June 24, 2024 • 1hr 39min
#307 ‒ Exercise for aging people: where to begin, and how to minimize risk while maximizing potential | Peter Attia, M.D.
The Peter Attia Drive
Key Takeaways
- It's never too late to start exercising, even for those over 50 who have never exercised before or are returning after a long break. The benefits can be significant at any age.
- Muscle mass and physical activity levels tend to decline gradually from age 25-75, then drop more steeply after 75. This decline can be mitigated through proper exercise.
- VO2 max declines with age but can be improved through training at any age. A high VO2 max is strongly associated with longevity and healthspan.
- When starting an exercise program, focus on exercise variability, movement quality, and setting realistic goals. Consistency is key.
- For cardio training, start with low-volume zone 2 training to build an aerobic base before adding higher intensity work.
- Strength training can increase muscle mass and strength at any age. Start with machines and bodyweight exercises before progressing to free weights.
- Fall risk increases dramatically with age. Strength training, balance work, and foot/ankle exercises can help mitigate this risk.
- Resistance training can improve bone mineral density even in older adults with low bone mass.
- Adequate protein intake (at least 1.6g/kg body weight) is crucial for muscle building, especially in older adults.
Introduction
In this special episode, Dr. Peter Attia addresses common questions about starting or returning to exercise for individuals over 50 years old. Many in this age group wonder if it's too late to begin exercising, often due to lack of prior training, fear of injury, or uncertainty about where to start. Dr. Attia emphasizes the importance of fitness for older adults, examining all four pillars of exercise (stability, strength, aerobic efficiency, and peak aerobic output), and provides practical advice on how to start exercising safely, minimize injury risk, and maximize potential benefits.
Topics Discussed
Key Points About Starting Exercise as an Older Adult (2:45)
Dr. Attia emphasizes that it's never too late to start exercising and that the benefits can be significant at any age. He uses the analogy of saving for retirement - while starting earlier is ideal, it's always better to start late than never. The key principles when starting an exercise program later in life include:
- Focus on exercise variability and movement quality over volume and intensity
- Set realistic goals and prioritize consistency
- Aim for a positive experience in the first 2-3 months to build long-term habits
Muscle Mass and Activity Level Decline with Age (10:00)
Dr. Attia discusses a graph showing how muscle mass (measured as fat-free mass) and physical activity levels change across the lifespan:
- Muscle mass peaks around age 25, then gradually declines until 75
- After 75, there's a steeper drop-off in muscle mass
- Physical activity levels follow a similar pattern
- There's likely a bidirectional relationship - less activity leads to muscle loss, and muscle loss leads to less activity
Dr. Attia notes that while population-level data shows smooth curves, individual declines often occur as a series of discrete drops, often triggered by health setbacks.
VO2 Max Decline with Age (15:30)
Dr. Attia explains how VO2 max (a measure of aerobic fitness) declines with age:
- VO2 max decreases across all fitness levels as people age
- To maintain high function in later decades of life, one needs to be in the top percentiles of VO2 max earlier in life
- A VO2 max of about 30 ml/kg/min is needed in the final decade of life for unencumbered activity
Starting a Training Program (18:30)
When starting an exercise program, Dr. Attia recommends:
- Prioritizing exercise variability and movement quality over volume and intensity
- Starting with bodyweight exercises and more complex movements (e.g., step-back lunges) rather than heavy weights
- Using machines initially to control range of motion
- Focusing on building the habit of daily activity, even if it's just walking
- For very deconditioned individuals, starting with 5000 steps per day on flat ground
Improving Aerobic Capacity (25:15)
Dr. Attia discusses the malleability of the aerobic system:
- Studies show significant improvements in VO2 max, workload, and endurance are possible even in individuals in their 80s
- Consistency is key - gains are lost more quickly in older individuals with inactivity
- Long-term goals (2-3 years) should be set for significant VO2 max improvements
Starting Cardio Training (30:45)
For beginners, Dr. Attia recommends:
- Starting with base building and low volume (e.g., 2 days/week, 30 minutes/session)
- Focusing on zone 2 training initially
- Using rate of perceived exertion (talk test) or heart rate (180 - age) to estimate zone 2 intensity
- Gradually increasing frequency before duration
The Critical Role of VO2 Max in Longevity (36:45)
Dr. Attia presents data showing the strong relationship between VO2 max and mortality risk:
- Moving from below average to above average VO2 max reduces mortality risk by 41% (equivalent to quitting smoking)
- Going from below average to high VO2 max cuts mortality risk in half
- VO2 max is possibly the single most important biomarker for lifespan
Introducing VO2 Max Training (46:15)
For older or deconditioned individuals, Dr. Attia suggests:
- Building an aerobic base with zone 2 training before adding higher intensity work
- Starting with short intervals (e.g., 1 minute) at the end of zone 2 workouts
- Progressing to dedicated VO2 max sessions with 3-8 minute intervals
- Focusing on safety and proper form, especially when fatigued
Options for Zone 2 and VO2 Max Training (53:45)
Dr. Attia discusses various exercise modalities:
- Zone 2: stationary bike, incline treadmill walking, rowing machine (if proficient)
- VO2 max: more options available, including outdoor cycling, swimming, running
- For older adults, walking on an incline can be effective for both zone 2 and VO2 max training
Strength and Muscle Mass Gains in Aging (57:00)
Dr. Attia emphasizes that resistance training can increase muscle strength and hypertrophy at any age:
- Studies show significant strength gains (70-80%) in individuals in their late 70s and early 80s with proper training
- Type II muscle fiber atrophy is a hallmark of aging, but can be mitigated through resistance training
Implementing Strength Training for Older Individuals (1:01:00)
When starting a strength training program, Dr. Attia recommends:
- Beginning with bodyweight exercises and machines to control range of motion
- Focusing on volume before intensity
- Starting with higher rep ranges (15-20) and gradually increasing weight
- Incorporating stability work and proper breathing techniques
- For those 65+, progressing even more slowly and emphasizing safety
Avoiding Injury When Strength Training (1:07:30)
To minimize injury risk, Dr. Attia suggests:
- Progressing slowly, especially with intensity
- Focusing on neuromuscular control and proper form
- Incorporating movement variability (e.g., single-leg variants instead of heavy squats)
- Using exercises with a higher margin of safety (e.g., floor press instead of bench press)
Fall Risk: Consequences and Risk Factors (1:12:15)
Dr. Attia discusses the significant impact of falls in older adults:
- 25% of people over 65 fall each year (likely underreported)
- Fall deaths have increased 30% from 2007 to 2016
- 15-30% of falls resulting in hip fractures lead to death within 12 months
- Risk factors include lower limb weakness, balance issues, visual difficulties, and certain medications
Mitigating Fall Risk (1:19:45)
To reduce fall risk, Dr. Attia emphasizes:
- The importance of foot and lower leg strength, particularly toe strength
- Ankle mobility and dorsiflexion exercises
- Balance training
- Maintaining type II muscle fibers for quick reactions
Improving Bone Mineral Density (1:24:30)
Dr. Attia discusses the importance of resistance training for bone health:
- Bones respond to load, which stimulates bone growth
- Estrogen plays a crucial role in bone health by mediating the mechanical-to-chemical signal transduction
- The "Lift More" study showed significant improvements in bone mineral density with just 8 months of twice-weekly strength training in postmenopausal women
Protein and Muscle Protein Synthesis (1:31:00)
Dr. Attia emphasizes the importance of protein intake, especially for older adults:
- Aim for at least 1.6g of protein per kg of body weight
- Older adults may need even more due to anabolic resistance
- Consume at least 20g of protein per serving
- Consider the type and timing of protein intake for optimal muscle protein synthesis
Conclusion
Dr. Attia concludes with some final advice for those starting an exercise program later in life (1:34:00):
- Prioritize safety and enjoyment to build long-term habits
- Try to do something active every day, even if it's just a 15-minute walk
- Gradually build up to a diverse exercise portfolio including resistance training and cardio
- Aim to look back after 90 days and feel glad about the changes made
The key message is that it's never too late to start exercising, and the benefits can be significant at any age. By starting slowly, focusing on consistency, and gradually increasing the challenge, older adults can make substantial improvements in their fitness, health, and quality of life.