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The commonest cause of death and disability in the world is cardiovascular disease, closely followed by cancer. Coming in at number three and closing in fast is Western health care. It is estimated that in the US alone there are 780,000 deaths on a yearly basis as a consequence of doctors treating patients.

A preventative health expert from the United Kingdom has recently suggested that 10% of hospital admissions are directly due to medical error. A recently released report from the Grattan Institute has basically assessed the complication rate for Australian hospitals. It appears that one in nine patients being treated in an Australian hospital will suffer a complication and this increases to 1 in 4 if the person is lucky enough to be admitted overnight. Interestingly, however, this review did show that some hospitals have a complication rate of a whopping 16.6% whilst others only 2.9%. This raises the question-if some institutions are so low why aren’t all witnessing complications at the same rate? It is not clear from the report if it is that the institutions with the highest rate are purely treating the sickest of the sick i.e. people at greater risk, or whether the higher complication institutions do not have the same rigid safety protocols, high-quality or less constant staff.

These complications range from anything between the catastrophic and very rare situations e.g. the two babies who were accidentally gassed with nitrous oxide leading to their tragic death at the Bankstown-Lidcome Hospital.

Complications may also involve healthy patients contracting infections after surgery. The federal government has published a list of 16 relatively common hospital acquired complications which in many cases may be prevented. To give some examples, these include pressure injuries leading to skin ulceration; unsupervised falls within the institution leading to either fractures or head injury; the very common infections which can be anything from hospital-acquired urinary tract infection to infections complicating surgery; other surgical complications requiring return to the theatre such as haemorrhage or wounded dehiscence, to name a few.

As I am suggesting, these complications can vary from minor wound infections or modest reactions to prescribed medications to the more life-threatening severe infections, bleeding, clotting or kidney failure.

In defence of my hospital colleagues, the reality is that the more serious complications typically occur in the sickest of the sick who would possibly die without medical intervention and it is hardly fair to blame the hospital, medical nursing staff for that person’s complications. But, often healthy people undergoing elective procedures may develop serious complications. Some examples here are a person who goes for a routine colonoscopy experiencing a bowel perforation. Another example is the person who has been sent for a radiologic procedure involving intravenous dye developing a serious, life-threatening anaphylactic reaction to the dye.

The reality is that strong medicine has strong effects but also strong side-effects and complications. The more aggressive the therapy, often the greater the benefit but also the greater risk.

Regardless, the current figures are unacceptable, especially where there is such variation between institutions and we do need better explanations and solutions than this report is offering. Hospital care is an essential component of modern society but those who avail themselves in this care need to know that hospitals are safe places.

Since the recent death of Steve Folkes at the age of 59, a well-known figure in Australian rugby league circles, still incredibly fit and a regular exerciser, along with the sudden death of the 31 year old Italian soccer player, Davide Astori, many questions have been raised about the role of exercise and its ability to prevent cardiovascular disease.

In my professional talks, I have a slide with the picture of Jim Fixx next to a picture of Winston Churchill. Jim Fixx, who wrote the Complete Book of Running, didn’t have an ounce of body fat and had completed multiple marathons, died in a race at of the age 53. Winston Churchill, smoked, drank, was overweight and depressed and died at the age of 91. I have recently completed a lecture series titled “Cardiovascular disease — it’s your genes that loads the gun and your environment that pulls the trigger”. The reality is that all cardiovascular disease has an element of genetics and those with the more severe genetic abnormalities may still die earlier despite exquisite lifestyle principles.

I have repeatedly suggested that the ideal amount of exercise every week is somewhere between 3 to 5 hours. So, is this just my gut feeling or is there any good evidence for these comments?

I would like to review a few recent interesting studies around exercise which address this important issue.

A recent, long term study of 25 years followed just over 5100 people aged between 18 to 30 years old at the entry of the study. For various reasons, the final analysis reviewed 3175 participants who had undergone eight examinations over the 25 year period and answered at least three questionnaires regarding the amount of exercise they performed along with other lifestyle factors as well.

A coronary calcium score was performed at some stage between age 43 to 55 and the participants were divided into three groups

1) Those who exercised less than 2 ½ hours per week

2) Those who exercised between 3 to 5 hours per week

3) Those who exercised more than 7 1/2 hours per week.

The results were quite surprising and, in many ways, somewhat disturbing. When the group who exercised more than 7 1/2 hours were compared to the other groups there was a 27% increase in coronary artery calcification, suggesting a lack of protection from heavy exercise for heart disease risk. Interestingly, and somewhat difficult to explain, is the fact that white males in the third group had an 86% increased risk for coronary artery calcification. The higher level exercise group, for some reason, did not appear to affect cardiac risk in black men or all women. Although there is no clear explanation for this difference, I would like to propose the following explanations.

Atherosclerosis, which is the progressive build-up of fat, inflammatory tissue and calcium in the walls of arteries, tends to occur later in women (on average 10 years) and a coronary calcium score performed between age 43 to 55 is too early to detect significant atherosclerosis in a female population.

People who exercise for more than 7 1/2 hours per week are typically (although not always) joggers or cyclists, or professional athletes. There is no doubt that African Americans do make up a significant proportion of the high-level athletes in America, not to mention the Africans who tend to win most of the marathons. It could be that people with darker skin are more physiologically adapted to exercise for longer periods and thus have less evidence of cardiovascular disease.

Regardless, it does appear for those of us who are not professional athletes (i.e. sport being their major source of income) that if you are exercising for good health, the 3 to 5 hour dose per week appears to be the healthiest level.

The second study was fascinating in that it looked at the type of exercise which may be important for specific disease prevention. There are two basic types of exercise, aerobic — cardio, or anaerobic — strength and resistance training. This study of 80,000 people, older than 30 years, commenced in 1994 and continued until 2008 with an average follow-up of around nine years. It looked at strength and resistance training for 50 to 60 minutes per week as opposed to moderate intensity exercise 50 minutes per week e.g. walking, as opposed to high-intensity exercise such as running or cycling for 75 minutes per week.

In all these groups, compared with people who were inactive there was around an 18% lower risk of early death purely by performing the various types of exercise. But, with resistance & strength training there was a 31% reduced cancer risk whereas with aerobic exercise a 21% reduction in cardiovascular risk. The reduction in cancer death has been repeated in a number of studies in people who regularly perform some form of resistance training.

My suggested reason for this is that cardio exercise improves cardiovascular efficiency through more efficient pumping of the heart and better blood flow to muscles. Because of the more efficient cardiovascular system there is logically a reduction in cardiovascular death. Interestingly, strength and resistance training increases the fitness and size of muscles thus improving muscle metabolism and requiring a much higher level of blood flow to the muscles. Logically, this would redirect blood flow away from tumours and thus help prevent cancer death.

A study in the American Journal of Preventive Medicine reviewed 140,000 people participating in the Cancer Prevention Study II Nutrition cohort. It found that as little as two hours per week of walking compared with those who did no exercise reduced overall death risk from all causes. Those who performed the recommended 150 minutes of walking demonstrated a 20% reduction in all-cause death. Interestingly those who walked for more than six hours per week had a 35% reduction in death related to respiratory causes, a 20% reduction in cardiovascular death and a 9% reduction in cancer death.

A study from the Journal, Circulation reviewed 152 middle-aged endurance athletes with an average age of 55 and compare these people with normal activity age matched controls. All participants in the study had no prior history of coronary heart disease or any other significant risk factors. A CT coronary angiogram was performed and in both groups 60% demonstrated no significant coronary artery disease. But, in the athletes there was double the amount of coronary plaque compared with those who performed normal activity. Those in the highest risk group had a direct relationship to the amount of years of training i.e. the more exercise the higher the risk.

Another study looked at males older than 45 again with an average age of 55 and show that 53% of these athletes had coronary artery calcification. Again, the more activity performed, the higher the coronary artery calcification and thus, a higher atherosclerotic burden.

Studies performed on marathon runners have shown that a third had elevated levels of troponin, a marker of heart damage, along with echocardiographic changes in the right ventricle at the end of the marathon.

Possible explanations for this are that

1) Many high-level exercisers have the delusion that because they perform so much exercise they can eat what they like which can still lead to significant cardiac issues

2) A study from many years ago published in the New England Journal of Medicine reviewed the psychological profile of marathons on runners and found this was very similar to people with anorexia nervosa. This is a condition which is also associated with sudden cardiac death

3) Possibly, the reason many people take up endurance running is because of a poor family history, again with the delusion that they can outrun their genetics

4) Another minor explanation is that many high-level athletes suffer recurrence musculoskeletal issues often requiring anti-inflammatory medications which have been associated with a higher risk for cardiac disease.

Probably the most disturbing statistic from all the studies is that 27% of people are inactive and only 50% of people meet the guidelines for recommended exercise.

I have stated on numerous occasions that exercise is the second best drug on the planet after happiness but it also appears that the correct dose of exercise is important along with the type of exercise to reduce specific conditions. This is why I constantly say that the suggested dose is 3–5 hours per week which should be divided into two thirds cardio and one third resistance training. Just as the real estate agents say the most important principle is “location, location, location”, those of us involved in preventative medicine state “movement, movement, movement”.

There is no doubt that the biggest killer across the globe is cardiovascular disease. The major cause of cardiovascular disease is atherosclerosis, which is the progressive build-up of fat, inflammatory tissue, calcium and other cellular constituents in the walls of arteries, over many decades. Eventually, these fatty plaques rupture to cause blockages within the channel of arteries, leading to heart attack, stroke or other conditions, depending on the site of the blockage.

This has been established beyond doubt with strong associations with a variety of cholesterol abnormalities, high blood pressure, cigarette smoking and the different stages and manifestations of diabetes, with strong genetic factors thrown into the mix.

Although this is well-established, it needs to be separated from what actually makes these plaques rupture. Or, in other words, what is the precipitating event for an acute cardiac syndrome, such as a heart attack, with the background of an atherosclerotic process that builds up in the wall of the arteries over decades?

There are basically five categories of precipitants:

1) Psycho-social stress — Within a few hours of becoming acutely angry or anxious, you increase your risk for heart attack eight times, if you have previously stable plaques in your coronary arteries. Depression raises coronary risk in some studies up to 50%. There is a link between social isolation, loneliness and acute coronary syndromes. There is also the well described link between serious life events, such as the death of a loved one, relationship issues, even relocating your life, and heart attack. Dramatic societal events, such as terrorist attacks and earthquakes have been shown to increase heart attack risk & sudden cardiac death, by a factor of seven.

2) Exercise — Although regular, conditioned exercise is the second best drug on the planet (after happiness), unusual, unexpected bursts of exercise, such as the unfit, obese person running for the bus or train, or shovelling snow during bouts of extreme cold, are enough to put enormous strain on fatty plaques, potentially leading to heart attack.

3) Infection — Severe infections activate the immune system switching on inflammation and may acutely weaken and rupture a fatty plaque. A study from the University of New South Wales demonstrated that people who had a yearly flu vaccination had a 30% reduction in heart attack by reducing the risk of the severe infection related to influenza.

4) Radical diets — Although rapid fat burning diets such as Atkins, Paleo and the ketogenic diet are efficient for rapid weight loss, I have seen a handful of high risk patients suffering heart attacks during the rapid weight loss phase. My explanation for this is that abdominal obesity isn’t just an ugly lump of lard but also a toxic reservoir, storing, over years of exposure, a variety of synthetic chemicals and heavy metals. Once the fat is broken down rapidly, the toxins overwhelm the circulation, rupturing fatty plaques. Although this is uncommon, it still happens. Thus, it is my opinion that weight loss should be gradual.

5) Acute life indiscretions — A heavy binge of alcohol or the use of illegal drugs have been well described as significant precipitants for acute cardiac events, such as heart attack or sudden cardiac death.

Finally, recent work from the United States has suggested a mechanism whereby an acute fatty load may also do the same thing as other life indiscretions. Ten healthy males with normal blood pressure and normal cholesterol were divided into two groups. Five were given a very fatty milkshake, whilst the other five a low-fat meal with the same number of calories. This acute fatty load led to rather dramatic changes in their red cells, changing shape, becoming spiky & sticky, along with an increase in a chemical known as myeloperoxidase which reduces blood vessel elasticity and also generates oxidation of the so called good cholesterol, HDL. All these issues thicken the blood and acutely damage blood vessels.

It is my clinical experience that patients who are at high risk for heart disease exposed to one or a combination of any of these precipitants are at a much higher risk for an event. In fact, I hardly see a patient who experienced a heart attack without one of these precipitants.