May 25 2015
This is the largest and longest exercise study ever conducted to find out if exercise can prevent disability in older adults.
Physical Function: What is physical function? It is the ability to carry out daily activities that require physical ability, ranging from self-care (basic activities of daily living (ADL)) to more-vigorous activities like carrying groceries, walking up the stairs and so forth. When the functional decline is severe ( termed disability), that is when you have no choice but to depend on others/ end up in a nursing home/or in bed. So physical function is a major determinant of quality of life in the elderly.
Muscle Mass Decline: Now guess what, decline in muscle mass and strength is largely responsible for the decline in physical function with age. As you get older (> 50), like it or not, there is a steady decline in muscle mass (1-2% per year) and strength (called sarcopenia).
Exercise & Function: The study was done to find out if exercise as claimed can prevent the onset of physical disability, especially walking disability (walking 400 m).
Previous Studies: Almost all the exercise studies were short-term and measured intermediates such as strength and muscle. The effect of exercise on long-term disability is unknown. It is unknown if frail older adults can keep exercising regularly and/or older adults who have multiple diseases can adapt well. It is the difference between a 12-week and a 3-year weight loss study
1635 Men and women aged 70 to 89 years, and who are at risk of disability (vulnerable folks), were randomly assigned to two groups. Subjects were recruited from 8 different centers in US.
The outcome measure is the failure to walk 400 meter in less than 15 minutes (also called walking disability or mobility disabilty).
In the exercise group, walking disability was seen 30%. Whereas in the control group, they observed a higher number of disabilities (296 or 35.5%).
In other words, there was a (5%) reduction in disability in high-risk older adults with exercise.
Physical function, Quality of Life & exercise: I have a Master’s in this field, worked as trainer for more than 10 years, ran a university fitness center for 4 years, and now doing my Ph.D. I have preached endlessly about the benefits of exercise when to comes to cancer, heart disease, obesity, diabetes and cognition to people. But I have never really given a thought about exercise to improve physical function in elderly until I saw my Mom’s struggle with cancer. She never really worried about dying, all she wanted was to do the basic things in her life without needing others help. And that affected her quality of the life the most.
In fact, research always focused on death as an endpoint since it is quantifiable and objective; quality of life on the other hand is qualitative and subjective and was less of a concern. Recently the concept of active life expectancy- the average number of years of life free from disability- has slowly come into picture. NY best-selling author Atul Gawande’s recent book “Being Mortal” talks about how in the mad race to make people live longer we forget how well they live those last years.
If you think about it, there is a pill for every major disease and people are living longer and longer. But, guess what, there is no medicine out there to reduce or prevent the decline in physical function in adults. The only option we have to slow the decline is exercise. Reducing the decline in physical function and thereby improving quality of life is probably one of the most important benefits of exercise and the one which is overlooked the most.
Healthy Participant bias: If you recruit subjects for an elderly study, the majority who show up for the study will be above average in health. The people who are in bad shape and need help are the ones struggling at home, not able to drive or walk around because of health issues (physical, cognitive, hearing, vision etc) and won’t see or able to read your study flier. This is called the healthy participant bias. This is the reason why all journals insist on reporting the recruitment protocols and why we shouldn’t skip reading those. The current study hence had a screening process and only recruited subjects who had lower physical function than average.
Osteoporosis: When I started r research in this area, I always wondered how come everyone knows about osteoporosis (loss of bone), but nobody really knows about the term sarcopenia (loss of muscle mass and strength). Loss of ,muscle mass and strength can lead to decline in physical function and falls, and is probably more important than osteoporosis. A large part of the reason FDA is still hesitant or slow in approving treatments or drugs is due to the lack of a consensus definition of sarcopenia. We still don’t know what is the cut-off point where loss of muscle starts to show up as decreased function. In fact, decrease in muscle and strength is not a good enough reason for pharmaceutical and regulatory agencies to approve drugs. This is similar to the development of drugs in osteoporosis; the drugs had to show a decrease in bone fracture risk than just increase in bone density.
Exercise Intervention: What was the specific exercise intervention used in the study?
- 30 minutes of walking at moderate intensity adding upto 150 min/week
- 10 minutes of primarily lower extremity strength training by means of ankle weights (2 sets of 10 reps),
- 10 minutes of balance training & large muscle group flexibility exercises.
-The intervention included attendance at 2 center-based visits per week and home-based activity 3 to 4 times per week for the duration of the study.
5% decrease means what: Now what really does a 5.4% decrease really mean? Does it mean you only get 5% of the disability or what? A large part of evidence based approach is communicating risk to the lay person so they can interpret and apply the evidence. A better way to convey risk is through numbers needed to treat (NNT). So a 5% decrease means you have to treat 19 people with exercise to prevent one case of disability in 2.5 years ( 19:1)
To give an example, aspirin is commonly used to prevent heart attacks. The NNT for aspirin is 1667 for cardiovascular problems. This means you have to treat 1667 people to prevent one cardiac problem annually. Now you can clearly see the uncertainty of taking a pill. You can also find out how many number of people get harmed using NNH (Number needed to harm). For example the NNH for apsirin for bleeding is 1: 3300. Next time the doc prescribes you a drug, ask for the NNT’s and NNH’s.
Harish Shetty | Mon May 25, 2015
Hi Anoop,
I am glad you touched on this subject, which is vastly ignored by majority of Fitness trainers. Also elderly or above 50 age people always live in a believe system where training is not for their age.
I Have 3 clients one is 85yrs old lady , 84yrs old man n 92 yrs old man.
With my experience in training them , They not only feel stronger and mobile but also more alert with exercise.
Anoop | Mon May 25, 2015
Thank you Anatloy for the comment. I have a lot of stuff planned.
Hi Harish,
Thank you. In fact, I have heard the same comments from some of the people in India. They think exercise is only for “looking good”. And exercise is very very important in developing nations where people don’t have loads of money to go join a nursing home and being taken care off.
And hard to find a fitness magazine/gym brochure having a older person on the cover.
Great job spreading the message!
James Harris | Tue May 26, 2015
Hi Anoop. Great article. Definitely worth the read and glad someone brought it up, I’ve been saying this since for a long time and never thought to write about. Great job.
Hi Anoop,
I wonder what the NNT and NNH would be in having men over 50 given low doses of testosterone to slow down the muscle loss. Would combining this with exercise even lead to a greater than 5%?
Great job on the article as always
Borysław Paulewicz | Wed May 27, 2015
Man I really like your blog. What other evidence based exercise blog would you recommend while waiting for another post of yours?
Anoop | Wed May 27, 2015
Hi James,
Thank you! You should write.
Hi Sully,
Thank you Sully. And great question!
There is a very famous trial published in NEJM and authored by one of the foremost experts in the field of T administration.
They administered testosterone for older adults between 65 and 80 and who have low test levels and mobility. Guess what? They had to stop the study even before they recruited enough subjects because of too high cardiovascular events in the test group. This maybe different from people who are younger and free of CV risk factors, mind you.
Here is the NNH for Cardiovascular events (6:1) ( in 3-4 years). Pretty high! When the NNH is so high, little point in looking at NNT you know
The bottom line is currently the only option we have is exercise.
I do write, but I hadn’t thought to write about this.
You can check out some of the content at Jamesharristraining.com if you want to see some examples.
MetroEast Beast | Wed June 10, 2015
Well done Anoop! The gym that I work out in has a significant amount of clients in the over 50 range. It’s very motivating to see people transform though exercise and diet. The cool thing is diet improvements stem from the exercise. The trainers don’t work with them on their diets. Seeing the results are almost as if a person gets younger! I think that many of them waited until they had a health issue or that they could finally afford a personal trainer. Once they get results they get super serious too!
Great job Anoop!
Anoop | Thu June 11, 2015
Thanks Rob for the comment!
And that is exactly the hard part. Evidence is not enough; how do you convey the evidence or communicate the evidence such a way that people do something about it. It is the million dollar question: How do you get people to start exercise and keep doing, especially when they are older/not in good shape/lack the motivation.
Most of my subjects in my studies do say they want to keep up exercising after the study is done. But not sure how many do.
Anoop | Sat July 18, 2015
Thank you Biju for he comment!
I am curious about something though. While we all know that exercise is good for you, we are also all told that too much can cause cardiovascular problems. Should elderly people being attempting to do the same exercises as those that are younger, or is there a happy medium there?
Great blog. I found it looking for info on the safety of deep knee bends - great info! Thanks. Then I found this article. As someone over “29,” I believe that we have turned into a sedentary society. I think we need to do more than our exercise plans 1 hours a day, 3-4 times a week. I think the research about the harm of having sedentary jobs and sitting all say are right on the money. My Mom is in her 80s and can run circles around me - she never had a formal exercise plan, she just never sat still and had jobs where she was on her feet all day. IN her youth she walked or rode a bike everywhere.
IN conjunction with our daily exercise routines, we need to get up every 20 minutes and move around. I have to remind myself to do this. I have found that it seems to help me be more alert and also has positive mental benefits. Generally, what keeps me motivated in maintaining my exercise/running/active lifestyle are the mental benefits along with the stress relief I get from activities like running.
Good article.
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