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    15 Comments for this article
    Push-Up Test Unclear
    John Cox |
    The precise way in which push-ups were administered is unclear for two reasons:
    1. A full push-up cycle (up and down) performed in an interval of .75 seconds (80 per minute) is pretty fast. Or did each tick of the metronome signal one direction -- one tick for up, one tick for down? 40 push-ups per minute is pretty slow. Would the participant be penalized for doing them faster? (Referencing text: "For push-ups, the firefighter was instructed to begin push-ups in time with a metronome set at 80 beats per minute.")
    /> 2. If the patient "missed 3 or more beats of the metronome," were these consecutive beats or cumulative beats? In other words, if on push-up 32 the patient paused for one beat, and then on push-up 35, the patient paused for one beat, and then on push-up 38, the patient paused for one beat, would the test be over at 38? Or could the patient pause as many times as desired as long as the pause did not exceed 2 beats?

    For push-ups, the firefighter was instructed to begin push-ups in time with a metronome set at 80 beats per minute. Clinic staff counted the number of push-ups completed until the participant reached 80, missed 3 or more beats of the metronome, or stopped owing to exhaustion

    More detail on how the test is administered would be very helpful.

    Thank you
    Push-up Test Methodology
    Jeffrey Fletcher |
    I also have a comment about the push-up protocol. There are many ways to do a "push-up" one only has to watch a group fitness session to see the variations (straight or sagged back, depth of drop, etc.) as well as the timing as noted previously. Perhaps if the test was executed using a force platform under each hand and temporal data collected then the actual force, power, and energy could be captured. This would seem to provide a more accurate and repeatable measure of the subjects physical state.
    Missing age compensation
    Geoffrey Landis, Ph.D. | NASA
    I don't usually comment on articles well outside my field, but on this one, I'm puzzled about the missing age compensation. The age of the firefighters who could do 10 or less push-ups was 48.4 plus or minus 10. The age of the ones who could do 41 or more was was 35.1 plus or minus 7 (table 1, first row.)
    These age cohorts barely even overlap. To be a fair comparison, the dark grey curve on figure 1 needs to be shifted to the right by 13 years compared to the teal curve, which is to say, it
    should be shifted entirely off the graph.
    The comparison of cardiovascular event rate among two cohorts that are so vastly different in age is unlikely to be meaningful. If the authors think that they can normalize this out and still retain statistical significance, that normalization method needs to be very well explained (and it is not).
    Push-up Specification
    John Brand, Ph.D. | Seagate Technology
    The Push-up procedure is specified in reference 25. Here's a link to the document:

    Briefly, the back is straight (neutral); hands shoulder-width apart; cadence is move down on one beat, move up on the next beat; chin must touch a 5" prop.

    A score of >40 implies that the subject was moving faster than the metronome.
    Not so sure!
    Mark Pickin |
    Now, I am a wimp and struggle to do 10 press-ups but I can (and do) run 10 miles no bother.. does this study mean my life miles have been of no benefit?
    Needed better normalization
    Todd Antenucci, DO | Private practice
    It really needs to be stressed that this is a fit for duty analysis as in, "I will determine if I should employ this guy for a physical job by seeing if he can do 40 push-ups."
    They didn't normalize for any of the cardiac risk factors (smoking, cholesterol, diabetes, blood pressure) and I don't see any mention of family history.
    In the study data, the group who could only do 10 push-ups were on average 48yo smokers w elevated BP and higher blood sugar as compared to the 40+ push-up group who was on average 10 years younger
    w lower BP and half as many smokers. There is no surprise that the higher risk group had more cardiac events.
    Push-up protocol
    Dan Matiesanu |
    The push-up protocol is described in detail in the bibliographical resource 25 available here: https://www.iafc.org/docs/default-source/1safehealthshs/wfi-manual.pdf?sfvrsn=7931df0d_5
    Effect of ahe
    Geoffrey Hui |
    The result should be as expected since the ability to perform push up is inversely related to age which is related to increased CV risks regardless of CV health.

    Thus study will be more relevant if the investigator address or adjust for age.
    A superb example
    Mark Laporta, MD, FACP | Private Practice, Dr. Iz
    A superb and subtle example of Disraeli-Twain statistics, that is, missed dimensions.

    How many of the men in shape did so because of hate? Fear?
    How many of the men out of shape were so because of sloth or melancholy?
    And if the answer is "not all," then what other dimensions were missed?

    Can those at peace be dissected from those in agitation?

    It's my observation, even since before MD 1979, that the more statistical manipulation, the less useful -- or true -- the conclusion. Perhaps that's
    why medical "science" changes every few years. We miss entire dimensions because we do not care to include-- or to admit -- that they do or do not serve us.

    And before I forget, have you ever, ever met an author or correspondent wo does not have potential conflicts of interest? (Another Disraeli-Twain statistic in itself.)

    “There are more things in heaven and earth…than are dreamt of in your philosophy.” W Shakespeare
    Reservations over multiple comparisons
    Myron Pulier, MD | Rutgers New Jersey Medical School
    The Discussion warns: "Given that the tests performed were not adjusted for multiple comparisons, some of the significant findings could be due to chance." I'm not clear how this applies in the instant case. If nearly all "multiple comparisons" reach statistical significance, then the contribution of "chance" to the underlying pattern seems to be minimized. Of course, among 20 independent studies, each reporting p=.05 (sic) one is fairly likely a fluke... but in this study, were there many comparisons not shown in the published article? Also, are the raw data available for outside review?
    Is this the 21st century or the ice age?
    Lori Kuchenbeisser |
    If heart disease is the number 1 killer in women and men, why were only male firefighters studied? Don't more women die from it than men?
    Concluding confusion
    Megan White, Global Health BSc | Barts and the London, Queen Mary, University of London
    It is a little confusing how throughout the point is stressed that push-up capacity represents a useful tool in objectively measuring functional status but the conclusion states: "The findings suggest that being able to perform a greater number of push-ups at baseline is associated with a lower incidence of CVD events among active adult men. Thus results from this study suggest that it is reasonable for clinicians to assess functional status during clinical evaluations by using basic questions regarding activity." If this is the case, the basic questions can suffice, how this the use of push-up capacity measurement provide any greater insight and how does this study lead to this conclusion?
    Useful study
    Dr Hana Fayyad, Pediatrician |
    With all potential drawbacks, this study is interesting and suggestive, and applied on individual basis may be helpful to allow for assessment of one’s CV fitness-even for a woman like me.
    Reply to some comments
    Chihchao Yang, MD, MPH | Harvard TH Chan School of Public Health
    Thank you all for your interest and in your comments to our paper. We are very humbled to see such great interests from all over the world in our research. As most of the questions we received are related to how the push-up test was administered, we have created a post explaining the protocol, which you can access on the following website.


    Should you have any other questions, please do not hesitate to contact me through my email address or post a comment here.

    Thank you,
    Justin Yang, MD, MPH (lead author)
    Nice study but so much more potential left hanging
    Zei Zed |
    I liked the study but when collecting so much data you could have done much more analysis from it. Comparison/grouping of BP, HDL, HDL/Trig, LDL, glucose levels, weight, age, smoking. It would be really nice to get hold of this data as a hobbyist #opendata
    Original Investigation
    Nutrition, Obesity, and Exercise
    February 15, 2019

    Association Between Push-up Exercise Capacity and Future Cardiovascular Events Among Active Adult Men

    Author Affiliations
    • 1Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 2Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
    • 3Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, Limassol, Cyprus
    • 4Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
    • 5Public Safety Medical, Indianapolis, Indiana
    • 6Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis
    JAMA Netw Open. 2019;2(2):e188341. doi:10.1001/jamanetworkopen.2018.8341
    Key Points español 中文 (chinese)

    Question  Is there an office-based objective measurement that clinicians can use to assess the association between fitness and cardiovascular disease risk?

    Findings  This longitudinal cohort study of 1104 occupationally active adult men found a significant negative association between baseline push-up capacity and incident cardiovascular disease risk across 10 years of follow-up. Participants able to complete more than 40 push-ups were associated with a significant reduction in incident cardiovascular disease event risk compared with those completing fewer than 10 push-ups.

    Meaning  Push-up capacity is a no-cost, fast, and simple measure that may be a useful and objective clinical assessment tool for evaluating functional capacity and cardiovascular disease risk.


    Importance  Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity; however, few have studied simple, low-cost measures of functional status.

    Objective  To evaluate the association between push-up capacity and subsequent CVD event incidence in a cohort of active adult men.

    Design, Setting, and Participants  Retrospective longitudinal cohort study conducted between January 1, 2000, and December 31, 2010, in 1 outpatient clinics in Indiana of male firefighters aged 18 years or older. Baseline and periodic physical examinations, including tests of push-up capacity and exercise tolerance, were performed between February 2, 2000, and November 12, 2007. Participants were stratified into 5 groups based on number of push-ups completed and were followed up for 10 years. Final statistical analyses were completed on August 11, 2018.

    Main Outcomes and Measures  Cardiovascular disease–related outcomes through 2010 included incident diagnoses of coronary artery disease and other major CVD events. Incidence rate ratios (IRRs) were computed, and logistic regression models were used to model the time to each outcome from baseline, adjusting for age and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). Kaplan-Meier estimates for cumulative risk were computed for the push-up categories.

    Results  A total of 1562 participants underwent baseline examination, and 1104 with available push-up data were included in the final analyses. Mean (SD) age of the cohort at baseline was 39.6 (9.2) years, and mean (SD) BMI was 28.7 (4.3). During the 10-year follow up, 37 CVD-related outcomes (8601 person-years) were reported in participants with available push-up data. Significant negative associations were found between increasing push-up capacity and CVD events. Participants able to complete more than 40 push-ups were associated with a significantly lower risk of incident CVD event risk compared with those completing fewer than 10 push-ups (IRR, 0.04; 95% CI, 0.01-0.36).

    Conclusions and Relevance  The findings suggest that higher baseline push-up capacity is associated with a lower incidence of CVD events. Although larger studies in more diverse cohorts are needed, push-up capacity may be a simple, no-cost measure to estimate functional status.