Education is the answer. More Health and Physical Education in schools - every day for every student... and yet school curriculum is going in the opposite direction. I am routinely shocked when I hear "educated" professionals say something that reveals they have little understanding of how our bodies function. Your articles are so informative. When will you write your Book of Everyday Health for us?
Lillie - 100% agree. We need to start young and put health and fitness in front of every kid in America. Instead, I see the same thing in our local schools here in AK. Growing up in HEB School District in Bedford, TX, I had daily PE and I learned so much. PE was my favorite class through elementary school (even more than recess). My kids get PE 2x a week now (there is a health class that is outdoors 50% of time for a 3rd day, full transparency and this is a wonderful class and my kids love Health). I think a book of Everyday Health is a great idea. Perhaps, I can start this summer as a separate substack link and write it in realtime chapter by chapter every month. I’ll think on that. Thank you!
Hi Jake, Nicely done. I note that on the Mortality Comparison Chart that low fitness is associated with increased mortality, the overall point of your post. Do we know that low fitness is a direct risk factor or might this be a surrogate marker for other risk factors? In other words, is it correlation and not causality. And, as a follow up, do we know that improving fitness will clearly lower mortality and might this also be a surrogate marker effect rather than enhanced fitness causes lower mortality? I continue to enjoy and learn from your writings.
Dr. Kirsch - it is great hearing from you (but it takes some thought and time to respond. Great question and accurate take. The major fitness studies I reviewed and included adjusted for smoking, diabetes, hypertension and BMI with fitness/CRF remaining an independent predictor of mortality, so I (we?) doubt that fitness is simply a proxy for overall healthy behavior. I think the strongest evidence comes from Kokkinos (93k folks with serial ETTs demonstrated for every 1 MET improvement in fitness was associated with a 15% reduction in mortality). This suggests that people who became more fit lived longer than projected. What we don’t have is Mendelian randomization or a RCT to give more substantial proof. However, based on Bradford Hill criteria for causation several metrics are made: independent association, dose-response, temporal sequence and strong biological plausibility. Also, I cannot think of a scenario where improved fitness makes your health worse (there may be?). As always, thanks for reading and being so inquisitive Michael!
As usual, another great, practical, article Jake. Not testing fitness parameters is typical of the ass-backwards US so-called "Healthcare" (appropriate name is really "Disease Care") approach where 97% of the annual budget is spent on treating health problems and only 3% on Prevention. There's no hope in short term to change that approach at the federal level but what about working for legislation at the state level (in Alaska and elsewhere) to include free fitness testing as part of every annual check-up?
Tom, thank you for the acknowledgement and I have been brainstorming how to incorporate more fitness testing into our daily levels across America. I do plan to start local and work towards national. I wonder if the annual lab and health fairs that pop up in most communities is a good place to start. I suspect high level exercise testing will not be allowed due to risk but you have me thinking. Certainly Get-up and go tests (sit-to-stand), push-ups, pull-ups, mobility exercises could be considered. Alternatively, we could link up many 5k, 10k and 1 mile runs nationally to build a database. Let’s keep this conversation going Tom. Thank you.
I wonder if life insurance companies would give a discount/lower annual premium to applicants who complete a fitness test (treadmill based? for simplicity) at or above a specified target level since that would indicate a lower early mortality risk - just like they offer lower rates to non-smokers.
Amazing insight (as always) Tom. We could be closer to such a reality than most people realize. John Hancock’s Vitality program already ties life insurance premiums to health behaviors (based on my review of what I could find)…but it rewards activity, not specific performance or thresholds achieved (10 METs or VO2 above 50th or 75th percent rule). Your idea is on point: incentivize targets associated with reduced mortality (both parties win: don’t die and save money!).
The barrier right now is specific data I believe. Actuaries need population level fitness data structured as mortality tables before they would price such a product. We have related data but it is research level. Im unsure what underwriting criteria would require.
A national fitness registry is part of the answer IMHO. The more people who have a measured or estimated VO₂ max on record, the faster the actuarial case gets made.
The advocacy path runs more locally through state insurance commissioners, actuarial societies and likely the CMOs and CEOs of the largest insurers, not legislators. AHA and ACC and other medical societies would need to get behind this most likely as well. Lots of work but I’m dreaming big and hope to start the process and build momentum. This article is my start.
Jake, thanks for further explaining the challenge and the progress. Talk about a win-win "Don't die and save money!" Many decades ago, I worked for a major Canadian insurance company and I designed, sold and serviced group health and dental plans so I'm very familiar with underwriting and actuarial needs. A national fitness registry sounds like a great step as long as it isn't biased toward healthier individuals who are more motivated to participate in data gathering. Jake, you may want to contact the founder of Virta Health, Sami Inkinen, a Finnish-born entrepreneur and world-class triathlete. Virta Health (based in California I think) works primarily with individuals who have type 2 diabetes and prediabetes, as well as those with obesity. Their core focus is reversing metabolic diseases through continuous remote care and nutritional ketosis. Virta Health has extensive, peer-reviewed clinical trial data proving the effectiveness of its continuous remote care model for reversing both type 2 diabetes and prediabetes. "60% of patients who completed one year reversed their type 2 diabetes (lowering HbA1c below the diabetes threshold while off all medications or only on metformin). Even at 5 years, 20% of participants achieved sustained remission. After one year, 94% of insulin users reduced or eliminated their usage. By year five, total prescriptions across all diabetes drugs were reduced by nearly 50%. Patients saw an average weight loss of 12% (just over 30 lbs) at one year, and retained an average weight loss of 7.6% at five years. Data published in the journal Nutrients highlights that Virta's model is highly effective in preventing disease progression: 97% of trial participants with prediabetes avoided progressing to type 2 diabetes over a two-year period.Reversal: Over half (52%) of prediabetes trial participants successfully achieved prediabetes reversal within two years." Jake, apparently Virta Health does NOT require or perform treadmill, VO2 max, or physical fitness testing to evaluate or monitor fitness parameters, instead they use blood biomarkers and lab tests to monitor progress. Nonetheless, either Sami, or a senior person at Virta might be a good resource person who may be able to direct you to large companies, or organizations, that do fitness testing to provide data to add to the population level fitness database. . . On a different approach, Johnson & Johnson claimed that investing in employee wellness yielded around 2 to 4 dollars for each dollar they spent. Citibank estimated their return on investment was $5 saved for every dollar spent. They may have useful employee fitness data to share with you. Also, publicly traded companies that got Corporate Health Achievement Awards outperformed the S&P 500 by 40% and C. Everett Koop Award winners outperformed the S&P 500 two to one. HR Managers at these companies may have non-confidential useful data they can share with you to help build the national fitness database. It will be time consuming to find, and contact, these companies but maybe you have an assistant who can do the initial research and contact work for you? Let me know if I can be of any help. Thanks.
Tom, Thanks for continued engagement and sharing your wealth of knowledge! I’ll definitely reach out to these entities and Virta Health. I’ll send you a DM to connect and develop an action. I really appreciate the wonderful wealth of knowledge you freely share! Health forward!
I totally agree Jake! People and their doctors should know their cardiorespiratory fitness (CRF) just as they know their blood pressure and LDL. I am familiar with the Attia vs Topol debate and VO2 max craze. The studies you cited measured CRF using MET's on a treadmill test. Do you ever use an easier way to measure CRF like the Bruce treadmill test instead of VO2 max?
Thanks Ali. Know your CRF! I estimate and measure CRF by any way I can: wearables, formulas, treadmill or bike with or without a metabolic cart. I find all of the data useful. I’m a cardiologist. I love Bruce Protocol but understand the limitations.
Once again great information! Thank you for all the data. I now know about MET. Thank keep up the great work! I'm a NBC-HWC and I talk with clients everyday about movement. It helps me to know the details so I can try to explain it in layman's terms. Thank you again!
Thanks Cindy for the feedback. So glad you learned about METs and thanks for your work improving the health of people every day! Keep it up and thank you!
Interested what the FRIEND database is. I am a strong-ish 80 year old and Apple Watch and Oura estimates VO2 max increasing from 24 to 25+ over the last year.
John - great work improving your fitness trend - maintaining and ideally improving are fantastic. The friend registry is is a multinational database across the lifespan of normative vo2 data. See a few links below.
John, amazing list of great health strategies. Sorry about the pacemaker but you should do just fine afterwards. Follow the recovery from your Cardiologist. Heal up fast!
Wow, another excellent essay. Thank you for these wonderful discussions. They are made more relevant by including patient vignettes. I am thankfully a healthy 66 yo and your insights and recommendations help me stay that way. I particularly like your 3 arm approach to health; digestible and actionable grounded in data!
RH - I appreciate the feedback as it keeps me motivated and reassured my writing is being read and reflected on positively and provides actionable items.
Great info. I am totally in support of getting a stronger support of fitness in preventative health. I see this in my community of aging mountain athletes, but it still fails to register as important in healthcare. Maybe putting a number on it would create motivation. Unfortunately most folks don’t have access to measured Vo2 max, or even mets for that matter. I personally can evaluate a patient’s fitness in a few minutes of history, and a cursory exam. I could also send them out with a standard program to improve fitness. It’s the accountability that’s tough. To be honest, it’s why I practice hospital medicine. I don’t have energy for people who want me to fix their lifestyle disease with a pill.
Great points Sean. Agree 💯. Unfortunately, it is why capacity, reserve and fitness are not calculated even though an estimate as you state with history and brief exam can be very easy. Good primary care and internal medicine takes time early on and then ongoing touch points (not time consuming) but the infrastructure and standard is episodic care not longitudinal care. I’m trying to change that in a small way, one patient at a time. If we all start mentioning fitness estimates in our notes maybe it will catch on! I remember and still number my problem lists but shortly after me # took over. Can we do the same with #estimated fitness? # > 10 Mets
I love it. I am an old school documenter as well. I was trained to write a note that the next doc could read and understand the decision making process. It’s sad what has happened to medical documentation. When I first started reading your article i was thinking that quantifying fitness is unnecessary, as if patients would just do the basics they would get healthier and feel better. ( 4 hrs zone 2, some high output work once or twice a week and 2 days of strength).
After thinking about it more, it could be a game changer. Linked to insurance premium discounts the motivation would increase!
Every other vital sign is taken from the patient. Blood pressure, glucose, and a lipid panel are drawn off someone sitting still. Cardiorespiratory fitness is the one number a patient has to perform: you cannot extract it at rest. It only exists while the person is being asked for everything at once.
That may matter more than the missing reimbursement code. A visit is built around measurements that take seconds and ask nothing of the patient's effort, and a number that requires maximal exertion does not fit that habit, even when it tracks survival better than anything else on the chart.
The deeper obstacle is structural. This number asks the patient to do something, while a visit is built to observe and record. It may be the only vital sign a patient has to earn, which is exactly why it stays uncollected.
What a beautiful description of what we do and what we should do. In all patients that I have participated in their exercise tests or exercised with them, I have learned much more about the patient - how they move, how they work, what they can give. This deep insight has strengthened the bond. There should be more of this movement (even lower intensity) in healthcare.
You name the other half of it. The same feature that makes this number uncollectable is what makes it revealing. A measurement taken from a still patient gives you a value; a patient you watch move shows you who they are under load. The clinic loses both when it skips the effort.
Any ideas how we can make this the norm and not the exception Dr. Lupu? Write our local, state and federal representatives. Policy advocacy grassroots? Insurers, health systems and other payers?
Honestly, I would be wary of leading with the policy lever, and not only because advocacy is slow. Reimbursement tends to follow what the profession already treats as standard of care, rather than create it. The stress-test codes already exist; they bend toward whatever clinicians have decided a complete assessment includes.
So the lever I trust most sits upstream of payers: what counts as a finished exam, and what trainees are taught to count as one. The day an assessment without any measure of capacity feels as incomplete as a missing blood pressure, the reimbursement question starts answering itself. Until then, the faster version is the one you already model. Build one low-intensity capacity measure into the visits where it would change a decision, and let the bond you described do the persuading. Norms move patient by patient before they move by statute.
I absolutely love this and commented on another post about this. Let’s put estimated Mets and or peak VO2 on all notes. I’ve done this intermittently in my traditional clinic (it is on all patients through ROOL health) and I’ll keep pushing. Keep educating. Appreciate the “push.”
Arthur send me a DM. I think there are PCPs and Cardiologists like me but probably hard to find given the current incentive and billing structures. I’m trying to teach and advocate so some of these techniques and strategies are taken up and improved and practiced for everyone ( myself included as a patient).
This one really landed for me. The institutional list is such a good move — NASA, the FAA, the fire service, Italian football. Everyone whose job depends on people not dying has been quietly measuring this for decades, and the one place it matters most for the rest of us just… doesn’t. That contrast does more work than any chart could.
Gary’s a great way in. The enviable lipid panel next to the unmeasured third leg — it makes the whole point land before you’ve quoted a single study.
The reimbursement bit is the part I keep thinking about. The test exists, the doctors know how to read it, and the one group left out is the one with the most to gain. That’s the quiet scandal, and I’d love to see you build a whole piece around that alone.
This is a strong reminder that what we can actually do and repeat in daily life often matters more for long-term heart health than what shows up on a lab report. It brings attention back to the basics of movement, capacity, and consistency over time.
Thanks for the great commentary. We absolutely can do better. All of us can improve our health with a bit more movement over time building our capacity to thrive.
Excellent article Jake. It highlights yet another major gap in clinical medicine driven by the lack of insurance reimbursement for testing that measures a metric with mortality implications. I like how you navigate around this with the short simple questionnaire to quickly measure CRF. We all should be using this in our clinical practice as metabolic physicians. Thanks for educating us!
Thanks for the acknowledgement Dr. Trivedi. It is frustrating that we can’t get a simple and reasonable test covered by insurance when a patient really wants the information. Luckily, there are so many effective ways to estimate and measure fitness. We as physicians and clinicians need to use these tools and ask, review and teach our patients about their fitness and ability to improve it.
Great article! Too many of my patients have been brainwashed into thinking cardio training is bad for them and it’s all about resistance, but I am also extremely keen for people to acquire an excellent VO2 max. I have just had three patients lower their fasted insulin from pre diabetic ranges to normal by just adding in 2 hard cardio classes a week. They were mostly doing everything else right. Two other major metabolic needle movers are walking after eating and eating an early dinner and/or occasionally skipping it completely .
Thank you for providing great supporting evidence. I definitely have neglected resistance training in previous years but started personally focusing on and advocating for my patients to strength/resistance testing 2ish years ago. The combination of resistance training with aerobic exercise is synergistic for general health, VO2 and metabolic health. Walking after meals and 12 hours of no eating, aka not eating late, are 2 of the best priorities for improving health. I look forward to further learning from you!
Great article!
We
Must
Move!
Thanks Keith! We need to move, measure our movement, track it, don’t lose our ability to move. If we do, gain it back!
Education is the answer. More Health and Physical Education in schools - every day for every student... and yet school curriculum is going in the opposite direction. I am routinely shocked when I hear "educated" professionals say something that reveals they have little understanding of how our bodies function. Your articles are so informative. When will you write your Book of Everyday Health for us?
Lillie - 100% agree. We need to start young and put health and fitness in front of every kid in America. Instead, I see the same thing in our local schools here in AK. Growing up in HEB School District in Bedford, TX, I had daily PE and I learned so much. PE was my favorite class through elementary school (even more than recess). My kids get PE 2x a week now (there is a health class that is outdoors 50% of time for a 3rd day, full transparency and this is a wonderful class and my kids love Health). I think a book of Everyday Health is a great idea. Perhaps, I can start this summer as a separate substack link and write it in realtime chapter by chapter every month. I’ll think on that. Thank you!
Hi Jake, Nicely done. I note that on the Mortality Comparison Chart that low fitness is associated with increased mortality, the overall point of your post. Do we know that low fitness is a direct risk factor or might this be a surrogate marker for other risk factors? In other words, is it correlation and not causality. And, as a follow up, do we know that improving fitness will clearly lower mortality and might this also be a surrogate marker effect rather than enhanced fitness causes lower mortality? I continue to enjoy and learn from your writings.
Dr. Kirsch - it is great hearing from you (but it takes some thought and time to respond. Great question and accurate take. The major fitness studies I reviewed and included adjusted for smoking, diabetes, hypertension and BMI with fitness/CRF remaining an independent predictor of mortality, so I (we?) doubt that fitness is simply a proxy for overall healthy behavior. I think the strongest evidence comes from Kokkinos (93k folks with serial ETTs demonstrated for every 1 MET improvement in fitness was associated with a 15% reduction in mortality). This suggests that people who became more fit lived longer than projected. What we don’t have is Mendelian randomization or a RCT to give more substantial proof. However, based on Bradford Hill criteria for causation several metrics are made: independent association, dose-response, temporal sequence and strong biological plausibility. Also, I cannot think of a scenario where improved fitness makes your health worse (there may be?). As always, thanks for reading and being so inquisitive Michael!
As usual, another great, practical, article Jake. Not testing fitness parameters is typical of the ass-backwards US so-called "Healthcare" (appropriate name is really "Disease Care") approach where 97% of the annual budget is spent on treating health problems and only 3% on Prevention. There's no hope in short term to change that approach at the federal level but what about working for legislation at the state level (in Alaska and elsewhere) to include free fitness testing as part of every annual check-up?
Tom, thank you for the acknowledgement and I have been brainstorming how to incorporate more fitness testing into our daily levels across America. I do plan to start local and work towards national. I wonder if the annual lab and health fairs that pop up in most communities is a good place to start. I suspect high level exercise testing will not be allowed due to risk but you have me thinking. Certainly Get-up and go tests (sit-to-stand), push-ups, pull-ups, mobility exercises could be considered. Alternatively, we could link up many 5k, 10k and 1 mile runs nationally to build a database. Let’s keep this conversation going Tom. Thank you.
I wonder if life insurance companies would give a discount/lower annual premium to applicants who complete a fitness test (treadmill based? for simplicity) at or above a specified target level since that would indicate a lower early mortality risk - just like they offer lower rates to non-smokers.
Amazing insight (as always) Tom. We could be closer to such a reality than most people realize. John Hancock’s Vitality program already ties life insurance premiums to health behaviors (based on my review of what I could find)…but it rewards activity, not specific performance or thresholds achieved (10 METs or VO2 above 50th or 75th percent rule). Your idea is on point: incentivize targets associated with reduced mortality (both parties win: don’t die and save money!).
The barrier right now is specific data I believe. Actuaries need population level fitness data structured as mortality tables before they would price such a product. We have related data but it is research level. Im unsure what underwriting criteria would require.
A national fitness registry is part of the answer IMHO. The more people who have a measured or estimated VO₂ max on record, the faster the actuarial case gets made.
The advocacy path runs more locally through state insurance commissioners, actuarial societies and likely the CMOs and CEOs of the largest insurers, not legislators. AHA and ACC and other medical societies would need to get behind this most likely as well. Lots of work but I’m dreaming big and hope to start the process and build momentum. This article is my start.
Jake, thanks for further explaining the challenge and the progress. Talk about a win-win "Don't die and save money!" Many decades ago, I worked for a major Canadian insurance company and I designed, sold and serviced group health and dental plans so I'm very familiar with underwriting and actuarial needs. A national fitness registry sounds like a great step as long as it isn't biased toward healthier individuals who are more motivated to participate in data gathering. Jake, you may want to contact the founder of Virta Health, Sami Inkinen, a Finnish-born entrepreneur and world-class triathlete. Virta Health (based in California I think) works primarily with individuals who have type 2 diabetes and prediabetes, as well as those with obesity. Their core focus is reversing metabolic diseases through continuous remote care and nutritional ketosis. Virta Health has extensive, peer-reviewed clinical trial data proving the effectiveness of its continuous remote care model for reversing both type 2 diabetes and prediabetes. "60% of patients who completed one year reversed their type 2 diabetes (lowering HbA1c below the diabetes threshold while off all medications or only on metformin). Even at 5 years, 20% of participants achieved sustained remission. After one year, 94% of insulin users reduced or eliminated their usage. By year five, total prescriptions across all diabetes drugs were reduced by nearly 50%. Patients saw an average weight loss of 12% (just over 30 lbs) at one year, and retained an average weight loss of 7.6% at five years. Data published in the journal Nutrients highlights that Virta's model is highly effective in preventing disease progression: 97% of trial participants with prediabetes avoided progressing to type 2 diabetes over a two-year period.Reversal: Over half (52%) of prediabetes trial participants successfully achieved prediabetes reversal within two years." Jake, apparently Virta Health does NOT require or perform treadmill, VO2 max, or physical fitness testing to evaluate or monitor fitness parameters, instead they use blood biomarkers and lab tests to monitor progress. Nonetheless, either Sami, or a senior person at Virta might be a good resource person who may be able to direct you to large companies, or organizations, that do fitness testing to provide data to add to the population level fitness database. . . On a different approach, Johnson & Johnson claimed that investing in employee wellness yielded around 2 to 4 dollars for each dollar they spent. Citibank estimated their return on investment was $5 saved for every dollar spent. They may have useful employee fitness data to share with you. Also, publicly traded companies that got Corporate Health Achievement Awards outperformed the S&P 500 by 40% and C. Everett Koop Award winners outperformed the S&P 500 two to one. HR Managers at these companies may have non-confidential useful data they can share with you to help build the national fitness database. It will be time consuming to find, and contact, these companies but maybe you have an assistant who can do the initial research and contact work for you? Let me know if I can be of any help. Thanks.
Tom, Thanks for continued engagement and sharing your wealth of knowledge! I’ll definitely reach out to these entities and Virta Health. I’ll send you a DM to connect and develop an action. I really appreciate the wonderful wealth of knowledge you freely share! Health forward!
Thanks Jake and thanks for sharing your wealth of knowledge in a format that we don't need a PhD or MD to understand and apply to our lives.
I totally agree Jake! People and their doctors should know their cardiorespiratory fitness (CRF) just as they know their blood pressure and LDL. I am familiar with the Attia vs Topol debate and VO2 max craze. The studies you cited measured CRF using MET's on a treadmill test. Do you ever use an easier way to measure CRF like the Bruce treadmill test instead of VO2 max?
Thanks Ali. Know your CRF! I estimate and measure CRF by any way I can: wearables, formulas, treadmill or bike with or without a metabolic cart. I find all of the data useful. I’m a cardiologist. I love Bruce Protocol but understand the limitations.
Once again great information! Thank you for all the data. I now know about MET. Thank keep up the great work! I'm a NBC-HWC and I talk with clients everyday about movement. It helps me to know the details so I can try to explain it in layman's terms. Thank you again!
Thanks Cindy for the feedback. So glad you learned about METs and thanks for your work improving the health of people every day! Keep it up and thank you!
Interested what the FRIEND database is. I am a strong-ish 80 year old and Apple Watch and Oura estimates VO2 max increasing from 24 to 25+ over the last year.
John - great work improving your fitness trend - maintaining and ideally improving are fantastic. The friend registry is is a multinational database across the lifespan of normative vo2 data. See a few links below.
https://cardiology.org/project/friend-a-fitness-registry/
https://pubmed.ncbi.nlm.nih.gov/26455884/
Strong believer in
1) good sleep
2) home cooking
3) exercise (tennis 4-5 times a week, 2-3 mile brisk walks 2+ times a week)
4) pacemaker tomorrow- av block 2 mobitz II
5) 40 year marriage going strong
6) nascent Substack poster
But always looking for ways to improve. After a 6 week post pacemaker going to incorporate resistance loading to improve bone health.
John, amazing list of great health strategies. Sorry about the pacemaker but you should do just fine afterwards. Follow the recovery from your Cardiologist. Heal up fast!
Wow, another excellent essay. Thank you for these wonderful discussions. They are made more relevant by including patient vignettes. I am thankfully a healthy 66 yo and your insights and recommendations help me stay that way. I particularly like your 3 arm approach to health; digestible and actionable grounded in data!
RH - I appreciate the feedback as it keeps me motivated and reassured my writing is being read and reflected on positively and provides actionable items.
Great info. I am totally in support of getting a stronger support of fitness in preventative health. I see this in my community of aging mountain athletes, but it still fails to register as important in healthcare. Maybe putting a number on it would create motivation. Unfortunately most folks don’t have access to measured Vo2 max, or even mets for that matter. I personally can evaluate a patient’s fitness in a few minutes of history, and a cursory exam. I could also send them out with a standard program to improve fitness. It’s the accountability that’s tough. To be honest, it’s why I practice hospital medicine. I don’t have energy for people who want me to fix their lifestyle disease with a pill.
Great points Sean. Agree 💯. Unfortunately, it is why capacity, reserve and fitness are not calculated even though an estimate as you state with history and brief exam can be very easy. Good primary care and internal medicine takes time early on and then ongoing touch points (not time consuming) but the infrastructure and standard is episodic care not longitudinal care. I’m trying to change that in a small way, one patient at a time. If we all start mentioning fitness estimates in our notes maybe it will catch on! I remember and still number my problem lists but shortly after me # took over. Can we do the same with #estimated fitness? # > 10 Mets
I love it. I am an old school documenter as well. I was trained to write a note that the next doc could read and understand the decision making process. It’s sad what has happened to medical documentation. When I first started reading your article i was thinking that quantifying fitness is unnecessary, as if patients would just do the basics they would get healthier and feel better. ( 4 hrs zone 2, some high output work once or twice a week and 2 days of strength).
After thinking about it more, it could be a game changer. Linked to insurance premium discounts the motivation would increase!
Every other vital sign is taken from the patient. Blood pressure, glucose, and a lipid panel are drawn off someone sitting still. Cardiorespiratory fitness is the one number a patient has to perform: you cannot extract it at rest. It only exists while the person is being asked for everything at once.
That may matter more than the missing reimbursement code. A visit is built around measurements that take seconds and ask nothing of the patient's effort, and a number that requires maximal exertion does not fit that habit, even when it tracks survival better than anything else on the chart.
The deeper obstacle is structural. This number asks the patient to do something, while a visit is built to observe and record. It may be the only vital sign a patient has to earn, which is exactly why it stays uncollected.
What a beautiful description of what we do and what we should do. In all patients that I have participated in their exercise tests or exercised with them, I have learned much more about the patient - how they move, how they work, what they can give. This deep insight has strengthened the bond. There should be more of this movement (even lower intensity) in healthcare.
You name the other half of it. The same feature that makes this number uncollectable is what makes it revealing. A measurement taken from a still patient gives you a value; a patient you watch move shows you who they are under load. The clinic loses both when it skips the effort.
Any ideas how we can make this the norm and not the exception Dr. Lupu? Write our local, state and federal representatives. Policy advocacy grassroots? Insurers, health systems and other payers?
Honestly, I would be wary of leading with the policy lever, and not only because advocacy is slow. Reimbursement tends to follow what the profession already treats as standard of care, rather than create it. The stress-test codes already exist; they bend toward whatever clinicians have decided a complete assessment includes.
So the lever I trust most sits upstream of payers: what counts as a finished exam, and what trainees are taught to count as one. The day an assessment without any measure of capacity feels as incomplete as a missing blood pressure, the reimbursement question starts answering itself. Until then, the faster version is the one you already model. Build one low-intensity capacity measure into the visits where it would change a decision, and let the bond you described do the persuading. Norms move patient by patient before they move by statute.
I absolutely love this and commented on another post about this. Let’s put estimated Mets and or peak VO2 on all notes. I’ve done this intermittently in my traditional clinic (it is on all patients through ROOL health) and I’ll keep pushing. Keep educating. Appreciate the “push.”
"But Medicare will not reimburse an exercise stress test for an asymptomatic patient."
Jake, this is just one reason why the system is in need of an overhaul.
Great work with today's post.
Any chance you do telemedicine?
How do find a PCP who thinks like you?
Arthur send me a DM. I think there are PCPs and Cardiologists like me but probably hard to find given the current incentive and billing structures. I’m trying to teach and advocate so some of these techniques and strategies are taken up and improved and practiced for everyone ( myself included as a patient).
This one really landed for me. The institutional list is such a good move — NASA, the FAA, the fire service, Italian football. Everyone whose job depends on people not dying has been quietly measuring this for decades, and the one place it matters most for the rest of us just… doesn’t. That contrast does more work than any chart could.
Gary’s a great way in. The enviable lipid panel next to the unmeasured third leg — it makes the whole point land before you’ve quoted a single study.
The reimbursement bit is the part I keep thinking about. The test exists, the doctors know how to read it, and the one group left out is the one with the most to gain. That’s the quiet scandal, and I’d love to see you build a whole piece around that alone.
Great piece, Jake. Really enjoyed the read.
This is a strong reminder that what we can actually do and repeat in daily life often matters more for long-term heart health than what shows up on a lab report. It brings attention back to the basics of movement, capacity, and consistency over time.
Thanks for the great commentary. We absolutely can do better. All of us can improve our health with a bit more movement over time building our capacity to thrive.
Excellent article Jake. It highlights yet another major gap in clinical medicine driven by the lack of insurance reimbursement for testing that measures a metric with mortality implications. I like how you navigate around this with the short simple questionnaire to quickly measure CRF. We all should be using this in our clinical practice as metabolic physicians. Thanks for educating us!
Thanks for the acknowledgement Dr. Trivedi. It is frustrating that we can’t get a simple and reasonable test covered by insurance when a patient really wants the information. Luckily, there are so many effective ways to estimate and measure fitness. We as physicians and clinicians need to use these tools and ask, review and teach our patients about their fitness and ability to improve it.
Great article! Too many of my patients have been brainwashed into thinking cardio training is bad for them and it’s all about resistance, but I am also extremely keen for people to acquire an excellent VO2 max. I have just had three patients lower their fasted insulin from pre diabetic ranges to normal by just adding in 2 hard cardio classes a week. They were mostly doing everything else right. Two other major metabolic needle movers are walking after eating and eating an early dinner and/or occasionally skipping it completely .
Thank you for providing great supporting evidence. I definitely have neglected resistance training in previous years but started personally focusing on and advocating for my patients to strength/resistance testing 2ish years ago. The combination of resistance training with aerobic exercise is synergistic for general health, VO2 and metabolic health. Walking after meals and 12 hours of no eating, aka not eating late, are 2 of the best priorities for improving health. I look forward to further learning from you!
Another amazing article with great information. I love the three arm approach.
Thanks for the feedback and support Ginny!