- Can you be so fit that you die?
- I asked that question in the second ever video
I uploaded to this channel,
but today I want to ask a slightly different one,
which is can you be so fit that you dddon't die
but you have significant health problems?
That previous video, which really was my rollaway success,
it's all been downhill since then,
concerned cyclists that pushed their bodies so far
that they actually placed themselves at risk of death
due to a combination of a very slow heart rate
and thick blood prone to clotting.
But the key point here
is that in the case of elite cyclists,
professionals in the 1990s particularly
that I was talking about,
they achieved this kind of superhuman state with drugs
and that if you don't take performance enhancing drugs,
you're not going to develop that pasta sauce blood.
But does that mean that extreme exercise
in the absence of drugs is completely safe?
That's what we're going to answer in today's video.
This video's sponsored by NordVPN,
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I'm on holiday in India at the moment.
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Now, statistically, I don't think many professional cyclists
are watching this channel,
but I imagine lots of you are keen
on getting out on your bike, just like I am,
probably you're far more serious about it than me,
or your keen runners or swimmers.
As I said, I'm on holiday in India right now
and when I go running around the local lake in the morning,
I've got loads of company, lots of people exercising.
We're seeing increase in popularity of Tough Mudders,
and Survival of the Fittest, Spartans, and all these kinds of races,
so I think endurance sport
is going through a popular phase right now,
which is fantastic.
And some of you are doing enough exercise
to qualify you as an athlete in medical terms
or perhaps that describes a loved one.
So this video is for you.
And indeed I've had a lot of requests for this video
because there have been some scary headlines in the press
that too much exercise is harmful.
And I think this message is now quite widely believed,
particularly in sort of sports circles, but how valid is it?
For those of you that haven't watched the channel before,
my name's Rohin, I'm a consultant cardiologist in the UK.
And I'm going to be focusing on the cardiovascular system.
I will mention the musculoskeletal system too,
but for reasons that I think are probably fairly clear,
you know about the skeletal system already.
Because if you're running so much
that you're damaging your knees,
you know about it, it hurts.
But with the heart,
sometimes it's not obvious if any damage is occurring
until much later.
And the videos that I found about this
either massively oversimplify it
or they're just plain wrong.
So I want this to be useful.
And I've also divided it up with chapter markings below.
Let me start by clearly stating one thing
because I know what you jokers
are going to put in the comments, you lazy bums:
"Oh, exercise is bad. I knew it.
That's all I needed to hear doc, thanks for the warning.
Back to the couch for me. Can't be too careful."
You're not funny, okay. Exercise is flipping amazing.
It has such a multitude of benefits, not just on your heart.
Mental wellbeing, diabetes, blood pressure,
chronic pain, cancer risk.
These are all based on good evidence.
The list goes on and on.
The general recommendation in most countries
is half an hour of moderate exercise five times a week,
which could be as simple as walking,
or half an hour's more vigorous exercise three times a week.
If you go from sedentary, and let's be blunt,
I think a lot of people these days do qualify
as having a sedentary lifestyle through no fault of our own.
Office jobs where they're working from home
or sitting in a cubicle have proliferated in recent years.
And so we do tend to spend most of our time sitting still.
So if you go from sedentary
to building in any form of regular exercise,
you will reap incredible benefits
because there's probably nothing else
you can do in your life to improve your health more
aside from maybe giving up smoking.
Now, please don't take up smoking just so you can quit it.
It doesn't work like that.
Exercise beats any other activity
for its overall effects on health.
So until we discover a way to age backwards, it's the king.
Definitely more useful than any particular diet
who your favourite influencer claims made them so attractive.
I made a whole love letter to exercise
in the form of a video, which you can watch here.
Now, almost 90% of Americans don't do enough exercise.
And fellow Europeans,
I know we like to look down our noses at the Americans
when it comes to food,
and we're correct to do that, their food is terrible,
but when it comes to obesity,
the UK is leading the charge to catch up with the US.
It's not that far behind
and Europe is also not faring so well.
And when it comes to exercise levels,
I was surprised that it's pretty similar across the board.
So exercise is good and you should do it.
Disclaimer out of the way.
But if exercise is a wonder drug, and it is,
does that mean that more of a good thing means more rewards?
Well, as with any drug,
you can probably guess that's not the case.
You need to aim for the optimal dose.
And we talk about exercise dose in the literature.
Because sometimes that enjoyment becomes an addiction.
The euphoria that exercise can produce
can make you exercise more and more.
Even those of us who don't compete at a high level,
we use apps like Strava, and step counters,
and Apple Watches, and wearables, and so on.
New ways to quantify our own exercise and compete,
not only with ourselves, but each other.
Of course, excessive exercise can cause other issues
like the musculoskeletal effects that I mentioned earlier.
Sore knees, Achilles tendinitis, tennis elbow, chafing bum.
I know all this from bitter personal experience.
I completely trashed my knees by 10 years of training
several times a week on a very fast, hard athletics track
in my youth when I was a serious 400 metre runner.
And even many years later,
I ran a half marathon about six years ago
and that took my right knee out,
honestly, for about three years.
And musculoskeletal problems, of course,
dominate strength training, but we're focusing on EEE,
extreme endurance exercise.
I'm talking about the marathon runners, the triathletes,
the ultra swimmers, the iron men and iron women,
the iron people who live in a primitive iron age society
where they evolved Nike Vaporflys
before the ability to talk about anything except running.
We get it, Dave. Stop telling me about it.
The people going out several days a week
for an hour or more of hard exercise.
You would assume that if exercise is good,
then more of it should be better,
but there's this interesting U-shaped curve
when it comes to the effect on your health.
Let's look at the y-axis here
and say that this is your overall health risk.
In some of the studies, it's cardiovascular risk.
In some, it's all cause.
So the higher up on the y-axis, the higher your risk.
You want to be low.
And then on the x-axis here,
we've got the amount of exercise from none
all the way to these ultra exercisers.
And as we begin going from no exercise,
where you have a very high overall risk,
with a bit of exercise, your risk drops precipitously.
And you get a huge benefit around a point,
which, surprise surprise, is in line with guidelines
for how much people should be doing.
We don't just pluck them out of nowhere.
So that is associated with a huge benefit
and reduction in your risk.
Then the first thing to notice,
and there were lots of studies done,
but one particular big study confirmed a lot of this,
which was over 600,000 people,
but there were multiple different
observational studies looking,
which proved the first thing to say,
which is there's a plateau phase,
which means that after a certain point,
even if you start, if even if you do more exercise,
they have a law of diminishing returns.
So you get fewer benefits
for quite a considerable increase in exercise,
but you're not coming to any harm yet.
However, this in particular, this big study,
showed an uptick when you got
to a certain level of exertion, of exercise,
then risk started climbing again.
And that was this very interesting U-shaped curve.
Let's be clear, extreme athletes' risk of adverse events
is lower than someone who does no exercise.
I've seen a Tech Insider video
that suggested that they were comparable.
They're absolutely not,
but the risk is definitely higher
than in someone who does a moderate amount of exercise.
There appears to be a sweet spot when it comes to exercise,
which is an important message.
So what's going on?
Well, extreme exercise isn't entirely benign.
If you measure the blood troponin,
this is a little chemical we measure in the bloodstream,
it shouldn't be detectable in your peripheral bloodstream
unless something is going on in the heart,
whether there's been a bit of damage to the heart.
So it goes up in a heart attack,
but it also goes up in 50% of marathon runners
if you take their blood after the race.
So that's an abnormal finding.
And if you put these people into an MRI scanner
to scan their heart,
you get a transient, subtle reduction in heart function,
which recovers completely.
But this, we believe, is reflective
of this mild irritation or inflammation of the heart.
Although you can't actually see the inflammation
on the scan because it's so subtle,
but you see the effects.
And repeated small inflammatory challenges like this,
we think eventually lead
to microscopic scarring and fibrosis,
which can cause electrical problems.
Having said all of that,
there have been some studies heavily publicised in the media
that really were scare mongering or over exaggerated.
You may have seen articles suggesting
that there are higher rates of coronary artery disease
in athletes or that athletes die earlier.
And these are wrong.
I'll talk a bit more about them.
But even the most extreme athletes
still live longer than sedentary people,
so that's another key thing to take home.
Let's start with what has the best evidence.
And the main risk from endurance exercise
is something called atrial fibrillation.
This is where the top chambers of the heart
instead of beating in a nice, coordinated way,
they're called the atria,
they stop contracting normally
and they start sort of quivering.
They fibrillate. So they just kind of lose efficiency.
And the overall efficiency of the heart decreases.
In some people, quite considerably. Maybe about 30%.
And atrial fibrillation's main impact
is that it can also increase your risk of having a stroke.
So we start a lot of these people
on anticoagulation blood thinning medication.
The rate of atrial fibrillation, or AF,
is five times higher among veteran athletes
than those that don't exercise often.
But, and this is important,
if you look up atrial fibrillation on Wikipedia,
you'll see that it's associated with stroke,
and higher rates of death, and heart failure.
However, this is not the same pattern we see
in athletes with atrial fibrillation.
Most people get atrial fibrillation
from high blood pressure, excess alcohol, heart disease,
or valve disease, heart valve disease,
and they don't do so well,
but the atrial fibrillation we see in athletes' hearts
seems to be more benign.
Or it's similar,
but they've dropped their overall cardiovascular risk
so much from their exercise
that it offsets the increased risk.
So atrial fibrillation is a risk,
but it doesn't seem to be as aggressive
as other people with atrial fibrillation.
When I'm trying to remember demographic features
about what kind of person is likely to develop a disorder,
I think of kind of a model patient, stereotypical patient.
And for this, I'm thinking of a man,
40 to 60 years old, and tall.
Yes, in yet another win for short people,
you've got a lower risk of developing atrial fibrillation
with extreme exercise.
More comfortable flying on planes,
more likely to get a match if you need a heart transplant,
surprisingly large amount of scientific evidence
that tall people die earlier than short people,
And now this. Truly, the short will inherit the Earth.
Well, anyway.
So this model patient also has been involved
in high level sport for a total of 1500 hours,
which doesn't sound like a lot,
but it's quite a lot when you think about it,
of intense exertion in their lives.
Now, we think this is caused by a number of mechanisms
related to the fact that athletes' hearts enlarge slightly.
You get repeated atrial stretch, inflammation in the tissue,
and you start accumulating these little micro scars
that I mentioned, or fibrosis.
A senior colleague of mine used to describe this
as the difference between a brand new CD
and one that's been left out of the box lying around
and it's kind of picked up some scratches
and gone a bit dull.
And if you're old enough to get that analogy,
then you're probably about the right age
to worry about this.
What about coronary artery disease?
I said I'd talk about those studies that have suggested
that there is increased coronary calcification in athletes,
which surely is a bad thing.
Well, it is complicated this one.
For a start, the relationship isn't entirely clear.
Yes, there does appear to be more calcified plaques
in the coronary arteries of athletes.
And generally calcification in coronary arteries
is not a good thing,
but we haven't seen that that translates
to clinically significant heart disease.
In other words, there's a bit of limescale present,
but it doesn't seem to be causing a problem.
I think more research needs to be done on that.
Some other things you might have heard about
are electrical issues.
Now, we've already discussed atrial fibrillation,
which is where the heart becomes irregular,
but there's some evidence to suggest that the fibrosis
can also affect not only the atria,
but the ventricles, the main pumping chambers,
and might cause abnormal ventricular rhythms,
although I would hesitate to say
anything too definitive on this.
There are dangers caused by a very slow heart rate.
Yes, you can be more prone to fainting,
but it is not accurate to say that athletes need pacemakers
at a higher rate than non-athletes.
We haven't observed that.
Some of this stuff, like the atrial fibrillation,
I think is pretty black and white,
but some of the other things we mentioned
like the coronary calcification and electrical issues
is based on evidence that, I think,
how much weight you put on it is going to be a bit subjective.
But the key message here should be
that you don't need to be committing
hours and hours of your life
to feeling the burn and embracing the pain.
Just exercise in a fun way. Exercise should be fun.
It should be something you look forward to.
What I hope I've shown
is that you don't need to be doing that much exercise
to reap enormous rewards.
And that's why we have the recommendations
in the form that they are.
They're not plucked out of nowhere,
but they're intended for everyone.
They are a minimum recommendation and by all means do more,
but the more exercise you do,
your additional benefits accrue less rapidly.
And there's a long plateau phase
where you're not necessarily that much better off
if you're doing 10 hours a week versus 5.
But, hey, if you're having fun, go for it.
And you should not be worrying about
the risks from excessive exercise,
as they affect people
who really, really are serious athletes
doing way more exercise than regular Joes.
Certainly much more than I do,
and I think I'm quite an active person.
So if your attention span is not as long as your cycle route
and you just want to kind of have a prescriptive amount,
then I would say for most people watching this
who probably skew to the younger end
of the overall population spectrum,
I would say that it should be
about five hours per week of moderate exercise,
which could be as simple as walking,
or 2.5 hours of more intense exercise.
This is a bit higher than some guidelines,
but I'm modifying this based on the demographics
that typically watch this channel.
And I still think it's a realistic goal for most people.
But remember the key message
is anything is better than nothing.
In an ideal world, we'd be on the move most of the day,
but that's not always possible
with the nature of work in the 21st century.
Yet another reason to be part of the anti-work movement.
Risks can be mitigated by diversifying your exercise.
Don't spend all of your time lifting weights
or running miles on the road.
Mix it up and you are much less likely
to suffer these adverse effects of extreme exercise.
And most importantly,
don't compete with Dave on Strava
with his 100 kilometres every day.
F*** Dave.
And likewise, don't shame anyone for their lack of fitness.
Encourage them.
If all else fails,
have a couple of kids and you'll never sit still again.
So why is this so important?
Why am I as a cardiologist so passionate about this?
Why am I making this video?
Because most Americans in surveys,
and I'm sure this is the same elsewhere,
think you need to be in the gym
or really working up a sweat to improve your health,
so they get put off.
But gardening, hoovering, walking, yoga, sex,
although, let's be honest,
I'm not sure many of you are going to make half an hour,
dancing, so many activities are exercise,
and they just get your body moving.
When I was going around the lake this morning,
every 100 metres I saw a local exercise club.
Aunties and uncles just getting their bodies moving.
Try and be in motion for a bit every day
and build in a small amount of more vigorous exercise
every week and I promise you, you will change your life.
(evening raga)
I'm on the roof of my in-law's house in Bangalore.
It's a beautiful sunny
monsoon evening. (dogs barking)
Dogs are barking peacefully.
Yes, perfect conditions for yoga you might think,
but in fact there's only one activity
that I'm planning right now, that's work.
And when I say work, of course, I mean about 50% Netflix,
but I can't actually access my NHS email from here.
I can't access loads of Netflix content,
videos in the news like sports and news videos.
You know, I can't see the whole match when I'm on holiday,
but I want to see the goals or the knockouts.
And I keep getting, "This not available in your region."
When my kids ask to watch Aang.
- [Young child] I want to watch Aang.
- Which is what they call "Avatar,"
it's just not available here.
But luckily I've got NordVPN set up, so it's very simple.
I just mark my location as back in the UK,
or New York, or wherever,
and can access all the usual content that I want.
There are over 5,500 locations in 59 countries.
I just open the map, one click, and it's done.
And one is going out specifically
to my massive viewership in Japan
and much of the Francophone world
because my video with Sabine Hossenfelder
from a few months ago has been age restricted
and also geographically restricted,
so viewers in French Guyana, for example,
can no longer access it.
And, my friends, that is a big problem.
Yes, the combination of medicine and physics
is just too inflammatory.
So use NordVPN to stick two fingers up to YouTube
telling you that you can't watch
two nerds sitting in a room talking about science.
And honestly, changing my geographic location
is the main reason I use a VPN.
The security stuff is great,
but there are people watching
who will know far more about that than me,
so I'll just tell you the reasons that I chose NordVPN.
I can use it on six devices, including my TV,
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And it's more than just a VPN because it's got
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Thanks for watching.