about may have had a problem that plagues even the best such long-term, free-living large sample studies. There’s the specification that you randomize a person to an there’s the actual behavior over the five years. Often those two things have only a tenuous connection.

          • I have used the same age approximation. Yes, 90 % feels unpleasant. It took me a year to get up to 90%. I’m good with exercising between 70-80%.

            Note how the study calculate peak heart rate:

            “Ergospirometry was used to measure peak oxygen uptake at baseline and after one, three, and five years and is described in detail elsewhere.15 As 41% of the participants did not meet the criteria for maximal oxygen uptake, we used the term peak oxygen uptake. We defined peak heart rate as five beats over the highest observed heart rate (Polar Electro, Finland) during the ergospirometry test and used this to determine exercise intensity.”

            That is more realistic calculation for older adults peak oxygen uptake.

            As I noted before, I would have followed closely their dietary habits too.

          • Phil says:

            That 220-age thing is bogus enough that I think people would be better off forgetting it.

            For one thing — I’m too lazy to search for this, but someone else can — the max heart rate doesn’t actually drop off at 1 bpm per year on average (wouldn’t that be quite a coincidence?), it’s more like 0.8 bpm per year. A better approximation is supposedly something like 215 – 0.8*age. For a large age, that makes a big difference.

            But for another thing, there’s a lot of interpersonal variability. My max heart rate has always been much higher than the equation predicts, perhaps related to the fact that I have a small heart for my body size (I have an average-size heart in spite of being 6’3″ tall).

            I’m 55 years old and my max heart rate is around 190, not either 165 or 171 as implied by the two rules.

            As for 90% of max heart rate: for me that would be about 170 bpm. I have no problem getting my heart rate over 170 and holding it there for many minutes. Indeed, that’s my target for a 20-minute maximum effort on a stationary bike. I do not consider this a high-intensity workout. One of the issues is that, as far as I know, “high intensity” doesn’t have an agreed-upon standard. Personally, I count myself as having done a “high-intensity” interval if I get my heart rate over 180 bpm for at least ten seconds as measured by my heart rate monitor. For me, 180 bpm is extremely unpleasant but 170 isn’t bad at all.

            I’m not sure what this has to do with the study, I’m just saying 90% of max heart rate isn’t necessarily all that bad — it isn’t to me — and that if someone determines their max heart rate according to that “220-age” formula they might end up with something much too high or too low, which might explain some of the difference in perceptions.

            • Andrew says:

              Phil:

              Sure, but that’s all consistent with this discussion. You’re in very good shape. You’ve always been in better shape than me, for example—even during the times in my life when I’ve been in good shape. So your experience is consistent with the idea that you live a healthy lifestyle of the sort that’s unusual for sedentary people such as the readers of this blog.

            • Hi Phil,

              In that study, 41% did not meet the criteria for maximum oxygen uptake. So peak oxygen rate at baseline would be doable.

              At the age of 50, I could achieve maximal oxygen uptake which was between 180-190. I was running and jogging a lot at that age.

              Now I engage 90% of maximal heart rate once or twice a month. Really for my purposes, 70-80% is sufficient. As we discussed earlier, 90% maximal heart rate is most uncomfortable whereas 70-80% is not.

              My point is really that I would not attempt extremely hard routines unless my cardiovascular health was very good to excellent. That requires much attention to a diet that improves vascular health in particular.

              • Phil says:

                Sameera,

                I guess I was too verbose. I do not find 90% of my maximal heart rate to be uncomfortable, at least not for ten or fifteen minutes.

                There’s a lot of interpersonal variability.

            • jd says:

              Having trained dozens of amateur road bicycle racers and spent years looking over heart rate and power data (as well as having myself been a Cat 1 racer), I agree that heart rate is widely variable and no formula based on max HR (or maybe any other standardization) is valid.

              “high intensity” may not have an agreed on definition, but there are certainly given ranges of effort (best defined by power (watts) in cycling (at least in terms of precision)) that correspond to physiological parameters that make up fairly well agreed upon training ‘zones’.

      • Kyle C says:

        +1. In my casual observation many people who perceive themselves to be exercising moderately are exercising lightly by the standards of the literature. The misperception may worsen as we age, since even people who take walks and garden for exercise are often rightly seen as “spry” and energetic for their cohort.

  2. Rodney Sparapani says:

    Did Paul Alper look like a Beatle?

    • paul alper says:

      The year was 1964: LBJ was about to use the Gulf of Tonkin Resolution in order to start the Vietnam War, bootstrapping was over a decade away, and Andrew Gelman had not yet been born. The brightest star in the firmament in 1964 was known collectively as The Beatles and the Jerusalem/Mecca was therefore Liverpool.

      • anon says:

        So it’s not because you looked like you enjoyed your scouse and beer?

      • Meg says:

        The end bit about Norway’s motto being to beat Sweden made me laugh, thank you for the article/post!

        My grandfather was Swedish (he came to the US when he was under 3 and only returned to Sweden once for a few years when he was 5-6.) So he was Swedish in the way that only a Swedish immigrant can be. Staunchly Swedish. 5 Generations of K/Carl’s (and 3 Carl Eric’s) and put-lit-candles-in-your-granddaughter’s-hair level Swedish.

        The mutual distaste between Swedes and Norwegians is impressive and long lived. God forbid someone mistook him for a Norwegian! (or suggest that genealogy indicated one of his grandparents might have been Norwegian)

  3. Martha (Smith) says:

    I have a friend (now in his late 70’s) who was diagnosed with congestive heart failure about six years ago. He was given a stent in one of his arteries, plus information on heart-healthy diet, and enrollment in a cardiac rehabilitation class that met two days a week for about six weeks (and was covered by health insurance). The class seemed to be carefully designed. Patients were first tested for heart rate, etc. while using stationary bikes or other exercise machines, then given graduated increases in their exercise “prescription”. They were trained to recognize physical sensations at different heart rates, and encouraged to get exercise two more days a week outside of class, trying to calibrate their heart rate by the physical sensations. After the six weeks, they were encouraged to continue physical activity on their own (typically brisk walking or exercise bike). My friend indeed continued with almost daily exercise, walking outdoors when weather permitted and using an exercise bike indoors when weather was inclement. At his last cardiologist checkup, he was told that he no longer has congestive heart failure. (But he continues the exercise routine and careful attention to diet.)

  4. gagan says:

    what’s up dr gelman,

    not sure how big of an REM fan you are, insofar as following members’ efforts outside of the band.

    i was just listening to bits of syd straw’s album “surprise”, and had to ask if you were aware REM’s lead singer did backing vocals.

    good album, great song. you came to mind as i heard his voice. thought i’d ask.

  5. Jens Åström says:

    In case anyone’s interested, here’s the website of the project behind the study (in Norwegian, but a short video pres in English): https://www.ntnu.no/cerg/generasjon100

    The research center has lots of other experience with 4×4 high intensive interval training. Here in Trondheim we hear about their recommendations now and again in the local paper.

    • Thank you Jens

      As long as the peak heart rate was calculated as described, It seems that the HIIT can be done safely. For me, doing high intensity exercise is value added. Again, I think that diet plays an even greater role in longevity based on the research and programs that Drs. Dean Ornish, Neal Barnard, John McDougall, and Caldwell Esselstyn have conducted.

      So the takeaway for me is: Exercise alone does not extend life.

    • paul alper says:

      Thanks, that video (in English) is very good, indeed. It does show that while “high intensity” has the greatest benefit; “moderate intensity” (surprisingly) fares worse than the control group. One wonders how to absorb/interpret/generalize that result.

      • Brent Hutto says:

        Paul,

        Keep in mind that the “control” group was more like a usual-care comparison group. And it turned out they were quite active including some of them engaging in HIIT.

        So that finding is best stated that those randomized to MICT fared slightly worse than those randomized to the comparison group. It does not imply (necessarily) that those engaging in MICT fared worse than those engaging in neither MICT or HIIT. In free-living behavioral trials the whole Intent-to-Treat framework is problematic and sometimes misleading in my opinion.

  6. A says:

    Shouldn’t they do instrumental variables instead of intent-to-treat? Given 25% dropout it could make a difference.

  7. Brent Hutto says:

    You know, the very earliest incarnations of public health/epidemiological recommendations were based entirely on research done on training for performance. As studies were done and the population-based evidence accumulated it was gradually recognized that the best advice for helping millions of non-athletes live a bit longer and experience better quality of life did not necessary accord with the best advice for helping an athlete improve his or her peak performance capabilities.

    I’m not saying there’s necessarily a complete disconnect between advice on “how active should I be to live a happier and healthier life” versus “how should I train to improve my 5K times”. But it’s important to realize some of what applies to one goal does not entirely apply to the other. And more importantly, what is a useful prescription for a middle-aged couch potato is quite different for what’s useful for a 30-year-old weekend athlete. There are millions of people for whom repeated 4-minute intervals of 90% exertion a couple times a week is quite off target.

    • Brent,

      Excellent points. As a 28 years old, I became very interested in perusing and trying out exercise regimes that penned by sports rehabilitation experts; thereby, escaped a good deal of sports-related injuries. I’m perhaps more cautious in how I proceed with an exercise regime.

      In reading the details of the study, I see that the participants were monitored frequently. Most exercisers don’t have that luxury.

      It looks as if the peak rates were individualized and not standardized.

  8. Michel Ney says:

    “More than 1,500 of the Norwegian men and women accepted. These volunteers were, in general, healthier than most 70-year-olds. Some had heart disease, cancer or other conditions, but most regularly walked or otherwise remained active. Few were obese. All agreed to start and continue to exercise more regularly during the upcoming five years.”

    Guess which effects on public health it mioght have if it was possible to involve those groups
    who are not physically active at all, in what was just the baseline activity here.

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