A more reasonable look at exercise guidelines

We are going to revisit the exercise guidelines because there is a new meta analysis in JAMA of Leisure Time Physical Activity and Mortality: A Detailed Pooled Analysis of the Dose-Response Relationship that tries to answer the question of how much training is optimal in a more precise way. As we discussed previously, the official exercise recommendations can be hard to understand from an amateur or elite athlete's perspective. Training at that level is not focused on health benefits per se, but on improving performance. The problem lies in the rough dichotomies for both time and intensity in the guidelines. For example:

"Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week" (WHO exercise guidelines 2010)

In my previous post we saw that I managed 164 minutes per week on average over a two year period including about 20% strengthening that should be counted separately. If we work that out, it is about 132 minutes aerobic training (mostly judo) and 32 minutes strength training per week. That is enough exercise if we count judo as a vigorous activity, which seems reasonable. However, we note that it does not reach the optimum of 300 minutes of moderate-intensity or 150 minutes of vigorous-intensity exercise plus two sessions of strength training per week. At the same time it is at the top level of recreational judo. So, something is not quite right.

The first problem we will tackle is the amount of exercise. The best way of measuring physical activity is using prospective logging. That is, each participant maintains a detailed log of all activities, usually for a week. This measure corresponds well with energy expenditure measured using doubly labelled water. However, for the kind of large epidemiological studies used to base the exercise guidelines on that is too much work. Instead they rely on seven-day recall questionnaires, which basically means asking the participants what they did last week hour by hour. This is a poor estimate of actual exercise but an acceptable measure for comparing different groups of people or the same people at different time points. As expected people tend to over estimate their physical activity using the recall method. One study found an average under estimation of 40% for total duration of exercise but a massive four-fold over estimation of vigorous exercise using recall instead of logs. The result was a 70% over-estimate of exercise amount when corrected for intensity. In addition, being part of a study means that logged exercise will probably be larger than exercise during an average non-logged week. Importantly, any of the methods will probably over estimate the average amount of exercise compared to a long-term exercise log, which includes vacations, injuries, and general laziness. Anyway, this is an important part of the reason why the guidelines basically give two intervals for training amount: Less than 150 minutes/week is bad for you, and more than 150 minutes/week is good for you.

Our second scab to pick is the intensity, which is dichotomised to moderate or vigorous both in the guidelines and in the original publications. Moderate is walking or bicycling in a brisk pace, but not strenuously. Vigorously is anything more intensive than walking or bicycling, for example jogging or swimming. Behind this artificial dichotomy lies the actual activities and in research about physical activity the intensity of different forms of exercise is quantified in metabolic equivalents or METs. The number of METs that an activity has is determined by how many times the resting energy expenditure the activity consumes. Using the kind of exercise and the number of hours we can then calculate an amount of exercise corrected for intensity. This is called MET-hours, that is the number of hours of exercise at a given MET-intensity. The minimum exercise in the guidelines correspond to 7.5 MET-hours per week, and the higher goal for additional benefits is accordingly 15 MET-hours/week.

Using the Compendium of physical activities we can calculate how many MET-hours my training actually corresponds to. Judo has a MET of 10 and weightlifting 6. This works out to 22 MET-hours Judo and 3 MET-hours strengthening for a total of 25 MET-hours, which is satisfyingly above the goal for maximum benefit.

Figure 1 adapted from Leisure Time Physical Activity and Mortality: A Detailed Pooled Analysis of the Dose-Response Relationship by Hannah Arem and co-workers, JAMA Internal Medicine 6 Apr 2015.

Finally, we can get back to the new analysis. What they did was go back to the original data and use the MET-hours recorded for each participant at leisure-time physical activity (i.e. exercise). This was then compared to the risk of death for different amounts of intensity corrected exercise. In figure 1 we can see that we can lower our risk of death by up to 40% by training more than 22 MET-hours per week and less than 75 MET-hours per week. However, we also see that the dichotomy holds. If we train at least 7.5 MET-hours per week we get the bulk of the benefit.

We can conclude that how long we, or our patients, should train depends very much on the type of training. When using these guidelines, even with correction for type of training, we should remember that they are based on reducing the risk of death. They are not meant to help you improve performance, certainly not at the serious amateur or elite level. Finally, while we can understand the reasoning behind making the guidelines as easy as possible, it would be useful to explain how to grade different forms of exercise quite early in the actual guidelines instead of leaving it to the reader to find in original sources.

Aerobic endurance

Today's post is about endurance. Physiologically, endurance is about energy delivery. In many ways the muscles are machines that can keep up a given amount of work for as long as there is sufficient energy. Chemically, fuel and oxygen is converted to carbon dioxide and water, which releases energy. This is the same thing that happens in a fire, but since we don't want to burn up, the energy release is very closely controlled by the use of the energy currency: adenosine triphosphate (ATP).

New ATP is produced through three basic mechanisms: nonaerobic metabolism, anaerobic metabolism and aerobic metabolism. The mechansims are listed in order of speed, that is the rate at which they can replenish ATP, which corresponds to the maximal level of effort that can be sustained by them.

Nonaerobic metabolism is the conversion adenosine diphosphate (ADP, with two phosphate groups), into ATP using creatine phosphate (CP). This is very fast and provides almost all energy the first 8-10 seconds of any exercise, and can produce around 1200 watt (Guyton & Hall, 10th ed.). It is limited by the intracellular stores of CP, which aren't that large.

Anaerobic metabolism is the breakdown of glucose or glycogen into lactic acid. The process is very fast, producing about 650 watt and can keep going for much longer than the CP-ATP conversion. However, it is limited by the acidity of lactate. All enzymes, including actin and myosin and the metabolic enzymes, have an optimal pH. When the pH varies from this they get less effective, and after about 60 seconds of pure anaerobic exercise the muscle pH will be far enough below the ideal for the process to be severely impaired and the muscle becomes fatigued. In judo, the combination of these first two kinds of metabolism is what provides energy during the intense parts of the workout.

Finally there is aerobic metabolism where glucose/glycogen, proteins, fat or lactate can be used to produce ATP through the Kreb's cycle, which requires oxygen. When burning glycogen, which is the most efficient, aerobic metabolism can produce about 280 watt. In judo this is what allows us to keep going for a full two hour session, and importantly what happens between the short periods of attack and defense to keep fatigue at bay. In the low intensity periods between bouts lactate can be removed from the muscle.

So, the most important part of endurance for judo training, and thus for keeping up with young elite athletes, is the aerobic capacity. The demands aren't as strenuous as for pure endurance sports like running or swimming, but you have to be fit enough to continuously recover from fatigue for a full two hours of training. Going back to our definition of endurance as energy delivery. This means the rate of oxygen consumption, which can be measured in ml/min. In order to be able to make comparisons between different athletes this in often normalised to body weight so that the most commonly used unit is ml/(min*kg).

According to the only english-language, judo-specific book on sports science I know of: "The sport science of elite judo athletes" by Wayland Pulkkinen, the maximal rate of oxygen uptake, or VO2max (that's "V" with a dot over it indicating volume over time, "O" with a "2" subscript as in oxygen, and max, as in max.), of judoka is around 60 ml/(min*kg).

The question then is: How do I measure up? To find out we have to find a way to measure VO2max, but actually measuring VO2max is impractical outside of a physiology laboratory. What remains is estimation from parameters we can easily measure. There are a number of more or less well validated methods to estimate VO2max. You can find them through your friendly, neighbourhood search engine (PubMed, not Google). Uth and co-workers presented their method in 2004 (Eur J Appl Physiol, 91(1), 111-115), so fairly recently, and they used well-trained men aged 21-51 years old by running while measuring their pulse.

The method by Uth et al calls for a resting heart rate, which I found to be about 50/min and a maximal heart rate which I found to be about 200/min. You then divide your maximum heart rate by your minimum heart rate and multiply by 15.3, let's say 15. That gives:

200 / 50 * 15 = 60 ml/(min*kg)

In conclusion, I can not blame my aerobic capacity for any of my shortcomings, but I did find out that I need to work on my running. My calves are killing me.

Fitness for judo

Physical fitness is a complex parameter that is not easily caught in any one number. As any role-playing gamer knows, there are three basic physical characteristics: constitution (CON), strength (STR) and dexterity (DEX).

In addition, judo competition is divided by weight categories so that each of the stats have to be optimised in relation to body weight. Some judoka have, apparently, rolled the perfect 18, 18, 18 and can beat everyone, but the rest of us will have to do with stats that aren't as stellar, and hopefully, bodies (and opponents) that aren't quite as large.

CON:

In judo constitution, or endurance, means that you have to be able to do two things: Control your opponent for at least five minutes, and launch your own attacks. The former is an inherently aerobic task because of it's length, but it is broken into shorter intervals by all sorts of breaks. At the same time the latter is anaerobic on the verge of nonaerobic. That is, during a match you use enormous amounts of energy very quickly, when attacking or defending, and then you have to re-coup this oxygen debt time and time again in the lulls of the fight.

STR:

For any given technical level, the stronger judoka always wins. The easiest way to get stronger is to increase muscle size, this increases the number of motor units and makes you stronger. It also makes you heavier. That's the reason for weight categories. Another way to become stronger is to learn how to activate as many muscle fibers as possible at the same time, while relaxing the opposing muscles as much as possible. This is an important reason for building strength using the movements that will actually be used in judo, and not only by lifting weights.

DEX:

Dexterity can be separated into speed and limberness, where speed is the most important. It is important to be limber enough to perform all techniques, but there are always techniques that require less flexibility. However, if you are faster than your opponent, he will be hard brought to avoid your attacks. Speed in judo means how quickly you can step and turn into your technique or out of your opponents. It also means how quickly you are able to notice and react to an opening in your opponent's defense. Both require very specific training, which is why years of recreational judo has surprisingly little impact on the ability to beat competitive judoka (not to mention that they have higher CON and STR as well, or do they?).

Next up will be a more detailed look at CON. How do competitive judoka perform, and how much do I have to catch up?

Judo!

I did include judo as something that the Nephrophysiologist blog would be about, but there hasn't been much about that. Actually, there hasn't been any judo here at all. It has been hard to find something sufficiently interesting to write about, something where I also feel I have enough to say that someone might find interesting.

So, what has changed? you might ask. My answer would be that my sights have been raised for me. As I moved home to Uppsala and changed labs and hospitals, I also changed clubs. From a small club with recent recruiting difficulties and therefore a clientele of slightly older, non-competetive judoka, to a large, competitive club with some recent successes. Anyway, while it is a lot of fun working out with the youngsters, they are in better shape than I am. It would be more fun if that wasn't the case.

To remedy the situation (so that I'm not that embarrassingly winded older guy) I started doing some supplemental training. At first I had the basic philosophy that anything is better than nothing (which is true). However, being a physiologist it's hard not to have a quick look at what the science says. The judo posts will try to handle the science of judo performance from a practical perspective as I play catch-up with elite judoka more than ten years younger than me.