James O’Keefe on exercise: prescient or premature?

Thanks to John Mandrola for reporting on the buzz being created by Dr. James O’Keefe from the Mid-America Heart Institute.  Besides the recent WSJ article that cites a yet to be published paper by O’Keefe, this recently posted 18-minute TED-x talk by Dr. O’Keefe informs us of the gist of his claims:



Here’s the play-by-play:

O’Keefe starts with Thomas Bassler’s 1977 proposal that “marathon running confers immunity against heart attacks” and counters that claim with an anecdote about a long-standing marathon runner whom he found to have a high coronary calcium score at age 68.  He then states that the patient had no risk factors (adding under his breath “…to speak of….” ).

What is that supposed to indicate?  That marathon running does not make us “immune to heart disease” is certainly not news to anyone.  Unfortunately this anecdote sets the tone for the rest of the monologue.

O’Keefe goes on to quote this Lancet study of 400,000 Taiwainese residents who were asked to complete self-administered activity questionnaires and were followed for 10 years or so.  Here is the graph shown during the talk:

O’Keefe stresses the point that the mortality benefit for those in the “vigorous activity” group levels off with increasing volume of daily activity, while for the moderate exerciser, it continues to increase.  That may well be true, but bizarrely he barely ackowledges the fact that the mortality reduction is far greater for the vigorous exercisers at any volume of activity!

Incidentally, he also makes the comment that he and his colleagues “published an editorial along with this.”   Well, the alleged editorial was actually a letter to the editor in which O’Keefe et al. asked the study authors if any adverse effects of vigorous exercise were seen at all.  Here is the response from the authors:

James O’Keefe and colleagues raise an interesting question as to whether excessive strenuous exercise can become deleterious. We showed graphically that the benefits of mortality reduction peaked at 50 min with a hazard ratio of 0·60, without showing that it continues beyond 70 min. By 120 min, the hazard ratio for all-cause mortality was around 0·55, with even better hazard ratios for cardiovascular diseases (although less than 0·3% did daily vigorous exercise at this level). The adverse effects of strenuous exercise for incremental efforts for more than an hour a day did not seem to outweigh the benefits. We were not able to identify an upper limit of physical activity, either moderate or vigorous, above which more harm than good will occur in terms of longterm life expectancy benefits—an observation similarly made by the 2008 Physical Activity Guidelines for Americans. (emphasis mine)

O’Keefe then switches gear to tell us of his love for “evolutionary medicine,” where supposedly “looking at nature and our deep past we can find the template for ideal health.”   What he means by that is not entirely clear but his bibliography on PUBMED seems to indicate some attraction to the “hunter-gatherer” lifestyle.

Next, he advances the point that exercise, like any other pharmaceutical, has a therapeutic window of some sort:  below a certain “dose” it is ineffective;  above another level it is toxic.  O’Keefe then makes claims that sustained high cardiac output can cause “stretching” and “burning” of the heart, pointing to the serum troponin elevations seen after marathon running and illustrated, for example, in this paper and in the graph below:

Click to enlarge

O’Keefe goes on to describe in dramatic terms these troponin elevations and studies showing increases in myocardial fibrosis, coronary calcium, atrial fibrillation, and ventricular tachycardia in veteran athletes, as if cardiac failure was an inevitable outcome of sustained high-endurance training.

Next, we again get an anecdote, this time the story of Micah True, whose autopsy report officially described a dilated cardiomyopathy.  O’Keefe will have us believe that from his reading of the autopsy report, Micah True had “what we might expect to see in some extreme endurance athletes,” as if the putative athletic heart cardiomyopathy bears a recognizable pathognomonic signature.  According to O’Keefe, caballo blanco had a classic case of “Phidippides Cardiomyopathy,” a term coined by Dr. Peter McCullough who seems equally enthusiastic about postulating the existence of an athletic heart disease.*

O’Keefe ends the talk by plugging his 2 yet to be published studies which will “revolutionize” how we think about exercise.  For this we’ll have to wait and see until the details are available for review.

Parting thoughts:

The detrimental effects of long-term endurance training are potentially very serious.  Who’s at risk, what the risk really is, and what should individuals do regarding their level of activity, however, is far from settled.

Is there a thoughtful to approach this problem?  I certainly hope one will emerge.  But at this point in time, athletes young and old deserve dispassionate appraisal of the available data, not hyperbole about “arteries becoming harder than bones,” premature pronouncements on hypothetical pathophysiological mechanisms, or romantic notions that health can be found in the Cro-Magnon way of living.

O’Keefe tells us: “as a cardiologist, I’m in the business of finding the ideal diet and lifestyle.”  I’m afraid that if he has his way, we will be served another platter of a one-size-fits-all recommendation.

For the last 40 years enlightened cardiologists have been telling us the wrong thing on what we should eat.  Does a handful of provocative studies give them now the necessary wisdom to tell us how we should run?


(*)  In my opinion, Phidippides’ sudden death is much more plausibly the result of Octopus pot disease than of any putative fibrosis induced by chronic endurance training.


UPDATE:  As always, Lawrence Creswell does an excellent job of putting things in perspective.  He shares his thoughts on the 2 studies that O’Keefe is alluding to.  He also points to other blog entries, notably one by Alex Hutchinson, the edits “sweat science” at Runner’s World.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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6 thoughts on “James O’Keefe on exercise: prescient or premature?

  1. Thank you for a thoughtful counter point to Dr. O’Keefe’s presentation. His review article in the June 2012 issue of Mayo Clinic Proceedings is a bit more appropriately restrained and less of a polemic but not entirely free of it. To know how much one should exercise for optimizing health and when to stop to avoid putative deleterious cardiac effects goes far beyond any data we now have. If the to be published articles contain enough data to revolutionize anything notwithstanding claims to the contrary,I will be very surprised.

    I hope to have more to say about the issue of chronic cardiac effects of prolonged endurance exercise . Meanwhile I am off for my Sunday run. If I add in a few hills that might resonate better with my paleolithic genome.


  2. Thanks for the update.After reading the commentaries by Creswell and Hutchinson,I am postponing any critique of O’Keefe’s presentation and his Mayo review. They have nailed most of my concerns.

    In regard to giving everyone advice on what to eat or how much water to drink ( the answer is 1.5 liters per day) I will mention without explicit commentary than Dr. O’Keefe seems to be recommending an “environmentally friendly” Omega 3 product called Ocean Safe Omega. O’Keefe has determined that if we eat all the fish we need to get the amount of Omega 3 he has determined we need, we will eat too much fish with toxic contaminants.Hence the need for this product which will also at least help the over-fishing problem as the organization supplying the calamari uses safe fishing techniques. Dr. O’Keefe is the Chief Medical Officer and founder of Cadiotabs which produces along with the new omega 3 product;CardioTea and Red Yeast Rice.

  3. Hello James, thank you for your interesting study review. I wonder if you also looked at endurancetraining like zumba, steptraining, cardio fitness and spinning. Is the problem the long duration (more than 1.5 hours) in combination with high intensity or is the problem also acuring within one hour of high intensity exercise?

    With energy,

    John van heel
    The netherlans

  4. John, if you are asking your question to Dr. James O’Keefe you may want to try to contact him at the Mid America Heart Institute