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PostScript
The dose of running that best
confers longevity
The Authors’ reply In the interim since
our editorial was published,1 the
Copenhagen City Heart Study focusing
on longevity in joggers, has been pub-
lished in a prestigious peer-reviewed
journal.2 This large prospective longitu-
dinal observational study followed 1878
joggers and 10 158 non-joggers for up to
35 years. They found that joggers, as com-
pared with the non-joggers, had a remark-
able 44% lower risk of mortality during
follow-up for both men and women. The
age-adjusted increase in survival was
about 6 years in both genders. However,
U-shaped curves were apparent for
Figure 1 Quantity of jogging and mortality. Green bars: significantly different than non-joggers
(referent).
588
mortality with respect to quantity of
jogging (figure 1), estimated running
speed (figure 2), and frequency of jogging
(figure 3). These curves suggest that the
benefits of jogging are most robust for
those who jog between 1 and 2.5 h per
week, at a slow to moderate pace, at a fre-
quency of about 2 or 3 times per week. In
those joggers who were doing a higher
volume, higher-intensity running, the
long-term mortality rates were not signifi-
cantly different from non-joggers. In
other words, overdoing the running sub-
stantially diminishes the remarkable gains
in longevity conferred by moderate
jogging.
These results were very similar to those
from the Aerobics Center Longitudinal
Study (ACLS).3 4 Dr Weber points out,
these data were presented in abstract-only
form on 2 June 2012 at the American
College of Sports Medicine in
San Francisco,3 and thus, did not contain
all the details of a full peer-reviewed
journal publication. One of us ( JHO) con-
structed a figure directly from the data in
that abstract showing a U-curve relation-
ship between running distance and mor-
tality risk that was included in our
editorial.1 4 These data were corrected for
many factors that may be improved by
running, including body mass index
(BMI), blood pressure, prevalence of
hypertension, lipids and factors that Dr
Weber did not mention, including glucose
and psychological factors. However, when
these data were corrected for age and
gender only (which of course are
unaffected by running), the mortality
advantage to runners over non-runners
was even larger, still the U-shaped rela-
tionship between running dose (mileage)
and prognosis, although somewhat
blunted, remained consistent with what
was reported. Specifically, higher running
Heart April 2013 Vol 99 No 8
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Figure 2 Jogging pace (running speed as estimated by the jogger) and mortality. Green bars:
significantly different than non-joggers (referent).
Figure 3 Frequency of jogging and mortality. Green bars: significantly different than
non-joggers (referent).
dosages (20 miles/week or more) did not
lead to further mortality risk reductions,
and actually appeared to be not as benefi-
cial as running at lower dosages (less than
20 miles/week). Even so, in both the
Figure 4 Marathon running trends in the USA from 1975 through 2011.9
Heart April 2013 Vol 99 No 8
Copenhagen City Heart Study and the
ACLS, the higher-dose runners did not
have a worse survival than the non-
runners. The high-dose running seemed
to simply negate the longevity benefits
PostScript
seen with low-dose to moderate-dose
running.
We devote a great deal of time and
energy in our academic endeavours and in
our clinical interactions with our patients,
emphasising and extolling the benefits of
regular physical activity for improving well-
being, cardiovascular (CV) health, and lon-
gevity.5 6 Without question, the larger
public health predicament for our culture as
a whole is inadequate amounts of daily
physical activity─not too much exercise.
Yet, we feel that it is constructive to frame
this debate using the ‘exercise as a drug’
analogy. If we had a drug in our therapeutic
armamentarium that conferred all the bene-
fits of regular exercise, it would, arguably,
be the single best treatment for preventing
disease and improving overall health and
life expectancy. Yet, just as with any potent
drug, a dose-response relationship exists,
whereby an inadequate dose will not bestow
the full benefits, and an excessive dose may
be dangerous. Generally, an ideal dose in
the moderate range will provide the full
benefits without predisposing to the
troublesome side effects that can occur fre-
quently with excessive doses. Evidence is
accumulating to indicate that exercise rou-
tines that are best for conferring CV health
and longevity are not identical to the fitness
regimens that are best for developing
maximal endurance and peak CV fitness.5 6
The potential for CV damage secondary to
extreme endurance exercise appears to
increase in middle age and beyond.5 7 Thus,
it would seem particularly important to
avoid chronic excessive exercise doses after
age 45 or 50 years.
‘Cardiac overuse injury’ is the term we
have coined for this issue.1 Most endurance
athletes, especially long distance runners,
understand and may have suffered ortho-
paedic overuse injuries including plantar fas-
ciitis, Achilles’ tendonitis, shin splints, or
patellar chondromalacia. In the case of
cardiac overuse injury, this might eventually
cause fibrosis and scarring of the myocar-
dium, potentially dangerous rhythms, and
accelerated coronary atherosclerosis8 (a con-
stellation of abnormalities which has been
labelled ‘Pheidippides’ cardiomyopathy’).5 7
The number of people participating in
marathons and other extreme endurance
events has been on a sharply rising trajec-
tory during the past 40 years. (figure 4)9 10
Some of these individuals might opt for
shorter, less demanding challenges if they
were aware of the possible long-term
adverse effects of these extreme efforts.
Most avid runners, cyclists and triath-
letes (swim, run and bike) are not engaging
in their sports solely because of perceived
health benefits. People do not scale
589
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PostScript
mountain peaks, skydive out of airplanes,
or race motorcycles and cars for health
benefits. They may do so because they may
find it exhilarating, or for the love of com-
petition, or for stress reduction, camarad-
erie, a sense of accomplishment, or the
‘adrenaline high’. On the other hand, if
your primary goal in performing regular
exercise is to maximise your longevity and
long-term CV health, the evolving data
suggest that a moderate amount of jogging
is ideal. As with alcohol, sleep and calorie
intake, just because ‘some’ is good, ‘more’
is not always better.11 Higher and stronger
doses of chronic running may be asso-
ciated with diminished health benefits
compared with less extreme doses.
Admittedly, this is currently still a hypoth-
esis, yet we suspect it will evolve into a
new paradigm for optimal exercise dosage.
For more information, view the TEDx
Talk, ‘Run For Your Life… at a Comfortable
Pace and Not Too Far.’ http://www.youtube.
com/watch?v=Y6U728AZnV0.
James H O’Keefe,1 Peter Schnohr,2
Carl J Lavie3,4
1 2013;110:17–20.
Saint Luke’s Hospital Mid America Heart Institute,
University of Missouri-Kansas City School of Medicine,
Kansas City, Missouri, USA
2 edged sword. J Am Coll Cardiol 2007;50:
Copenhagen City Heart Study, Frederiksberg Hospital,
Copenhagen, Denmark
590
3
John Ochsner Heart and Vascular Institute, Ochsner
Clinical School-The University of Queensland School of
Medicine, New Orleans, Louisiana,USA
4
Pennington Biomedical Research Center, Baton Rouge,
Louisiana, USA
Correspondence to Dr James H O’Keefe, Saint Luke’s
Hospital Mid America Heart Institute, Kansas City, MO
and University of Missouri-Kansas City School of
Medicine, 4330 Wornall Rd, Ste 2000, Kansas City,
MO 64111, USA; jokeefe@saint-lukes.org
Contributors All authors contributed to the concept,
analysis, and formation of this manuscript. It was
reviewed and accepted by all involved.
Competing interests None.
Provenance and peer review Commissioned;
internally peer reviewed.
To cite O’Keefe JH, Schnohr P, Lavie C J. Heart
2013;99:588–590.
▸ http://dx.doi.org/10.1136/heartjnl-2012-302886
▸ http://dx.doi.org/10.1136/heartjnl-2012-303556
Heart 2013;99:588–590.
doi:10.1136/heartjnl-2013-303683
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comfortable speed and not too far. Heart
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2 Schnohr P, Marott JL, Lange P, et al. Longevity in
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Heart Study. Am J Epidemiol first published online
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Heart April 2013 Vol 99 No 8
 Downloaded from heart.bmj.com on March 22, 2013 - Published by group.bmj.com

The dose of running that best confers

longevity
James H O'Keefe, Peter Schnohr and Carl J Lavie

Heart 2013 99: 588-590

doi: 10.1136/heartjnl-2013-303683

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http://heart.bmj.com/content/99/8/588.2.full.html

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References This article cites 6 articles
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