The One Number That Predicts Your Longevity More Than Blood Pressure or Cholesterol

A meta-analysis from the British Journal of Sports Medicine put together 119 cohort studies and discovered about 20.9 million observations. Your VO2 max number was a more powerful predictor of how long you will live than your smoking status, than your blood pressure, or existing cardiovascular disease. That literally should stop everyone in their tracks. But just by increasing your fitness level, you can reduce your the rate or your all-cost mortality by 11 to 17% compared to a person whose exercise capacity is going down every year. So when patients ask me what they can do to live longer, I tell them train your aerobic capacity. There is no pill, no shortcut, no byhack, but the evidence is absolutely overwhelming.

But a number almost no one in this country has ever heard of. Today the cardiologist who treats hearts for a living is going to tell us exactly what the number is, why it matters, and how to measure and improve it without ever stepping into a lab. Dr. Moran, welcome back to your own show. It's good to always. How are you doing today? Doing good. How are you doing, Leila? Good, good. Glad to be here and dive into another great conversation with you. So let's start off by talking about exercise and weight. So I know most people associate exercise with weight loss or even aesthetics, but as a cardiologist, why do you keep coming back to VO2 max as the most important number?

So let me start with this is a conversation which people don't focus on, or this is a topic people have very less awareness about. So I'm so glad that we're gonna explore this and dissect it out. As a cardiologist, one of the things I ask myself every day when I look at a patient is how long is this patient going to live and also how well? And out of every modifiable variable I can measure, such as blood pressure, cholesterol, blood sugar, smoking status, none of them predicts mortality as powerful as VO2 max, not even close. There's a Mansager study published in the JAMA network in 2018, which looked at 122,000 patients who went treadmill testing at the Cleveland Clinic. The lowest fitness group had nearly four times the mortality of the highest fitness group. To put that into context, like smokers had 1.4 times the mortality of non-smokers. People with heart disease or blockages in their blood vessels had 1.3 times the higher chance of dying compared to a person who does not have heart disease. But your VO2 max number was a more powerful predictor of how long you will live than your smoking status, than your blood pressure or existing cardiovascular disease. That literally should stop everyone in their tracks. Now, is this a one-time thing or was this replicated? In 2024, a meta-analysis from the British Journal of Sports Medicine pulled together 119 cohort studies, and this covered about 20.9 million observations, and with every one MET metabolic equivalence, improvement in fitness, that's about 3.5 ml per kg per minute of VO2 max. This was associated with a 11 to 17% reduction in all cause mortality. That's enormous. So just by improving your fitness level, one point, okay, we'll dissect or define these terms a little bit more, but just by increasing your fitness level, you can reduce the rate or your all-cause mortality by 11 to 17% compared to a person whose exercise capacity is going down every year. So when patients ask me what they can do to live longer, I tell them train your aerobic capacity. There is no pill, no shortcut, no by hack, but the evidence is absolutely overwhelming.

Absolutely. And speaking about VO2 max, some people have heard it, but I'm sure a lot of people have not heard it. It might be the first time they're hearing it. So what exactly is VO2max?

Okay. VO2max is the maximum amount of oxygen your body can take in or deliver and use during peak effort. So we measure it in milliliters of oxygen per kilogram of body weight per minute, ml per kg per minute. Here's a way I like to explain it. Okay. Your VO2 max is like an integrated output of your entire cardiovascular and metabolic system working together. It's how well your lungs can absorb oxygen, how efficiently your heart pumps oxygen, and how well your blood vessels carry it, and how well does your muscles or specifically your mitochondria get extracted and use it. So when any one of those links is weak, your VO2 max drops. When all of them are strong, it climbs. So this is truly, you know, it's not a fitness number, it's a system performance number. That's why VO2 max correlates not just with your cardiovascular health, but with heart failure, dementia, frailty, fall risk, and ultimately all-cause mortality. You're not measuring how athletic someone is, you're measuring their physiological reserve, how much margin they have between what their body can do and what their life demands of it. So think of it as a resilience factor more than your aerobic capacity. For example, a 70-year-old with a VO2 max of 35 walks up a flight of stairs without thinking about it. Then you have a 70-year-old with a VO2 max of 18 that, even though they both are of the same age, the person with a lower VO2 max has a higher chance of all-cause mortality, aka death, compared to the 70-year-old who can climb who has a VO2 max of 35. So, same task, completely different experience of life, or you know, how long you're going to live. So I kind of obsess over this number with my patients.

Absolutely. And speaking about age, how does VO2 max change with age and how much of it is genetic versus trainable? Genetics gives you about half of your starting point.

The rest is training, lifestyle, and consistency. So, yes, some people have a higher ceiling, but almost no one is anywhere near their ceiling. You know, all of us can't be Michael Phelps. His VO2 max is ridiculously high. How much of our honesty Martin can train for the rest of my life and I will never become a Michael Phelps. But I don't need to become a Michael Phelps. I can just, you know, find my magic number. So obviously, like everything in life, VO2 max declines about 5 to 10% per decade after your peak number in your late 20s. It definitely accelerates, the drop accelerates in your 60s and 70s. But if you do nothing, that is, if you don't go to the gym, you don't work out, you don't focus on your own personal health and training, by age 75, a sedentary person crosses what we called a disability threshold. VO2 max drop so low that walking up a slope or carrying a bag of groceries becomes near maximal effect. I don't like to focus on negative things. So here's the part that excites me. Training can erase 20 to 30 years of that decline. We have the genes, but we also have what we can modify. And I think that's what I'd like to focus on because you can't do anything about the genetic gifts or not gifts you get. Okay. So studies in the adults, um, you know, in their late 60s and 70s, even if they train consistently, shows a 15 to 20 percent improvement in their VO2 max over 6 to 12 months. That's turning biological clock back two decades on the single most important variable in this conversation. So my message is your VO2 max number today is your starting point. It's not your verdict. Even if you have done nothing for the past 20 years, the biggest gains are available to those who are willing to make up the uh lost ground they have by not exercising.

That's interesting. And you touched on how it's your VO2 max is something that's very trainable. So for someone that's a busy working professional, what does an evidence-based week of exercise actually look like? Especially maybe for someone who's doesn't work out a lot or someone who isn't active.

Okay. I get you, I get you. Like a normal person, not a Brian Johnson who has all the time in the world to just focus on exercise or not a model which expects you to put, you know, several hours or something. So a model which, you know, I can do and you can do, and anybody who wants to, you know, do it. So this is uh I came up with a structure, it's a WHO guidelines based. Okay. We need 150 to 300 minutes of moderate activity per week plus two days of strength. Okay, that's abstract, that's a generic construct. So let me make it concrete. Okay, three buckets every week. Bucket one, zone two cardio, 150 to 180 minutes per week, conversational pace. Your heart rate is roughly to 60 um to 70 percent of your max. That is kind of correlates to or breaks down into three to four sessions of 45 minutes of workout. It can be brisk walking, easy cycling, swimming, jogging, whatever you like to do, rowing. This is what builds your mitochondrial density and your aerobic pace. Okay, so this is bucket one. Bucket two, one high intensity session, 20 to 30 minutes. The Norwegian 4x4 protocol, that is four minutes of near maximum effort, three minutes easy, repeated four times. This group uh from the Norwegian group and the Generation 100 trial both show this is the single most efficient stimulus for racing VO2 max specifically. So there are multiple iterations of it, right? There's this Japanese protocol. There are different methods, just you know, uh four minutes on, three minutes off. That's how I like to think. Then your bucket three, strength training. Two sessions, 30 to 45 minutes, compound movements, squat, hinge, push, pull, carry. Uh 2022 BJS meta-analysis showed just 30 to 60 minutes of weekly strength training was associated with a 10 to 20% reduction in all-cause mortality, independent of aerobic exercise. So, yes, do some gentle walking some days. Gentle but brisk walking. Do some four minutes on, three minutes off a couple of days. Then two days, do 30 to 45 minutes of uh strength training. The total commitment is four to five hours per week. That's about the time most people spend streaming services in two to three days. So, what I say, you want to binge watch your Netflix and do some zone two walking, take your iPad and drop it over your treadmill, watch your favorite show, just in zone two pace, that is conversational pace, and be done with it. Another day, instead of doom scrolling on YouTube, just focus, pick on exercise, waist strength training, workout on YouTube and do that. So just, you know, get creative with it and most importantly, make it uh non-negotiable in your week. Put it on your calendar.

No, that's such a good way to describe that. And even the way you broke it down, if you think about four or five hours in your week, like you said, people spend that scrolling or watching TV or something like that. It's so it should be such a non-negotiable. It makes so much sense the way you break it down like that. And within one of those buckets is HIT high-intensity training. And I know so many people talk about that online. There's a lot of buzz around that. And I know there's also some debate online about zone two versus HIT. So, what do you think really matters more?

The internet has turned this conversation into a false binary, this or that. That's just absolutely ridiculous. The honest answer from the physiology standpoint is you need both, and they do completely different things. Okay. So let's start with zone two. Zone two builds the engine, it increases mitochondrial density, which is a cellular machinery, which ultimately burns fat for fewer. Okay? It improves fat oxidation, insulin sensitivity, and your aerobic base. So that is your foundation. Most of the long-term cardiovascular adaptations come from zone two. This is the work that makes you the kind of person who can recover from a tough day, sleep well, and not feel wrecked by your own life. Okay? High intensity interval training, H-I-I-T, raises the ceiling. Your VO2 max specifically responds best to short intent bursts at 90 to 95% of your max heart rate. So again, that Norwegian protocol, 4x4, twice a week, you know, if you just do that, it roughly you get the you can improve your VO2 max much more faster than just time spent on zone two workout. So if forced to pick, I don't recommend that. I tell most sedentary patients to start with zone two. So if you've never done any exercise, then take your iPad, put it on your top of your uh treadmill, watch your favorite show and be at zone two. Okay? The Mansager curve isn't linear, it's hyperbolic. The biggest survival benefit happens at the bottom end, moving from completely unfit to moderately fit. So zone two, build on that, build that over a few months, then kind of add one hit session per week. Okay, and then as you get comfortable, maybe a few months later, you go twice a week. So, you know, it's just just it's not this or that, it's both, and how you can kind of add in without your whole body hurting. This is what I call it a science path sequence.

Absolutely. And I like the way you lay it out. You can start with zone two, get comfortable, and then increase your workouts over time and over the week. And you mentioned the movement not being negotiable. So why is strength training non-negotiable, but especially for those over the age of 40?

I have three reasons, and all these three reasons are backed by science and evidence. Number one, sarcopenia. This is real and this is very silent. You lose 3 to 8% of your muscle mass per decade after 30. And the rate honestly accelerates after 60. So loss of muscle directly translates to loss of metabolic health, fault risk, and mortality. The link between grip strength and all-cause mortality is one of the most robust findings in geriatric medicine. Having said that, just improving your grip strength with one of those, you know, the grip machines or something is completely useless. You need to build your overall muscle mass. Muscle is your ultimate metabolic hack you have. So sarcopenia is real, and you do not want to, you don't want to be playing catch up to that. You just want to keep maintaining and growing your muscle mass. Now, number two, strength training is the most powerful intervention for insulin sensitivity, glucose dispersal, and your bone density. As a cardiologist, I want my patients metabolically active. Type 2 diabetes is a cardiovascular disease, so is fatty liver. Strength training treats both. Okay, so that's extremely important. Number three, strength is the ultimate foundation of independence in your 70s and 80s. Here we are sitting here and talking about quantity of life in your longevity, blah blah. But what you want is a good quality of life. So strength training builds that. And it ultimately decides whether you can get up fast, go get sit on your toilet without anybody's help, or do you need railings to get on and off your toilet, etc. And then you know it's really strange and almost hilarious when patients, especially female patients, uh in their 40s, like, oh, I don't want to strength train, I don't want to get bulky. And I'm like, do you know how much you need to work out to build muscle in your perimenopause and menopause or in your 60s and 70s? You know, it's really, really hard. So two sessions a week, 30 to 45 minutes, focus on compound movements. It's not going to get you bulky, but it's going to make you live longer and feel much more stronger. So that's my prescription.

Absolutely. And most people and most listeners will probably never step foot into a metabolic lab. So, what's the most accurate way to estimate VO2 max for someone that's at home? Okay.

So I honestly think people should not spend too much money getting their VO2 max because it's again micromanaging. Okay, so there are three field tests I trust in descending order of accuracy. Okay, so the first one, it's the gold standard, the Cooper 12-minute run. Go on a flat 400-meter track. Run as far as you can in 12 minutes, then plug it into a formula. It's a formula, you can Google it, but it's called the Cooper 12-minute run formula. The formula goes like this your VO2 max is your distance in meters minus 504.9. Take that number and divide it by 44.7. Okay, so if you cover 2400 meters, six laps of track at the and your estimated VO2 max is about 42 ml per kg per minute. This equation was validated and showed a 0.9 correlation with what you get in the regular lab. The standard error is about 3 ml per kg this way or that way, but you know, this is enough. This is enough to make real decisions. Okay, so that's you know, you need to find a track and you need to measure your run and you need to kind of do all of this. So let's take it, make it a little bit simpler. The second uh way is the 1.5 mile run test. Same idea, fixed distance instead of 12. In the previous one, it was uh you have to run for 12 minutes. Here you run one and a half miles, so it's uh the formula goes as 483 divided by the time in minutes, that number plus 3.5. It's better for patients who can pace themselves more accurately against a known distance. Now the third thing is the Rockport 1 mile walk test. For listeners who shouldn't or can't run yet, walk one mile as fast as you can. Record your time and your heart rate at the finish line. The published rockport equation adjusts for age, sex, weight, time, post-exercise heart rate. It's validated across fitness levels, and this is the test I recommend most often for most sedentary patients who are just starting. The key with any of this is you have to pace correctly and give your true maximal effect. First timers often go out too hard and crash. The second test is more accurate than the first, so pick one, do it twice, two weeks apart, and trust the second number. That's how I would recommend you to do it.

That's so interesting. I haven't heard about any of these tasks, so I'm already planning to do one of them in my head. Probably not the first one because I don't think I'm there yet. You gave us options. So also I have another question about wearables. So, do you think that wearables, for example, Apple Watch, Garmin, whoop are good enough trackers? So you're asking me two different questions here.

Are they good enough to track trends of your VO2 max? Yes. Are they good enough to replace and tell you your most accurate VO2 max in one go? No. They're not good enough to replace a test. So Apple Watch and Garmin estimate the VO2 max from heart rate response during walking run. Using algorithms which are validated against the laboratory cardiopulmonary testing. The published validation studies show that they are typically 5 to 6 ml per kg per minute of the true VO2 max. So if your watch says 38, your year number is actually between 33 or 43. So that's quite vast, right? But here's what they say, which is very useful. If your Apple Watch VO2 number goes from 38 to 42 over six months of training, then that direction is real. So the trend is more reliable than the absolute number. So tracking the trend is absolutely genuinely valid and valuable. So my prescription: use the variables for trends. Do a Cooper or a Rockport or a 1.5 mile thing once or twice a year to get the real number. And if you have a cardiac history, you can totally talk to your cardiologist and get a real cardiopulmonary exercise test through the lab, you know, and then you get the accurate VO2 number, and then you can use your variables for threats.

And speaking about VO2 max numbers, and we talked about a little bit about the test, but what VO2 max number should listeners actually be aiming for at their age?

Ooh, so I I can't put it all under one bucket. It has to be men versus men and women. Okay. So let's think about men who are in their 40s, okay? A low VO2 max for a man in his 40s would be below 35. Average would be 35 to 42, above average would be 42 and uh 42 to 50. If you're an elite athlete, you'll be above 50. So I would say try to aim for a number between above 35, okay? If you are a woman in your 40s, you have a low VO2 max if you're below 27. Your average when you're 27 to 34, above average is 34 to 42, and you're an elite athlete if you're above 42. So aim for a number above the 27s and maybe in the mid-30s. But the useful framing of it is the mortality data shows biggest survival benefits comes from moving out of the lowest fitness category to higher up. So if you are 30 ml per kg per minute as a middle-aged adult, your highest leverage health intervention is to push that number into 35 to 40 range. That move alone halves your mortality risk over the next two decades. There is no medication, no biohack that does that. So if your goal is to, I want to live longer and I and then aim about the 75th percentile for your age and sex. If you want to optimize, target the VO2 max of someone two decades younger than you. So a 50-year-old aiming for a VO2 max of a 30-year-old, that's the difference between average aging and exceptional aging.

Wow, that's so interesting. And speaking about, we touched on strength training, but what about mobility? Why does mobility matter as much as cardio and strength training for someone who's sitting eight, nine hours a day?

You know, we were not designed to be sitting still. The modern body is mismatched to the modern environment. Humans were evolved for varied movements, squatting, walking, climbing, lifting, pulling, pushing. We have replaced it almost all of it with sitting. And sitting in a chair for eight hours a day creates predictable mechanical adaptations that compromise both performance and longevity. Sitting shortens your hip flexors, weakens your glutes, rounds your thoracic spine, tightens your pectorals, reduces your ankle dorsiflexion. And none of those are abstract. They directly relate to lower back pain, shoulder impingement, knee pain, which all ultimately leads to increased fault risk later in life. The honest part, the evidence of static stretching alone reducing injury is mixed, but the evidence for dynamic mobility, controlled movement through full range of motion, it's much more stronger. It improves joint health, reduces pain, and preserves movement. The quality you need to keep training cardio and strength as you age. So mobility is the connective tissue between everything else. Without mobility, you can't load strength train safely, you can't run efficiently, your spine doesn't age well. So at least 10 to 15 minutes a day, at the least, five days a week, that would be the dose.

Perfect. And can you walk us through what five days of mobility actually looks like for someone, especially if they have a packed schedule?

So, you know, there's a lots of things you do. A lot of my patients are virtual workers, etc. So I say start the day at least with 10 to 12 minutes of mobility exercises. And you know, different apps like Calm and everything has integrated mobility into their system itself, morning mobility protocols. YouTube has a bunch of videos, okay? But whatever fits. So day one, you can do couch stretches, just you know, sit 90-90, do deep squats and hold, just controlled hip movements, like extend and rotate it. Then you can do thoracic spine, which is you know, rotations. We we're all sitting in front of a lap. Use your foam roller and kind of look behind and do that. You can do cat cow, you can do shoulder and neck extensions because our neck mobility gets fixed because we're all like, so you know, use your shoulder rotations and use a tennis ball against the wall and kind of relieve your tight muscle, calf wall straight, uh stretches, you know, glute bridges, pigeon pose. There's a full body flow integrator called the world's greatest stretch, where you kind of you're in a Spider-Man position and you know you do Cossack squats, etc. So it's very difficult for me to describe all of these in detail on a podcast. But if you just you go to YouTube and search for 10-minute morning mobility workout, it's gonna cough up a bunch of this. But the thing is, all of this is very doable. Even if you have a meeting for two hours straight, at the end of two hours, you can take 10 minutes and just move your joints. So I think you consistently do this just even for four to six weeks. Your back pain gets better, your sleep gets better. Now you can push and train harder.

Absolutely. It's so I like that idea of getting up even between meetings. It's so easy, I feel like, for people, especially if you're working on a computer, so just keep going and going. And it's good to take those minutes and get up and move around. And we talked a little bit about tools and wearables, but in your opinion, which tools, wearables, and apps are actually worth a busy professional's time?

Okay, I'll give you a short list of what I personally recommend or use. Uh, let's have a disclaimer. I'm not being paid by any of these companies. Uh, so I myself will experiment with different just to get a feel of what it is. So, in general, for tracking any modern variable, Apple Watch, Garmin, Whoop, they all generate on resting heart rate variability, sleep activity, and it's pretty good quality, very high quality. But don't trust the numbers, don't focus on the absolute number, but instead focus on the thread. That's what I would do. For training prescriptions, apps like Training Peaks, Garmin Coach, Apple Fitness on Apple Plus, they are all increasingly using your heart rate data to prescribe individualized zone two and hit sessions. They are not perfect, but they remove the decision friction. The biggest reason people don't exercise consistently is not lack of motivation, it's decision fatigue. What do I start with? What do I do? They don't have a plan. I mean, you know, because I mean I'm not an exercise physiologist, but I love my Peloton app. I will go on it and I'll just, you know, depending on the flavor of the day, I will just pick whatever strength training exercise, or I will do their one-month program or something just to so that, you know, I don't need to think about it, and the decision is made for me. So for mobilities, apps like Go Ward, like workout of the day, do an actual movement assessment, identify your weakest joints, and prescribe targeted daily flow. It's the closest thing to having a movement coach in your pocket. What I would definitely skip is the AI Fitness Coach apps, which are being released just rampantly and they are just marketing dressed up as personalization. The data they collect rarely changes the prescription in any meaningful uh way. It will eventually change as AI gets better, but it is not there yet.

And speaking about those AI apps, where do you think AI taking personalized exercise prescription in the next five years is headed?

The interesting question. There are three plays, all of which I'm watching very closely. One is the real-time dynamic prescription. Today's exercise prescription is very static, right? You're told to do four by four intervals for 12 weeks, um, a model that ingests your continuous heart rate, adjusting heart rate, heart rate variability, sleep, and recovery data will be able to tell you daily whether today is a hit day or a zone two day or a rest day based on what your body is actually showing them. HRV guided training already produces better outcomes than fixed schedules and published trials. The technology exists, but it's a matter of integration. The next is prediction of training response. There's a huge amount of variability in how people respond to identical training, which is completely dependent on genetic, metabolic, and environmental. Also, if you had a bad night's sleep, you're not going to respond to the same exercise as you would have in another day. AI models are getting good at predicting high responders versus low responders before even training starts using genetic, metabolic, and baseline phenotypic data. That changes the game. Instead of exercise more, it'll be able to tell you based on your profile, this specific protocol will give you a 6 ml per kg per minute VO2 max increase in 12 weeks. Imagine that. So it's more specific, measurable, and identified. And finally, my favorite thing, integration with cardiovascular uh risk modeling. This is a layer I'm building towards my own work. So imagine that takes your continuous variable data, your lipid panel, your blood pressure trends, your VO2 max trajectory, and outputs a real-time cardiovascular risk for uh score that updates as your behavior changes. Right now we calculate 10-year atherosclerotic cardiovascular disease risk once a year on a paper chart. The future is risk that updates daily based on what you're factually doing. The future of cardiology isn't fewer doctors, it's better signaling. And exercise is one of the highest resolution signals we have.

Absolutely. And if a listener could change one thing about how they think about exercise after this episode, what would it be?

Stop thinking of exercise, something you do for weight loss or your aesthetics or your mood. Those are real, but they are just side effects. The real thing exercise does is buy you decades of physiological reserve. It is a difference between a 75-year-old who can walk their grandkids to school and a 75-year-old who can't get out of a chair without help. It's not vanity, it's truly not optional. It's the most powerful intervention you have access to that can make you live longer and live better. And the prescription can start with just two to three hours a week. If there's one thing you want to take from this episode, is that VO2 max is the single most important number that you are not currently tracking or you may not be tracking. Find out what is your VO2 max. Then make a plan to improve it. The data on what this one decision does to your future is completely overwhelming.

This was such a great conversation. We covered the number that may predict your future health more than almost anything else and why cardio is really medicine and why strength keeps you independent and how mobility protects your body that you're building. It's been a great conversation. And Dr. Marin, thank you so much for translating the science into something practical and beyond being practical, also actionable and honestly urgent. I feel, I know, I feel like I need to get up and take a walk and do some movement today. And I hope our listeners feel the same way. And to everyone listening, you don't need to overhaul your life tomorrow. Start with movement, start with a walk, start with one workout, start with 10 minutes of movement, but start. So that's how I feel. I feel like the urgency from this episode is so important. And this has been another great episode, another great conversation of infinite help with Dr. Moran. I can't wait for our next conversation. And for those listening, make sure you share and follow the show and make sure you send it to someone who can benefit from it as well. And I will see you next time.