A RESPONSE TO THE WSJ ARTICLE ON “WEIGHT LIFTING”

M.Doug McGuff, MD
President, Ultimate Exercise, Inc.

I initially responded to the WSJ by sending an email to the author. I thought this would be a means of getting a response letter published in the WSJ. Instead, it turned out that you must subscribe to WSJ in order to have a response letter published. I did communicate twice by email with the author, and was able to communicate my objections to him. The article was full of errors in logic and misunderstanding of both strength training and medical issues. However, I limited my criticism to two basic issues. First, he confuses weight lifting and high intensity weight training and uses the terms interchangeably and out of context in his article. Weight lifting or powerlifting is dangerous. Maximal weights are lifted with the aid of valsalva and poses the dangers noted in the article. High intensity weight training involves lifting moderate weights until the muscle fatigues and weakens to the degree that it can no longer continue to move the load; attention is paid to avoid valsalva and any other blood pressure spiking maneuvers. If Mr. Helliker had simply said to avoid powerlifting movements, I would have been in agreement with the article. Second, Mr. Helliker constructs a slippery slope argument based on anecdote and conjecture. The fact that these anecdotes and arbitrary statements were made by people at Ivy League institutions does not give it any more value. Anecdote, no matter who generates it, is not evidence. At the request of several of my clients, I will now provide specific comment on the relevant segments of the article. Article excerpts will be inset and in italics and quotations. My responses will follow. The full article can be looked up at wsj.com.

“As a fitness trainer and health fanatic, Michael Logan knew that weight lifting could strengthen his bones and protect his heart.

What he didn’t know was that it could be lethal. Mr. Logan had a bulge in his primary artery, the aorta. Knowledge of that bulge, or aneurysm, would have prompted doctors to allow only light-weight lifting. But like the vast majority of people with aneurysms, Mr. Logan didn’t know he had one.

So he continued heavy-weight lifting- until an aortic aneurysm killed him last June at age 46. ‘It is very surprising that something he did for his health might have hurt him’ says Mike Logan, the late Chicago trainer’s son.”

The opening paragraphs certainly provide a dramatic introduction, designed to immediately alarm the reader. Only 3 paragraphs into the article, we already have a variety of logical errors in thinking. First, this is an anecdotal report. Anecdote is not evidence. The fact that Mr. Logan was a weight lifter and had an aneurysm is an association. Association cannot imply causation. Mr. Logan may also have jogged, played tennis or golf or participated in other activities. Intuitively, it is easy to make the leap that weight lifting might pose more of a problem, but it is still a leap of faith. In this introduction, Mr. Helliker fails to make the distinction between weight lifting and weight training. He also fails to tell us if Mr. Logan died while lifting weights. If his death occurred while attempting a single repetition maximal lift, I might find the connection more plausible. If Mr. Logan was simply weight training (even with less than optimal form), and the death did not occur during actual exertion; then this is implying causation from an association. Essentially, this is the thinking error that underlies superstition. A tribesman that experiences a poor hunt remembers that he saw a rabbit run across the trail before setting out. Now, he thinks that this was a bad omen. Not only does he avoid hunting if he sees a rabbit, the tribe sacrifices a rabbit before each hunt to ensure success. This is an extreme example, but the thinking error is the same. Research actually shows that properly performed weight training actually produces a lower rate-pressure product than aerobic type training such as treadmill exercise. Rate pressure product is defined as mean arterial pressure x heart rate, and is the major determinant of arterial wall stress that can contribute to the development or rupture of arterial aneurysms or dissections. If Mr. Logan also worked out on a treadmill, this might have been more of a risk factor than his “weight lifting”. (Degroot DW, et al. J Cardiopulm Rehabil. Mar-Apr;18(2);145-52.).

“In a nation obsessed with looks and fitness, weight lifting is the latest workout craze. Recent studies have shown that lifting can lower blood pressure, combat diabetes and strengthen bones. Bookstore shelves are teeming with new fitness tomes touting weight lifting. Over the three years ended in 2001, participation in weight lifting in the U.S. has risen 12%-while aerobic exercise declined 2%, according to American Sports Data, Inc.”

This paragraph represents Mr. Helliker’s attempt to offer “balanced” reporting. But buried in his attempt to be fair are smear tactics aimed at discrediting weight training. He characterizes weight training’s ascent in popularity as a “craze”, and implies that this may be due to an obsession with looks. The increase in publications on this subject is characterized as “teeming”, which is most closely defined by the word “swarming” and is usually used in the context of pestilence or contamination; i.e. “teeming with bacteria”. Rather than saying these books support or instruct weight training, he describes them as “touting weight lifting”. Not only does he confuse his terms again, he selects a verb which means “to solicit customers, votes, or patronage, especially in a brazen way” (American Heritage Dictionary). The benefits of weight training cited are real and are based on soundly conducted research. Citing this does not make any of his article balanced, because his supporting evidence is based on anecdote and conjecture; anecdote will never balance the scale against scientific evidence. Even 10,000 anecdotes do not equal one study. His last sentence tells us a lot. Weight training does provide tangible results, whereas aerobics commonly only provides fatigue and injury. Is it any wonder that such a shift is occurring?

“Now, however, a small but growing number of researchers are raising concerns about the safety of lifting heavy weights. Such lifting can trigger strokes and aneurysms, and perhaps even cause a highly fatal arterial disease called dissection, believe doctors at prominent health centers such as Yale University School of Medicine and the Stanford University Medical Center.”

Before we even begin, let us note that he again mixes terms. Here we are talking about “lifting heavy weights”. Mr. Helliker does not define what constitutes heavy, but the only type of lifting that evidence supports might pose a risk is powerlifting. That aside, who are these researchers? How small a number of them are there and how much are they growing? No figure is given, because there really is not one. “Perhaps” it might also cause dissection “believe” doctors. The fact that these doctors are from prominent health centers (Yale, Stanford) should not put a shine on the fact that this is pure conjecture. As best as I can tell, none of these concerns occurred spontaneously. Rather, Mr. Helliker called some of these experts and posed a hypothetical situation (based on anecdotal reports). Such as, “Suppose someone had an undetected aneurysm and participated in heavy-weight lifting, what kind of danger might that pose?” Then he recorded their responses. Having solicited this from these experts, he characterizes it as “a small but growing number of researchers are raising concerns about the safety of lifting heavy weights”. This is not reporting news; it is creating news to report.

“Aneurysms alone kill 32,000 Americans a year, making them as big a killer as prostate cancer, and a more common killer than brain cancer or AIDS. Especially vulnerable to aneurysm and other arterial conditions are senior citizens-a group that has been urged to take advantage of the bone-strengthening effects of weightlifting.”

Once again, the elderly have been encouraged to take advantage of the health benefits of weight training, not weightlifting. Mr. Helliker then tries to established that the incidence of aneurysm and other vascular abnormalities is quite high, higher than other diseases that cause great social concern. This would be especially important if he had established that weight training was a risk for these people (which thus far, he hasn’t). But that aside, he has made some silly statistical errors. First, he elects to compare the number of people who die from these illnesses. Many more people are diagnosed with prostate cancer and AIDS, than die from prostate cancer and AIDS. Thus, these diseases are infinitely more common than these vascular abnormalities and there are reliable early detection tests that do not have offsetting morbity or mortality associated with them. 32,000 deaths sounds like a lot, but compared to the total population of the U.S., you are about 4 times as likely to be killed by lightening. Counting the anectdotal reports in this article, you are about 40 times more likely to be killed by lightening than die from an aneurysm in the weight room. Finally, Mr. Helliker confuses conditional probability. The fact that more people succumb to these vascular events in old age does not mean that being elderly means you are at risk for an aneurysm. Another medical scenario demonstrates this thinking error quite nicely. If a woman has breast cancer, the chance that the cancer will show up on a mammogram is about 90%. Many people (including physicians) take this fact to mean that if a woman has a positive mammogram, that her chance that it is cancer is 90%. In actuality, a woman with a positive mammogram has a 9% chance of having cancer. If event A occurs given event B, it does not mean event B occurs given event A.

“Aneurysm experts express little concern about moderate to light-weight lifting. Some define light as an amount that can be lifted 60 times, in four sets of 15. A leading aneurysm research(sic) and surgeon, John Elefteriades of the Yale University School of Medicine, recommends that people over 40 years old bench press no more than half their body weight. Equally important is breathing regularly during exertion to minimize spikes in blood pressure.”

Once again, Mr. Helliker uses the term weight lifting. He cites definitions of light weight lifting from two experts, but neither expert cites any supporting evidence for their recommendations. Dr. Elefteriades provides a definition that is completely arbitrary. What evidence supports 40 years as a cut off? Why no more than half of your body weight? Why not 40% or 72%. The reason: the recommendation is not based on any data. And citing “my clinical experience” is not an acceptable answer for Dr. Eleferiades, because as a subspecialist at a tertiary referral center he suffers from referral bias. Essentially, any unusual or freak vascular event will get sent to such a specialist. As such, the specialist gets a skewed view of reality; he sees only the numerator with no knowledge of the denominator (which numbers in the thousands or millions). Referral bias is one reason why the opinion of “medical experts” needs to be looked at with a very jaundiced eye.

“Heavy-weight lifting can spike blood pressure to dangerous heights. In maximum-effort lifting, which pits a participant against the most weight he can hoist at one time, studies have shown that blood pressure rises to as high as 370/360 from a resting rate of 130/80. Conventional blood pressure monitors can’t even measure above 300. ‘At that level, nobody would be surprised if you had a stroke.’ Says Franz Messerli, a hypertension specialist at the Ochsner Clinic foundation in New Orleans."

At least here we know we are dealing with powerlifting, which is not what anyone in our field advocates. Mr. Helliker hopes that the reader will assign the guilt that should be attached to powerlifting to proper weight training. But even if we allow that to occur, what remains is still full of holes. The narrow pulse pressure (difference between systolic and diastolic measurements) suggests that a cuff pressure device was used, which is notoriously inaccurate under these conditions. Secondly, elevated measured pressure during muscle contraction is due to external compression, as opposed to internal expansion-which is the real danger with extremely high blood pressure. But even if we concede all these issues, and accept Dr. Messerli’s assertion that we should not be surprised to see strokes under these conditions, we must ask: “where are all the bodies?” Despite numerous amateur and professional weight contests occurring all over the world for decades, we do not see an incidence of stroke any higher in this population than any other (even if we include masters class competitors). It is a safe bet that at least 100 times more strokes occur on the golf course than occur on the weight lifting platform. Scientific study confirms my assertions. A recent study (Can J Cardiol 200 Jan;16(1):35-8), looked at left ventricular (LV) function and morphology in 21 elite powerlifters. LV function and morphology changes in response to vascular stess such as hypertension or recurrent blood pressure spikes. The study concluded “Contrary to common beliefs, long term resistance training as performed by elite male power-lifters does not alter LV morphology.”

“John Robertson witnessed just such an event one day when he was lifting weights as a medical student. Lifting beside Dr. Robertson was a fellow medical student who suddenly keeled over backward. A vessel in his brain had ruptured. He was rushed to the hospital and survived. “During the time that you’re lifting, the pressure on the artery wall is intense,” says Dr. Robertson, chief of cardiovascular surgery at St. John’s Health Center in Santa Monica, Calif.”

Intending no disrespect to Dr. Robertson, but “witnessing” or providing testimonial may work under the revival tent, but it does not wash in scientific discourse. Without proper experimental control, there is no way of knowing if this was just a coincidental occurrence. Furthermore, the fact that he survived suggests this was a leak rather than a rupture. If vascular tension was a contributor under this scenario, it may have actually saved his life. It may be that this event produced a grade I hemorrhage (also known as a warning leak), which allowed surgeons to clip his aneurysm before it could grow to rupture as a grade IV hemorrhage later in life, perhaps killing him at age 35 while playing catch with his son. Unlike the other experts, I will point out that this is simply a plausible conjecture-but a conjecture that is worth just as much as the conjecture of these experts (which is zilch).

“Dissection typically occurs in older adults, or those who have a family history or who suffer from a syndrome called Marfan’s disease. Yet Dr. Elefteriades has treated two young dissection victims who had none of the traditional risk factors, but who were heavy-weight lifters. Similarly, a study conducted at Los Angeles County Harbor-UCLA Medical Center profiled four young men who entered the emergency room suffering dissection-all heavy-weight lifters. Steroid use may increase the risk.”

Once again, we must be clear that we are talking about weight lifting. That aside, Dr. Elefteriades’ report of his experience of two weight lifters suffers from the referral bias that we have already discussed. No meaningful conclusions can be made when this sort of bias is involved, certainly not the broad-sweeping recommendations made in this article. The article from Harbor UCLA that Mr. Helliker refers to was NOT a study. A study is the testing of a scientific hypothesis derived from observed data. The testing of the hypothesis in a study involves appropriate randomization of study subjects and controls, and blinding the researchers as to who is a study subject and who is a control, as well as blinding the subjects as to the intent of the study and to which group they as a subject belong (study subject or control). Only by taking these steps to eliminate all forms of bias, and including enough subjects to have statistical power, can an article be called a study. The article in question is actually something known as a case report. Case reports are included in journals because they represent unusual or freak presentations of an illness. They are presented for novelty and interest, and perhaps to solicit other reports of similar presentations. My mentor in residency pointed out to me that I should never structure my practice in response to case reports. Case reports are by definition extraordinarily rare, otherwise it would not be reportable. My mentor maintained that the fact that someone has made a case report means that statistically, it is very unlikely to occur again. Lastly, steroid abuse does increase the risk for vascular events, so much so that it is truly and independent variable. A study performed in 1996 (Br. J Sports Med 1996 Mar 30;(1):11-4), compared lifters who did and did not use steroids to subjects who performed aerobic exercise and found that “Resistance training in the absence of steroid use results in the same positive effects on cardiac dimensions, diastolic function, and blood lipids as aerobic training”.

“One option for anyone over 60 or with a family history of aneurysms or dissection is to get scanned before starting a lifting program. Most aneurysms and dissections can be detected by CT scans. Also, an inexpensive ultrasound test can detect the abdominal aortic aneurysm which ranks as the nations 13th-leading cause of death.”

This is the kind of simplistic thinking that gives well-informed physicians migraines. Yes, if only we could pull out Star Trek tricorder and detect the unforeseen illness or defect. Unfortunately, it is not that simple. First, the accuracy of a given test is not a fixed phenomenon. The sensitivity of any test is contingent on the pre-test probability. If you perform a screening HIV test on the general population (as done by the military or insurance companies) a positive test has about a 95% chance of being a false positive. If you instead reserve use of the test to those at high risk (ie, homosexual male, receptive anal intercourse with multiple partners) the chance that the test will be falsely positive is less than 5%. The context of detection also matters. Mr. Helliker is correct that CT scans can detect aneurysms and dissections, provided that the scan was prompted by symptoms to suggest the illness, and that the dissection or aneurysm is acutely leaking blood. If you use a CT scan as a screening tool in asymptomatic patients you will miss aneurysms and dissections close to 100% of the time. MRI is significantly better provided that the patient being examined has some sort of symptoms that raise his pre-test probability. MRI is also prohibitively expensive on a financial basis alone. Ultrasound is a relatively cheap and non-invasive test for detecting abdominal aortic aneurysms; however financial costs are not the only costs to consider. In our society physicians and patients alike have an over reliance on tests. We remember their benefits, but fail to include the morbidity and morality associated with tests. For instance, let us say you undergo a CT scan of the chest and abdomen to screen for an aortic disorder. During your test, it is noted that while your aorta is normal, you have a nodule on your right lung and a cyst on your left kidney. Your doctor notifies you of this finding, says it is probably an incidental finding, but cannot guarantee that it is not cancer. Further testing is suggested. You are worried sick. MRI scans are ordered for the next week during which time you cannot sleep a wink. The MRI is inconclusive as well, and $10,000 later you are no closer to an answer. You agree to be admitted to the hospital to undergo CT scan directed needle biopsy of the lung nodule and kidney cyst. The procedure itself is quite painful, despite best efforts to make you comfortable with local anesthesia and IV morphine. During the procedure, the radiologist accidentally collapses your lung, and you are rushed to the ER where the emergency physician places a chest tube to re-expand your lung. This is a very painful procedure where the intercostals muscles are pierced using large forceps, then a large plastic tube is inserted between the lung and the chest wall. You are then admitted to the hospital. While you are sleeping a nurse notes your blood pressure to be 80/40. She calls your physician, but before she can arrive at the hospital you suffer cardiopulmonary arrest and die. Autopsy shows that your renal artery was lacerated during the performance of the renal cyst biopsy. The pulmonary nodule was benign, and the renal cyst was a harmless congenital cyst. This is an incredible scenario, much akin to the scenario the Mr. Helliker is trying to construct for weight lifting. However, screening tests such as those suggested by Mr. Helliker are not done commonly because research has shown that for many tests the number needed to treat (the number of patients you need to subject to testing to save one life) exceeds the number needed to harm (the number of patients you need to subject to testing to result in one death as a result of complications). Such analysis does not even take into account the mental anguish, or financial toll incurred chasing down false positives in the cases where death does not occur. If it were only as simple as Mr. Helliker suggests.

“The latest trend in weight lifting is called slow lifting, in which the participant takes 10 seconds to raise a light to moderate amount of weight and 10 seconds to lower it. Proponents tout it as a safer and more effective alternative to both regular lifting and aerobic exercise.”

“But the authors of two books on slow lifting concede they haven’t measured its blood-pressure spikes, which is arguably the most crucial safety issue. The two authors, Adam Zickerman amd Michael Eades, say that slow lifting produces smaller spikes than regular lifting.”

“Other doctors and fitness experts disagree. They say that one cause of blood pressure spikes during weight lifting is the contraction of the effected muscle. During slow lifting, a muscle may be contracted for more than 60 seconds compared with two or three seconds in regular speed lifting. For anyone concerned about stroke, aneurysm or dissection, or for the vast number of Americans with uncontrolled hypertension ‘I would not recommend slow lifting’ says Wayne Wescott, a slow-lifting proponent who is director of research at the South Shore YMCA in Quincy, Mass.”

In these paragraphs Mr. Helliker concedes that “slow lifting” uses “light to moderate” weight, which meets his earlier criteria for what is safe. He then states the the authors haven’t measured blood pressure spikes. This was probably not done because the preponderance of scientific evidence shows that conventional weight lifting (which pays much less attention to blood pressure raising maneuvers such as valsalva, facial grimacing, excess gripping , etc) has not produced worrisome blood pressure elevations. He states that such concerns are “arguably the most critical safety issue”. This would be true if one accepts what Mr. Helliker peddles in this article. However, if you look at objective data, the bigger issue is orthopedic and musculoskeletal trauma related to explosive (too fast) lifting technique. Fortunately, the protocol (SuperSlow-tm) that most protects the subject from orthopedic trauma is the same protocol that avoids maneuvers that produce precisely the blood pressure responses Mr. Helliker warns against. Again Mr. Helliker enacts the phrase “other doctors and experts” (argument from authority-unsubstantiated by specific reference) when he states that prolonged contractions of the muscle is one of the causes of blood pressure spikes. Assuming this were true, it is not significant, because external compression as a cause of elevated arterial pressure is not risky for the integrity of the vessel wall; it is internal expansion against a stiff vessel that is risky. But it is not true. In a recent study (Am J Cardiol 1999 Jun 1:83(11):1537-43.) Researchers monitored subjects with a central pressure catheter (a measuring device inserted into a central artery) while performing leg press. Even at the highest workloads they recorded a decrease in systemic vascular resistance, and only a modest increase in blood pressure. However, this was coupled with an increased end diastolic pressure, which directly correlates with coronary artery blood flow. Thus the modest increases in blood pressure were offset by decreased peripheral vascular resistance (the resistance the heart must pump against), and enhanced blood flow into the coronary arteries (the mechanism by which the heart muscle is supplied with oxygen).

Wayne Wescott does not recommend “slow lifting” for anyone concerned about stroke, aneurysm, or dissection. Well Dr. Wescott, exactly who isn’t concerned about these things. This isn’t a useful, evidence-based recommendation; it is a liability-dodging sound-bite. Don’t get me wrong. These vascular disorders are very serious and deadly. Anyone with risk factors, or warning symptoms should seek evaluation, and should probably avoid exertion until safety is established. However, the broad generalizations and grand leaps of this article are not appropriate. I hope this critique of the WSJ article will help SuperSlow instructors and their clients to evaluate the relative risks of their exercise program in a more rational context.