Walking associated with reduced risk of dementia, cardiovascular disease and cancer

Walking associated with reduced risk of dementia, cardiovascular disease and cancer


  • Participants in a prospective study who walked more had a significantly reduced risk of dementia, premature mortality (all causes), mortality from cardiovascular disease, and cancer incidence.
  • The optimal beneficial effect of walking is obtained at almost 10,000 steps/day for the risks of dementia, premature death and cancer.
  • As little as 3,800 steps/day is associated with a 25% reduced risk of dementia, half the maximum effect (50%) obtained at 9,800 steps/day.
  • Higher intensity (steps/minute) of walking was associated with favourable effects on premature death and the incidence of cardiovascular disease and cancer.

Several studies published to date suggest that increasing the number of daily steps is important to prevent the development of chronic diseases and premature death. We often hear in the news or on social media that 10,000 steps/day is the target to reach to enjoy the maximum health benefits. However, some studies indicate that at 6,000 to 8,000 steps/day, the maximum protective effect is achieved and that taking more steps does not significantly reduce the risk of death from all causes, for example. However, there is relatively little data on the subject, and the studies published to date do not distinguish between the different types of walking (daily life vs. exercise) and have paid little attention to the relative importance of walking intensity or cadence.

A prospective study recently examined the dose-response association between the amount (number of steps/day) and intensity (cadence) of walking and the incidence of dementia. The study, which lasted an average of 6.9 years, was carried out among 78,430 people aged 40 to 79 who were part of the UK Biobank cohort. Participants wore an accelerometer around their dominant wrist 24 hours a day, 7 days a week for at least 3 consecutive days and had no diagnosed cardiovascular disease, cancer or dementia at the start of the study. From the data collected by the accelerometer, it was possible to determine:

  • the total number of steps/day;
  • the number of steps related to activities of daily living (e.g., walking from one room to another), defined as less than 40 steps/minute;
  • the number of steps taken during intentional physical activity, defined as 40 or more steps per minute (e.g., walking for exercise);
  • the maximum 30-minute cadence (i.e., the average number of steps per minute recorded for the 30 minutes, not necessarily consecutive, when the cadence was maximal).

By the end of the study, 6.9 years after its start, 866 participants had developed dementia. The results show a nonlinear association between the number of total steps/day and the risk of dementia. The risk of dementia decreases with the number of total steps/day up to a 51% decrease at 9,826 steps/day. A number of steps/day of 3,826 is associated with a reduction in the risk of dementia by 25%, or half of the maximum effect.

Figure 1. Dose-response association between total daily steps taken and incidence of dementia. Adapted from del Pozo Cruz et al., 2022.

For the number of steps related to daily life, the optimal dose was 3,677 steps/day, with a 42% reduction in the risk of dementia. Regarding the number of purposeful steps, the optimal dose was 6,315 steps, with a decrease in the risk of dementia by 57%. For the maximum cadence over 30 minutes, the optimal dose was 112 steps/minute, with a reduction in the risk of dementia of 62%.

Associations with risk of mortality, cardiovascular disease and cancer
In a second publication by the same researchers and with the same UK Biobank cohort mentioned above, the dose-effect association between the amount and intensity of walking and premature mortality, mortality due to cardiovascular diseases, and cancer incidence was examined. During the seven years of the study, 1,325 participants died from cancer and 664 participants died from cardiovascular disease.

The risk of premature mortality decreases with increasing number of total steps/day, up to approximately 10,000 steps/day. For every additional 2,000 steps, the risk of premature death decreases by 8%, 10% and 11%

Figure 2. Dose-response association between total steps walked/day and all-cause mortality (panel A), cardiovascular disease mortality (panel B), and incidence of 13 cancers known to be associated with a low level of physical activity (panel C). Adapted from del Pozo Cruz et al., 2022.

The strengths of this study are the very large cohort size and the use of accelerometry and algorithms that helped distinguish walking steps from other ambulatory activities (a problem in some previous studies). Among the limitations, there is firstly that this type of study, of an observational nature, does not make it possible to establish a causal link. Second, the accelerometry data at the start of the study was collected only once and therefore may not fully reflect participants’ walking habits. However, multiple measurements carried out 4 years after the start of the study indicates that there is little variation between the data obtained during the different measurements. In addition, there remains a risk of reverse causation, i.e. that the disease (dementia, cardiovascular, cancer) could be the cause of a low number of steps, despite certain precautions taken by the researchers to minimize this risk.

The researchers are of the opinion that the right part of the dose-response curves does not reflect a real reduction in the favourable effect of walking after 10,000 steps, but rather reflects the scarcity of walking data or events (diagnoses of dementia, cardiovascular disease, death) for these few great walkers. In addition, some particularly health-conscious participants may have set a target (popularized in the media) of 10,000 steps/day, which could explain why the optimal effect is observed at this amount of walking.

Walking more and walking faster are associated with health and longevity benefits. Although the optimal health effect seems to be achieved around 10,000 steps/day, it is important to note that walking between 5,000 and 8,000 steps/day allows us to greatly benefit from the positive effects associated with walking. Moreover, there is no minimum threshold for the beneficial association between the number of total daily steps walked and mortality and morbidity. For example, as few as 3,800 steps/day are associated with a reduction in the risk of dementia equivalent to half of the maximum effect obtained at approx. 10,000 steps/day. Future recommendations for the prevention of dementia, cardiovascular disease and cancer could take this new evidence into account and encourage the population to walk more and at a faster pace, in order to optimally benefit from the health benefits of walking.

Vigorous exercise decreases appetite and promotes weight loss through the production of the metabolite Lac-Phe

Vigorous exercise decreases appetite and promotes weight loss through the production of the metabolite Lac-Phe


  • Vigorous exercise (e.g., running) considerably increases the concentration of the metabolite N-lactoyl-phenylalanine (Lac-Phe) in the blood of animals (mice, racehorses) and in humans.
  • Chronic administration of Lac-Phe to obese mice reduced appetite, body weight and adiposity, in addition to improving blood sugar control.
  • In humans, Lac-Phe is produced in large quantities after very intense exercise (sprinting), more than after resistance exercises (weight training) or endurance exercises (e.g., running, walking, cycling, swimming).

Exercise is highly effective in protecting against obesity and related cardiometabolic diseases, including type 2 diabetes. However, the cellular and molecular mechanisms by which exercise exerts beneficial effects on metabolism are not yet well known. A team of researchers recently investigated the issue using a metabolomics approach, i.e. by studying the expression of all the metabolites following vigorous exercise sessions (running). The metabolite that increased the most in response to exercise in mice was N-lactoyl-phenylalanine (Lac-Phe), a result that was later confirmed in thoroughbred racehorses.

Lac-Phe: An already known metabolite
The metabolite N-lactoyl-phenylalanine was first identified a decade ago, but until recently its function was unknown. Lac-Phe is produced from lactate, which is generated in muscle cells during vigorous exercise and then released into the bloodstream, and the amino acid phenylalanine (see figure below). The formation of this metabolite is catalyzed (i.e., greatly accelerated) by the CNDP2 enzyme, which is expressed in several cell types (e.g., immune system cells, epithelial cells). Without knowing its exact function, we already knew that this metabolite increases in the blood of people who have exercised.

Figure 1. Lac-Phe formation catalyzed by the CNDP2 enzyme.

Lac-Phe decreases appetite and body weight
The activity of Lac-Phe was tested in obese mice (fed a high-fat diet). Daily administration of Lac-Phe caused obese mice to lose 7% of their body mass after 10 days, reduced adiposity, and improved blood sugar control. The activity level of the mice remained normal, but they simply ate less food (–50% over a 12-h period). Curiously, the administration of Lac-Phe to lean mice had no effect on their appetite. The researchers hypothesized (unconfirmed) that this difference could be due to a greater permeability of the blood-brain barrier in obese mice, which would result in higher concentrations of Lac-Phe in the brains of these mice, compared to lean mice.

In order to demonstrate the contribution of the Lac-Phe metabolite to the anti-obesity effect of exercise, the researchers used CNDP2-KO mice that are genetically modified to produce less Lac-Phe (by removal of the Cndp2 gene). CNDP2-KO mice and normal mice were fed a high-fat diet and subjected to a regular exercise protocol for 40 days. CNDP2-KO mice ate more food and gained 13% more weight (after 40 days) than normal mice. These results clearly show that Lac-Phe is involved in appetite control in mice.

And in humans?
The researchers looked at Lac-Phe levels in healthy people before and after exercising in two independent cohorts. In a first cohort of 36 people, Lac-Phe was the third metabolite that increased the most after exercising. This increase in Lac-Phe persisted until at least 60 minutes after ceasing to exercise, whereas that of lactate returned to near zero after 60 minutes.

Participants in the second cohort participated in three distinct types of exercise: sprint (maximum-intensity cycling), endurance (moderate-speed cycling), and resistance (strength training). Lac-Phe levels increased after all three types of exercise (Figure 2), but much more after cycling sprints (approx. 8 times) than after resistance exercise (approx. 2.6 times) or endurance exercise (approx. 1.6 times).

Figure 2. Lac-Phe levels before and after exercise in a cohort of eight people. All participants did three different types of exercise: intense exercise (cycling sprints), endurance exercise (90 minutes of cycling at moderate speed), and resistance exercise (bilateral knee extension exercise). Lac-Phe concentration was measured in blood samples taken before and after each exercise at t=0, 60, 120 and 180 minutes. Adapted from Li et al., 2022.

It is not yet known whether Lac-Phe decreases appetite in humans as it does in mice; this remains to be demonstrated. Furthermore, does Lac-Phe act on appetite control in the brain as has been shown for ghrelin and leptin, appetite and satiety hormones? There is no doubt that future research on this subject will provide us with interesting discoveries that could have a significant impact on human health.

Researchers hope to one day be able to produce a drug based on Lac-Phe that could decrease the appetite of obese people who cannot exercise due to other health problems. However, dietary supplement enthusiasts should be aware that Lac-Phe is completely inactive when taken orally. For people who want to lose weight through exercise, it therefore seems to be beneficial to increase the intensity as much as possible in order to further reduce appetite and consequently post-workout calorie intake.

Brisk walking associated with a slowing down of the aging process

Brisk walking associated with a slowing down of the aging process


  • According to a study of more than 400,000 participants, walking pace is associated with telomere length, a genetic marker of biological age.
  • Among the participants, aged 56.5 years on average, those who walked the fastest had telomeres whose length was equivalent to a biological age 16 years younger.
  • This association depended on the intensity of walking (speed) and not on the total amount of physical activity.

Telomeres are repetitive DNA structures found at both ends of chromosomes that ensure the integrity of the genome during cell division (see also our article on the subject). Each time a cell divides, the telomeres shorten, until they become too short and the cell can no longer divide; it becomes senescent and eventually dies. The accumulation of senescent cells in the organs of the human body contributes to the development of diseases related to aging and frailty. Researchers consider telomere length to be a marker of “biological age”, independent of an individual’s date of birth.

The benefits of walking on physical and mental health are well documented, but researchers wanted to know if brisk walking could also be associated with slowing biological aging, as estimated by telomere length. In the UK study, 405,981 participants with an average age of 56.5 years reported information on walking speed, either by self-report or by wearing an accelerometer-type recording device. Telomere length was assessed in leukocytes (white blood cells) by PCR from a blood sample from each of the participants. The results show that faster walking speed was associated with longer telomeres (younger biological age) regardless of the total amount of physical activity. Complex statistical analyses (bidirectional Mendelian randomization) suggest a causal link between walking speed and telomere length, but not the reverse, i.e., that the lengthening of the telomeres is not responsible for a greater walking speed. A causal link can only be established with certainty by well-controlled and well-conducted intervention studies.

The results of this study reinforce the importance of brisk walking for the maintenance of good health. An earlier study by the same researchers at the University of Leicester in the UK indicated that as little as 10 minutes of brisk walking was associated with longer life expectancy, up to 20 years longer when comparing fast walkers to slow walkers. Brisk walking can be done at any age, indoors or outdoors, and requires no special athletic skills or expensive equipment.

Smart wearable devices: Useful tools to monitor our health

Smart wearable devices: Useful tools to monitor our health


  • Smartwatches and other wearable devices are equipped with sophisticated sensors that can record several useful parameters to monitor our health: heart rate, electrocardiogram, amount of physical activity (quantity and intensity), oxygen saturation in the blood, detection of falls and cardiac arrhythmias, etc.
  • Wearing an activity monitor encourages physical activity in general and more specifically moderate to vigorous intensity physical activity, according to all of the studies that have been published on the subject.
  • Smartwatches are not yet sensitive and specific enough for reliable detection of atrial fibrillation, the most common type of cardiac arrhythmia.
  • Smart wearable devices are constantly being improved and have a bright future ahead of them. However, it will be necessary to ensure that these devices are accessible to all and that they do not negatively impact the health system by generating too much biometric data and unnecessary clinical tests.

Exercise monitoring devices, or physical activity monitors, have been used for decades in the physical activity research community. Early versions of these devices simply recorded the duration and intensity of physical activity. Modern versions of physical activity monitors can additionally give direct feedback to the user and thus have the potential to promote behavioural changes, i.e., to encourage physical activity and possibly detect health problems. Review articles on the applications of these wearable devices for cardiovascular disease care have been published here and here.

There are several types of devices for sale on the market. So-called smartwatches, such as Apple Watch, Fitbit, Garmin, Omron, and TomTom watches, contain sensors that measure physical activity (the number of steps, the energy spent) using the accelerometer and gyroscope, distance travelled (GPS), heart rate, as well as detect falls, monitor sleep, detect cardiac arrhythmias (electrocardiogram), and estimate blood oxygen saturation and cardiorespiratory capacity (VO2max). These devices are increasingly popular for tracking our health and fitness, especially during physical activity sessions, including walking, running, cycling and many other sports.

Other smart wearable devices
There are also devices that are worn around the thorax (e.g., BioHarness, Polar straps), around the wrist (bracelets), or that are inserted into “patches” that are attached to the chest (e.g., Zio Patch, Nuvant MCT, S-Patch cardio), clothing (e.g., AIO Smart Sleeve), or shoes. These smart wearable devices mostly measure heart rate and record electrocardiograms. These devices are less popular because they are bulkier and their functions are more limited.

An encouragement to exercise more?
A systematic review and meta-analysis of studies on the effect of interventions based on physical activity monitors was carried out by Danish researchers in 2022. As a first step, the researchers did a systematic review where they analyzed 876 articles published on the subject, of which 755 articles were excluded because they did not meet the established quality criteria (poor study design, protocol, intervention, comparison, population, etc.). They then contacted the authors of 105 studies to obtain detailed protocols and relevant data that would not have been included in their studies. This illustrates how difficult it is to carry out this type of synthesis study and that the studies published are of variable quality.

The systematic review retained 121 randomized controlled studies with 16,743 participants, where the average duration of the interventions was 12 weeks. At the very beginning of the intervention, the number of steps taken daily was 6994 on average, and the average body mass index was 27.8 (overweight). The three main aims of the study were to assess the impact of the intervention (wearing a monitor) on: 1) physical activity in general; 2) moderate to high intensity physical activity; 3) sedentary lifestyle.

  • Physical activity in general. For this meta-analysis, the results of 103 studies with 12,840 participants were included. Participants who wore a physical activity tracker did on average more physical activity than those who did not wear it. The increase was significant, albeit modest: 1235 steps more on average daily by wearers of a physical activity monitor.
  • Moderate to vigorous intensity physical activity. The meta-analysis on the effect of a monitor intervention on moderate-to-vigorous intensity physical activity, which included 63 studies with 8250 participants, also showed that wearing a physical activity monitor had a positive impact on the amount of moderate-to-vigorous intensity physical activity, about 48.5 minutes more per week.
  • Sedentary lifestyle. Interventions with a monitor indicated a slight favourable effect on sedentary time, a reduction of 9.9 minutes on average per day.

The authors conclude that the level of evidence for the effects of interventions based on the wearing of physical activity monitors is low for physical activity in general and moderate for moderate-to-vigorous intensity physical activity and for sedentary lifestyle. The effects on physical activity and moderate-to-vigorous physical activity of monitor-based interventions are well established, but may be overestimated due to publication bias, i.e., that researchers sometimes tend to publish their results only if their study is positive.

Detection of atrial fibrillation with a smartwatch
Atrial fibrillation is the most commonly diagnosed type of cardiac arrhythmia and affects more than 37 million people worldwide. This type of cardiac arrhythmia is associated with an increased risk of cardiovascular disease (5 times higher for stroke) and premature mortality.

Smartwatches, such as the Apple Watch for example, contain optical sensors that measure users’ heart rate by emitting green light through the skin of the wrist. An Apple Watch app uses algorithms that help identify abnormalities that suggest atrial fibrillation.

In a study funded by Apple, researchers wanted to test whether the Apple Watch could really be useful for detecting episodes of atrial fibrillation (AF). During the 8 months of the study with 419,297 participants, 2161 (0.52%) of them received irregular pulse notifications. Of these, those whose symptoms were not urgent were mailed an electrocardiogram (ECG) recorder (ePatch), which they wore for 7 days. Of the 450 participants who returned the ECG recorder for data analysis, 34% had confirmed episodes of atrial fibrillation, while 66% of them could not be confirmed. The main criticisms (see here and here) of this study are that the detection of AF by the Apple Watch is not very specific and not very sensitive, and that this type of use could do more harm than good by creating concern, promoting overdiagnosis and overtreatment and therefore causing a waste of health system resources. In addition, the high cost of this type of smartwatch means that it could not be deployed on a large scale, if the technology were to improve one day.

Smartwatches are continually being improved, so the performance gap with medical-grade devices keeps getting smaller. Physicians should be open to reviewing the data generated by smartwatches as it could yield personalized information useful for patient treatment. However, there is a lack of a regulatory framework to standardize these data and incorporate them into regular clinical practice. These devices have the potential to generate huge amounts of biometric data that could lead to unnecessary and costly testing, with consequences for patients and the healthcare system.

Other uses

Blood pressure measurement
Hypertension is a very common cause of several cardiovascular diseases and premature death. The presence of blood pressure sensors in consumer wearable devices could potentially improve the detection of hypertension, particularly nocturnal hypertension which is associated with the worst consequences. There are devices with a cuff, but devices without a cuff have recently been developed, making it possible to consider their use for the measurement of ambulatory blood pressure. The results of comparisons of these new devices with existing medical devices are encouraging, but this new technology is still in its infancy and will need to be further refined and studied.

Other sensors
There are minimally invasive biochemical sensors that measure molecules of interest in physiological fluids. For example, continuous glucose monitors measure glucose in the interstitial fluid (under the skin, not in the blood). These monitors have been clinically validated, but it remains difficult to integrate them into consumer portable devices. Sensors using sweat or saliva could be more easily integrated into wearable devices, but this remains to be developed.

Biomechanical sensors incorporated into clothing or shoes, such as the ballistocardiogram and seismocardiogram or dielectric sensors, have been developed with the aim of passively and continuously measuring cardiac output, as well as the volume and weight of liquids in the lungs. These devices could be useful for monitoring the condition of people with heart failure.

Smart wearables are constantly being perfected and they have a bright future ahead of them. However, it will be necessary to ensure that these devices are accessible to all and that they do not negatively impact the health system by generating too many biometric data and unnecessary clinical tests. In addition, smart wearables will need to be evaluated and subjected to strict standards to ensure their quality and effectiveness. The medical profession will probably have to open up more to the use of these devices, which allow remote monitoring, especially in these times of the COVID-19 pandemic when there has been a significant decrease in patient visits to their doctor’s office.

Sudden cardiac death in senior high-performance athletes

Sudden cardiac death in senior high-performance athletes


  • Sudden cardiac death that affects senior athletes during exercise is a very rare phenomenon, with an incidence about 100 times lower than sudden death affecting the general population.
  • On the contrary, regular exercise is associated with a strong reduction in the risk of sudden death and premature mortality in general.
  • The large volumes of exercise performed by senior athletes are associated with an increased risk of certain cardiac anomalies (calcification of the coronary arteries, myocardial fibrosis), but the contribution of these anomalies to the phenomenon of sudden death remains uncertain.
  • In the majority of cases, it is rather the presence of an underlying coronary artery disease that is responsible for sudden death affecting athletes, and they must therefore remain attentive to the appearance of unusual symptoms and ensure that they control well-established risk factors for atherosclerosis, such as cholesterol levels, blood pressure and type 2 diabetes.

As the name suggests, sudden cardiac death is defined as death caused by the sudden and unexpected stopping of the heartbeat, usually an hour or less after the onset of the first symptoms. Sudden death is responsible for approximately 50% of deaths from cardiovascular disease and is often the first (and last) symptom of an underlying cardiovascular disease. In Western countries, the incidence of sudden cardiac death ranges from 50–100 events per 100,000 people per year and is caused in approximately 75% of cases by the presence of coronary artery disease (known or unknown), the remainder being mainly of congenital origin (cardiomyopathies, channelopathies). In Canada, for example, it is estimated that sudden cardiac death affects 97 people per 100,000, which corresponds to about 35,000 deaths annually (about 9,000 per year in Quebec), or about 10% of overall mortality (there were 307,132 deaths in Canada in 2020-21).

Sudden death of athletes: A rare phenomenon
Although sudden cardiac death is very common, we mainly hear about this phenomenon when it affects athletes, for example, during a marathon. This is paradoxical, because while it is understandable that the deaths of people in excellent physical shape and in the prime of life might strike the imagination, the heavy media coverage surrounding these deaths can give the impression that the practice of sports activities represents an important risk factor for sudden death, which is absolutely not the case. In fact, it is well established that sudden deaths associated with sports are very rare phenomena, accounting for only about 5% of all sudden deaths that occur each year in the general population.

Despite this low incidence, it is important to understand the factors responsible for these sudden deaths in athletes. A very large number of studies have looked into this question in recent years to better understand the mechanisms involved, of course, but also to determine whether the risk of these premature deaths could be related, at least in part, to the very large volumes of exercise that are required to achieve athletic performance. In other words, can you exercise too much? Is there a limit beyond which the amount of exercise becomes excessive for the heart and can cause damage that will increase the risk of sudden death?

Senior athletes
Sudden cardiac death in sports is defined as death that occurs during or within one hour of the completion of a sports activity. A French study, which has since become a classic, has shown that the vast majority of these deaths affect people aged 35 and over and occur mainly (90%) in the context of leisure sports activities (Figure 1). These senior athletes (master athletes) represent the sub-population most at risk of sudden sports death, especially since this group of people is constantly increasing, with more and more middle-aged people participating in endurance sports. In the United States, for example, the number of people who have completed a marathon has quadrupled over the past 25 years, increasing from 5 to 20 million runners per year, more than half of whom are over the age of 35.

Figure 1. Distribution of sports-related sudden cardiac death by age. The values represent the total number of athletes who died in France during a 5-year period in the general population (blue rectangles) and among young people participating in individual or team organized competitive sports (red rectangles). Note that the vast majority (95%) of deaths occurred among people aged 35 and over. Taken from Marijon et al. (2011).

Men at risk
As mentioned earlier, sudden death caused by intense physical exertion remains a rare phenomenon, with an incidence of about 0.5-1.0 deaths per 100,000 participants, which is about 100 times less than the sudden death that occurs in the general population, outside of a sports context (50–100 per 100,000 people) (Table 1).

Male athletes represent the vast majority of these deaths, with a risk of sudden death 10 to 20 times higher than that observed in women. This difference is observed for all sports activities, including the marathon, and is probably related to the protective effect of estrogen against the development of coronary heart disease, one of the main causes of sudden death (see below).

Table 1. Incidence of sports-related sudden cardiac death, by age and sex.
Note the increased risk of sudden death in older men, especially for triathlon.
*For comparison, the incidence of sudden death observed for the Montreal metropolitan area in 2001 is shown.

Incidence of sudden cardiac death
(per 100,000 participants)
Sport in generalTotalMenWomen
All ages0.551.010.05
35-54 years0.661.250.05
55-75 years0.751.420.07
All ages
(22-65 years)
40-49 years3.966.080.96
50-59 years6.679.612.12
≥ 60 years12.918.610
Sudden death in general
(not related to sport)*

The risk of sudden death for male athletes also seems to increase with age (20% increase among those aged 55-75 compared to 35-55-year-olds for sports in general), while women do not seem to be so affected by aging. This impact of age is particularly striking for triathlon, where the risk of sudden death begins to climb as early as age 40 and increases each decade thereafter to become several times higher at age 60 (18.6 per 100,000) than the risk observed for all triathletes (1.74 per 100,000). It should be noted that two thirds of sudden deaths that occur during triathlons occur in the initial swimming stage, which could explain the much higher risk of death during these events than that observed for the marathon. It has been proposed that this higher incidence of sudden death during the swimming event may be due to a combination of several factors, including 1) a sudden rise in catecholamine (adrenaline, noradrenaline) levels caused by the stress of the beginning of the competition; 2) the chaotic start caused by the simultaneous entry of several participants into the water, which causes contact between the competitors and exposure to difficult conditions (big waves, cold water). These factors could play a role in triggering arrhythmias leading to cardiac arrest, especially in people with underlying coronary artery disease.

Overall, sudden sports-related deaths are therefore relatively infrequent and most senior athletes are not at major risk of death during periods devoted to exercise. On the other hand, older men (40 years and over) should be aware that certain very demanding sports, such as triathlon, carry a higher risk of sudden cardiac death.

The exercise paradox
As mentioned earlier, sudden death caused by exertion is most of the time the clinical manifestation of an underlying and asymptomatic coronary artery disease, but which manifests itself suddenly following the significant increase in the workload of the heart during intense exercise. In most cases, the stress imposed on the heart causes the atherosclerotic plaques present inside the coronary arteries to rupture, leading to the formation of thrombi (clots) that block the flow of blood to the heart muscle.

First of all, it should be mentioned that athletes are much less at risk of sudden cardiac death caused by intense exertion than people who are sedentary and therefore less physically fit. Several studies (herehere and here, for example) have indeed reported dramatic increases (17 to 56 times) in the risk of sudden death related to effort in these sedentary people, with in particular an increase in the risk of infarction of up to almost 100 times.

In all cases, however, these large increases in the risk of sudden death are greatly mitigated in people who regularly exercise. This protection is particularly dramatic with regard to the risk of infarction caused by exertion, with a reduction in risk of approximately 50 times observed in people who train regularly, at least 5 times per week (Figure 2). There thus seems to be a certain “exercise paradox”: on the one hand, vigorous exercise can considerably increase the risk of sudden cardiac death in the short term, while, on the other hand, regular exercise confers a strong protection against this risk of sudden death. For example, several studies have shown that just 30 minutes of moderate activity such as walking, 5 times a week, reduces the risk of cardiovascular disease by 20%, a reduction that reaches 30–40% for an equivalent amount of vigorous exercise. The benefits associated with regular physical activity therefore far outweigh the low risk of mortality that can occur during sporting activities.

Figure 2. Effect of regular physical exercise on the risk of myocardial infarction caused by vigorous exercise. Taken from Mittelman et al. (1993).

Cap on the health benefits
It is usually recommended to do a minimum of 150 minutes of moderate exercise (e.g., walking) or 75 minutes of vigorous exercise (e.g., running) per week to reap the health benefits of physical activity. It should be mentioned, however, that these recommendations are a little “timid”, as several studies indicate that higher volumes of exercise maximize the reduction in the risk of premature mortality associated with physical activity (Figure 3).

Figure 3. Reduction in the risk of mortality according to the volume of exercise carried out per week. Note the cap of benefits (40% reduction in mortality) observed from a volume of exercise corresponding to 2–3 times the amount recommended by the WHO. Adapted from Arem et al. (2015).

Someone who follows the WHO recommendations to the letter, for example by doing 150 minutes of moderate activity, which corresponds to approximately 7.5 MET-h per week (see the box for the calculation), sees their risk of dying prematurely decrease by 20%. An interesting protection, but which nevertheless remains well below that obtained if the volume of exercise is increased to reach 2 to 3 times the recommended quantities (40% reduction in mortality). On the other hand, it is important to note that there is a limit to the benefits of exercise, since higher volumes of physical activity do not bring additional reductions in mortality, even at amounts 10 times greater than those recommended (Figure 3). As a result, the considerable volumes of exercise that are carried out by senior athletes must above all be considered as sporting feats, often remarkable and beyond the reach of ordinary people, but not as a way to improve health.

Exercise intensity and volume
Exercise intensity is usually expressed as a metabolic equivalent (MET), using resting basal energy expenditure as a benchmark. For example, brisk walking, which is considered moderate-intensity physical activity, causes 3 to 4 times more energy expenditure than sitting still (3 to 4 METs). The energy expenditure of running, which is considered vigorous physical activity, is 6 to 8 times greater than at rest (6 to 8 METs). The volume of exercise performed by a person can be easily calculated by multiplying the duration of the exercise by its intensity. Thus, 150 minutes of moderate activity (4 METs) or 75 minutes of vigorous activity (8 METs) correspond in both cases to a volume of 600 MET-min or 10 MET-h per week.

In the study presented in Figure 3, the greatest reduction in the risk of premature death is observed in people who do 2 to 3 times the recommended amounts of exercise, i.e., 300–450 minutes of moderate activity or 150–225 minutes of vigorous activity (15–22.5 MET-h per week). In concrete terms, these volumes of exercise correspond to approximately one hour of walking or half an hour of running per day.

While the cap on the benefits of regular physical activity on reducing mortality is well established, there is still a gray area with regard to the extremely high volumes of exercise carried out over many years by some senior athletes. In several studies (hereherehereherehere and here, for example), it is indeed observed that athletes who do enormous amounts of exercise (10 times or more of the recommended amounts) have a risk of mortality slightly higher than those who do it optimally (3 times the recommended amounts) (see for example Figure 3). This diminished benefit is not statistically significant due to the small number of extremely active athletes (typically less than 3% of study participants), but it nevertheless raises the possibility that very large amounts of exercise, repeatedly performed for many years, can exceed the physiological capacities of the body and cause certain damages that reduce the benefits normally associated with an optimal amount of exercise. Sudden deaths affecting athletes despite their great physical condition could therefore be a manifestation of this damage.

Athlete’s heart
It has been observed that very high levels of exercise promote the appearance of three main cardiac abnormalities, namely atrial fibrillation, calcification of the coronary arteries, and myocardial fibrosis. The increased risk of atrial fibrillation in senior athletes is a very well-documented phenomenon, but this electrical disorder does not seem to play a major role in the phenomenon of sudden death in healthy people and so will not be discussed in more detail here.

However, coronary artery calcification and myocardial fibrosis deserve special attention because of the potential contribution of these abnormalities to the two main causes of sudden cardiac death, i.e., cardiac ischemia (blockage of blood supply) and ventricular arrhythmia (dysregulation of electrical signals allowing the orderly contraction of the heart).

Calcification of the coronary arteries. Coronary artery atherosclerosis is the leading cause of sports-related sudden cardiac death, both in the general population and in athletes, including high-level athletes such as marathon runners. A frequently used method to visualize these plaques is to measure the presence of calcium in the coronary wall by cardiac computed tomography (CT scan) and multiply the area by the signal density to obtain what is called a calcium score (CAC score). These scores have some prognostic value: a score between 1 and 100 is associated with a probability of 13% of cardiovascular events over the next 3 years, a risk that reaches 16% for scores 101–400 and 34% for scores >400.

This approach was used to compare the degree of coronary artery calcification of 284 men with an average age of 55 years based on the usual amount of exercise carried out each week since the age of 12 years. The results show that 68% of the most active participants throughout their life (>2000 MET-min per week, which is equivalent to approximately one hour of running each day) had a calcium score greater than zero, compared to only 43% in those who were moderately active (<1000 MET-min per week) (Figure 4).

Figure 4. Comparison of the prevalence of coronary artery calcification according to the amount of exercise performed each week over several years. Note the increase in the percentage of athletes with a calcium score greater than zero (red rectangles) for higher volumes of exercise (>2000 MET-min per week for more than 30 years). Taken from Aengevaeren et al. (2017).

In the same vein, a study carried out among senior athletes (over 40 years old) who had practised a very intensive training program for at least 10 years (more than 16 km of running or 50 km of cycling per day, with participation in at least 10 endurance competitions such as marathons and half-marathons) showed that these athletes had a higher prevalence of atherosclerotic plaques in the coronary arteries than men in the control group who exercised much less (44% compared to 22%). In this study, high CAC scores (>300) were observed only in athletes, as well as a significant narrowing (≥50%) of the diameter of the arteries (stenosis) and the presence of this narrowing in more than one vessel. Similar results have also been observed in marathon runners over the age of 50, and so it seems increasingly clear that high amounts of exercise are closely correlated with a higher prevalence of atherosclerotic plaques in the coronary arteries. A very athletic lifestyle therefore does not prevent the development of atherosclerosis, both in the coronary and peripheral arteries.

However, the very low prevalence of sudden cardiac death (and cardiovascular events as a whole) observed in senior athletes suggests that this acceleration of atherosclerosis is not as risky as in the general population. On the one hand, studies indicate that the majority of calcified plaques found in athletes are present in a stable form, unlikely to crack and form a thrombus (clot) blocking the coronaries. In other words, a higher calcium score in an athlete would not have the same prognostic value as a score of the same value in a sedentary individual. On the other hand, the physiological adaptations associated with regular exercise (increased diameter and elasticity of vessels, among others) improve coronary blood flow, which would allow athletes to be less affected by the presence of stenoses and thus avoid coronary events that would affect most people with a similar degree of atherosclerosis.

That being said, atherosclerosis still remains an important cardiovascular risk factor and it would be premature to conclude that the increased presence of plaques in the coronaries of athletes has no impact on their health. In this sense, it should be noted that a follow-up of marathon runners after 6 years showed that an increase in the calcium score is nevertheless associated with an increased risk of cardiovascular accidents in these athletes, going from 1% for scores <100, to 12% for scores of 100–400, and to 21% for scores >400. This is consistent with a study showing that the cardiac arrests suffered by marathon runners during an event were largely caused by an underlying coronary disease that caused an insufficient supply of blood to the heart (ischemia) to sustain the effort. On the other hand, and contrary to what is observed in the general population, none of these ischemia had been caused by a rupture of the atherosclerotic plaques. Overall, it therefore seems that atherosclerotic plaques are indeed more stable in athletes and that their rupture does not represent a major risk of ischemia and sudden death. However, in some athletes, the presence of these plaques can still reduce blood flow to the heart and cause cardiac arrest during sustained and intense effort.

The contribution of coronary artery calcification to the phenomenon of sudden death associated with sports should therefore not be overlooked, even in athletes who display exemplary physical fitness. This is especially true for those who have “converted” to sports later in life, after being exposed for several years to factors that accelerate the development of atherosclerotic plaques, in particular smoking and poor diet. Since atherosclerosis is a generally irreversible process, the burden of plaques that have accumulated during the period preceding the adoption of a more athletic lifestyle remains present and can be expressed in the event of intense and sustained effort. It is thus important to remain attentive to certain signals that could suggest the presence of an underlying coronary disease (unusual shortness of breath, palpitations, pain in the chest, arms or throat). Moreover, it should be noted that about half of senior athletes who suffered a sports cardiac arrest had experienced symptoms in the month preceding the cardiac event.

Myocardial fibrosis. Intense and prolonged exercise (marathon) was observed to be associated with a significant increase in the blood levels of certain markers of damage to cardiac cells (troponin, natriuretic peptide type B) and with dysfunction (reduction in ejection fraction) of the right ventricle (RV) of the heart immediately after the test. This reduction in RV function in response to very intense exercise has been observed in several other studies (see this meta-analysis), suggesting that this area of the heart is particularly at risk of being damaged by very high levels of exercise performed repeatedly and over long periods of time.

These myocardial injuries cause cell breakage and the appearance of fibrotic areas that can be visualized by cardiac magnetic resonance using the late gadolinium enhancement (LGE) technique. A contrast product (gadolinium) is injected and rapidly eliminated from the normal myocardium, but persists longer in the fibrotic areas. By acquiring images more than 10 minutes after the injection, the signal obtained late makes it possible to identify areas of fibrosis.

An analysis of 19 studies involving a total of 509 healthy endurance athletes found that approximately 6% of athletes had a positive LGE signal, indicative of myocardial fibrosis. Studies that have compared LGE in endurance athletes with that affecting less active people (physical activity equal to or lower than the recommendations) show that fibrosis is much more frequent in athletes, with a prevalence of 12% compared to only 1.5%. More recently, a meta-analysis of 12 studies (1350 participants) estimated that the risk of fibrosis is increased by about 7 times in endurance athletes compared to sedentary or less active people (Figure 5).

Figure 5. Increased risk of myocardial fibrosis in senior athletes. Athletes who perform large volumes of exercise over several years have a significantly higher LGE signal than controls who exercise 3 hours or less per week. Taken from Zhang et al. (2020).

This higher prevalence of the LGE signal (and therefore of fibrosis) in athletes is strongly correlated with the number of years of intensive training as well as the number of endurance competitions completed, which strongly suggests that large volumes of high-intensity exercise represent a risk factor for myocardial fibrosis. As mentioned before, the right ventricle seems more sensitive to the stress imposed by intense exercise, and the majority of cases of fibrosis detected in athletes are located in this ventricle, especially in the area that is in contact with the septum separating the two ventricles of the heart.

The presence of these fibrotic areas can in principle disturb the electrical signal and create a “short-circuit” that can cause rapid ventricular tachycardia, capable of degenerating into ventricular fibrillation (causing sudden death). It would therefore be possible that myocardial fibrosis, which preferentially affects endurance athletes, could play a role in the sudden death affecting some of them. In this sense, it should be noted that one study observed that marathon runners who presented an LGE signal were more at risk of cardiovascular events in the two years following diagnosis than athletes without an LGE signal, and another study observed ventricular arrhythmia in athletes with areas of fibrosis (at the level of the epicardium).

In sum, the studies carried out so far indicate that senior athletes who have done large volumes of high-intensity exercise for long periods of time are more likely to have fibrotic lesions in the myocardium. However, the consequences of these fibrosis remain uncertain given the low incidence of sudden cardiac death in this population, and because of studies showing that vigorous physical activity does not seem to increase the risk of ventricular arrhythmia and that people in excellent physical shape are at lower risk of premature mortality. For example, elite athletes (Olympic medallists, for example) live 3–6 years longer than the general population.

In conclusion, sudden cardiac death that occurs during a sports activity remains an extremely rare phenomenon, especially among senior athletes who are regularly active. The health benefits provided by physical activity thus far exceed the very slight risks involved in practising a sport. The amounts of exercise required to benefit the most from this protection are equivalent to approximately 1 hour of walking or ½ hour of running per day, which is far from excessive and represents a goal within reach of most people.

Very large volumes of intense exercise, such as those performed by high-level senior athletes, can induce certain cardiac abnormalities (coronary artery calcification, myocardial fibrosis), but the impact of these abnormalities on the risk of sudden death affecting these athletes remains uncertain. Large-scale prospective studies focusing specifically on athletes, for example the Master Athlete’s Heart study recently initiated in Europe, should make it possible to better identify the risk factors for sudden death in athletes.

In the current state of knowledge, the main risk factor for sudden death in athletes seems to be the same as that of the general population, i.e., the presence of an underlying coronary artery disease which blocks the supply of blood to the heart muscle. For example, in the study of sudden deaths during triathlons, researchers found that 30% of deceased athletes had signs of advanced coronary atherosclerosis. Putting on running shoes every morning does not completely prevent the development of coronary plaques and above all does not eliminate the atherosclerosis that has developed over the years. This is particularly true for athletes who have adopted sports later in life, after having had a suboptimal lifestyle (sedentary lifestyle, smoking, poor diet) for several years. Like the general population, senior athletes who regularly engage in large volumes of exercise and/or participate in endurance events therefore have every advantage in controlling well-established risk factors for atherosclerosis, such as cholesterol levels, blood pressure and type 2 diabetes.

We should also not neglect certain factors such as electrolyte imbalances (hyponatremia, in particular), heat stroke or pure and simple exhaustion which can alter cardiac function, regardless of the state of health of the coronaries. These factors cause intense physiological stress that could explain why the vast majority of deaths that occur during marathons occur in the last quarter of the race

Cycling: A particularly beneficial exercise for the health of diabetics

Cycling: A particularly beneficial exercise for the health of diabetics


  • Exercise and physical activity bring many benefits for people with type 2 diabetes.
  • Among a large cohort of 110,944 people from 10 European countries, 7,459 people had type 2 diabetes, 37% of whom were cyclists.
  • After a 5-year follow-up, the researchers found that fewer premature deaths and deaths from cardiovascular disease occurred proportionately among cyclists than among non-cyclists.
  • Participants who started cycling after the start of the study also saw their risk of death significantly reduced, showing that it is never too late to get on that bike and reap the health benefits.

Diabetes increases the risk of developing cardiovascular disease and of dying prematurely from cardiovascular causes and from any cause. Regular physical activity and exercise reduce risk factors for cardiovascular disease in people with diabetes.

Benefits of aerobic exercise
In diabetics, aerobic training (brisk walking, running, cycling, etc.) increases insulin sensitivity, mitochondrial density (production of energy in cells), vascular reactivity, immune and pulmonary functions, and cardiac output. In addition, regular training lowers the level of glycated hemoglobin and triglycerides in the blood as well as blood pressure.

Benefits of resistance exercise
Diabetes is a risk factor for having poor muscle tone, and it can lead to a faster decline in muscle strength and function. A few mechanisms have been proposed to explain this phenomenon in diabetics, including: 1) endothelial dysfunction secondary to high blood glucose levels which cause vasoconstriction of the vessels that nourish muscles and 2) disruption of skeletal muscle energy metabolism through a dysfunction of the mitochondria (elements of the cell that produces its energy).

Benefits of resistance training (weightlifting, use of a resistance band, etc.) in the general population include improvements in muscle mass and strength, fitness, bone mineral density, insulin sensitivity, blood pressure, lipid profile, and cardiovascular health. For diabetics (type 2), resistance training improves blood sugar control, insulin resistance, blood pressure, muscle strength, lean body mass vs. fat mass.

Benefits of other types of exercise
People with diabetes are particularly affected by the loss of joint mobility, a condition caused in part by the build-up of end products of glycation that occurs during normal aging, but is accelerated by hyperglycemia. People with diabetes can therefore benefit from stretching exercises that allow them to increase the flexibility and mobility of their joints.

Cycling and mortality risk in diabetics
Is there one physical activity that is more beneficial than others to improve the health of people with diabetes and reduce the risk of premature death? A prospective study of 7,459 adults with diabetes, with an average age of 55.9 years, assessed whether there is an association between time spent cycling and cardiovascular mortality or from any cause. Participants, who had been diabetic for an average of 7.7 years at the start of the study, completed detailed questionnaires upon enrollment and 5 years later. Compared with participants who did not cycle at all (0 minutes/week), those who did had a lower risk of death from any cause, from 22% (1 to 59 min/week) to 32% (150 to 299 min/week). Reductions of the same order of magnitude (21 to 43%) were observed for cardiovascular mortality. These reductions in mortality risk were independent of other physical activities reported by participants and other confounding factors (level of education, smoking, adherence to the Mediterranean diet, total energy intake, occupational physical activity).

Another question the study researchers wanted to answer was whether stopping or starting to cycle during the 5-year follow-up had an effect on the risk of death of participants with diabetes. The results indicate that participants who cycled after the start of the study had a significantly lower risk of cardiovascular and all-cause mortality compared to non-cyclists. Participants who instead stopped cycling after starting the study had a similar risk of premature death to that of non-cyclists. It is therefore never too late to start cycling and reap significant health benefits, provided that this exercise is practised regularly, without interruption.

Other researchers found it surprising that the association between cycling and a reduction in the risk of mortality is independent of other physical activities. They point out that there is a relationship between the amount of physical activity and the reduction in mortality (4% reduction in risk per 15 minutes of additional physical activity per day) for healthy people and those with cardiovascular disease according to published data. They questioned whether a bias comparable to that of the “healthy worker effect” is not at issue here. This bias could be caused in this case by the fact that diabetics who cycle are healthier than those who do not, resulting in lower premature mortality. In their response to this criticism, the study authors say they agree that cyclists might be healthier than non-cyclists, but they say they did all they could to minimize this potential bias by adjusting the results to take into account risk factors for premature mortality, including diet, physical activity other than cycling, incidence of myocardial infarction and cancer, and excluding smokers, former smokers and individuals who play sports. The authors conclude that they are convinced that cycling can directly contribute to reducing premature mortality, but that in this type of study it is always possible that there are known or unknown confounding factors.

An earlier study had previously reported that cycling had advantages over other physical activities. This study was carried out about 20 years ago with 30,640 participants in the Copenhagen region of Denmark. In the 14.5 years of follow-up, people who cycled to work had a 40% lower risk of dying prematurely than non-cyclist participants, after accounting for possible confounding factors, including the amount of physical activity during leisure time.

Cycling requires being fit, having a good sense of balance, and having the financial means to buy a bicycle. In addition, cycling must be done in a safe environment, which is increasingly possible with the addition of cycle paths in recent years. In Quebec, cycling cannot be practised safely during the winter, namely for more than 4 months, but it is fortunately possible to ride a stationary bike at home or in training centres. In recent years, there has been real enthusiasm for cycling, including the electric bicycle, which allows older or less fit people to climb slopes without much effort. Let’s hope that this enthusiasm continues so that more people who are healthy or have a chronic illness can benefit from the health benefits of this extraordinary physical activity.