Is Pickleball the Best Physical Activity for a Long Life?

It is inherently social, activates multiple muscle groups, and involves HIIT but does it really add 8 more years to your life compared to working out in a gym?

I had a lot of good comments on my recent pickleball post but one in particular seized my attention.

I recently subscribed to the youtube channel of Cara Beth Lee (CBLeeMD), an orthopedic surgeon in Seattle. I think she's well above the quality of many youtube medical channels (I know that's a low bar, but she's good) who thinks pickleball is the no. 1 best physical activity for long life

That would be amazing. Pickleball as a simple, fun way to extend our lives!

I was quite skeptical that if one were to take up playing pickleball one's life would be extended significantly and I asked the reader for references.

In the video link below Dr. Lee (who comes across as a thoughtful and engaging promoter of pickleball) does indeed cite two studies to support her contentions.

The Copenhagen City Heart Study: Tennis as the Elixir of Youth

The major study Lee discusses in this 9-minute video was published in 2018 in the Mayo Clinic Proceedings.

This was an observational study using data from questionnaires.

The Copenhagen City Heart Study (CCHS) is a prospective population study that included detailed questionnaires regarding participation in different types of sports and leisure-time physical activity. The 8577 participants were followed for up to 25 years for all-cause mortality from their examination between October 10, 1991, and September 16, 1994, until March 22, 2017.

Relative risks were calculated using Cox proportional hazards models with full adjustment for confounding variables.

The results were astonishing!

Multivariable-adjusted life expectancy gains compared with the sedentary group for different sports were as follows: tennis, 9.7 years; badminton, 6.2 years; soccer, 4.7 years; cycling, 3.7 years; swimming, 3.4 years; jogging, 3.2 years; calisthenics, 3.1 years; and health club activities, 1.5 years.

For those who like graphics and speculation, here is Lee explaining that pickleball likely has the same miraculous life-expanding benefits as tennis although pickleball was not studied in the paper she quotes

Now, I am a huge advocate of exercise, physical activity, pickleball and tennis. I love all 4 and I do believe they provide many social, mental and physical benefits to all and if I were not such a skeptical cardiologist with an attachment to the unbiased truth I would double-down on Lee's video in order to prod my sedentary patients into picking up paddles.

But the idea that playing tennis as opposed to working out in a gym, running or cycling adds 6 or 7 years to your life is absurd.

Sadly, these kinds of associations are the norm in observational epidemiologic epidemiologic studies and lazy authors, editors, and journalists love to portray these mostly meaningless associations as causal.

The parallels between sports and nutritional epidemiology are striking.

We can substitute types of physical activity/sports for the foods that Johann Ionnadis mentions in his classic JAMA piece skewering the lack of good scientific principles in nutritional observational studies and come to the same conclusions he did:

Assuming the meta-analyzed evidence from cohort studies represents life span–long causal associations, for a baseline life expectancy of 80 years, nonexperts presented with only relative risks may falsely infer that eating 12 hazelnuts daily (1 oz) would prolong life by 12 years (ie, 1 year per hazelnut), drinking 3 cups of coffee daily would achieve a similar gain of 12 extra years, and eating a single mandarin orange daily (80 g) would add 5 years of life. Conversely, consuming 1 egg daily would reduce life expectancy by 6 years, and eating 2 slices of bacon (30 g) daily would shorten life by a decade, an effect worse than smoking. Could these results possibly be true? Absolute differences are actually smaller, eg, a 15% relative risk reduction in mortality with 12 hazelnuts would correspond to 1.7 years longer life, but are still implausibly large. Authors often use causal language when reporting the findings from these studies (eg, “optimal consumption of risk-decreasing foods results in a 56% reduction of all-cause mortality”). Burden-of-disease studies and guidelines endorse these estimates. Even when authors add caveats, results are still often presented by the media as causal.

The gullible reader would conclude from these types of studies that by combining 12 hazelnuts and 3 cups of coffee along with taking up tennis they can add 34 years to their lifespan.

But this is absurd!

These implausible estimates of benefits or risks associated with diet probably reflect almost exclusively the magnitude of the cumulative biases in this type of research, with extensive residual confounding and selective reporting. Moreover, given the complicated associations of eating behaviors and patterns with many time-varying social and behavioral factors that also affect health, no currently available cohort includes sufficient information to address confounding in nutritional associations.

The Social Network

The authors of the absurd Mayo Clinic Proceedings article wildly speculate in their discussion on the reasons that tennis might prolong your life.

Possibly, the observed differences in mortality benefits were due to the differing social aspects of the various sports studied. Interestingly, sports that require 2 or more individuals to play together and socially interact, tennis, badminton, and soccer, were the sports that were associated with the best improvements in longevity, whereas the less inherently interactive forms of PA, such as jogging, swim-ming, cycling, and health club activities, were associated with less impressive longevity benefits. This is in line with previous studies consistently showing that social isolation is among the strongest predictors of reduced life expectancy.

They also dis "health club activities:"

The smallest improvement in life expectancy was noted in people who predominantly did health club activities. The reason for this could be that their working heart rate was lower than for the other sports, but the reason could also be due to the tendency for people to exercise alone on stationary machines with weights in the health clubs, thereby missing out on the social interaction mandated by racquet sports and soccer, for example.

Another Study with different findings

Dr. Lee mentions a more recent paper that summarized a cohort study of 272 550 older adults that found that "participation in 7.5 to less than 15 metabolic equivalent hours (METS*) per week of running, cycling, swimming, other aerobic exercise, racquet sports, golf, and walking for exercise was associated with lower mortality risks compared with nonparticipants."

The authors assumed these MET values for various sports:

The MET value for each sport was multiplied times the estimated average hours per week in the prior year participants spent playing that sport to get MET-hours per week.

Thus, if you played a racquet sport (7 METS) on average for 3 hours per week you would be assigned 3 x 7 or 21 MET-hours spent on racquet sports.

In this analysis, all racquet sports whether singles or doubles were lumped together and had about the same relative risk reduction as running:

In comparison with those who did not participate in each activity, 7.5 to less than 15 MET hours per week of racquet sports (HR, 0.84; 95% CI, 0.75-0.93) and running (HR, 0.85; 95% CI, 0.78-0.92) were associated with the greatest relative risk reductions for all-cause mortality, followed by walking for exercise, other aerobic activity, golf , swimming, and cycling.

Given that running is generally not considered a "social" sport, this paper came up with its own theory for the associated mortality risk reduction:

The larger reduction in risk of mortality associated with running and racquet sports than for other activity types for older adults may be associated with the specific physiological demands and adaptations that occur with these sports. These activities both require synchronized action from many muscles for correct form, and racquet sports also require hand-eye coordination and intermittent bursts of very high intensity, which may additionally improve physical functioning

Fitness, Fun, Racquets, and Socializing

When my kids were growing up I was obsessed with teaching them tennis. I felt that it provided a fun method for enhancing their physical fitness, hand-eye coordination, ability to withstand mental stressors, competitiveness, confidence and strength. I know it provided all of those things for me as an under-sized asthmatic teen.

As they reached adulthood the positive social aspects of tennis emerged.

I don't think tennis or pickleball provide any longevity benefits over physical activities which reach equivalent MET levels but I highly recommend pickleball for sedentary individuals.

There is considerable anecdotal and some published evidence to support encouraging sedentary older individuals to take up pickleball.

A 2021 paper reported on a feasibility study of "Pickleball for Inactive Mid-Life and Older Adults in Rural Utah" and found following a brief training period of six weeks, improvements were noted in vertical jump height, cognitive performance, and self-reported pain of the participants.

There was an overwhelmingly positive response from the participants and the majority expressed a desire to continue playing after the study completion.

The bottom line message with respect to sports and physical activity that I convey to patients remains "Do something at a moderate to vigorous intensity, do it consistently, and do it for at least 150 minutes per week." The MET-hours per week should be a vital sign along with BP and heart rate.

I also recommend measuring max VO2 to assess and track how our exercise is impacting our cardio-fitness.

Perhaps I need to add a message to my patients on the value of friends, family, and socializing but I sense that is not an area that responds to physician prompts.

Eudaimonically Yours,

-ACP

*If you'd like to learn more about METS I highly recommend reading "The compendium of physical activities: METS for all."