Metabolic Health

Predicting Medical Costs with VO2max

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Key points

  • Healthcare expenses are skyrocketing, with consumers and employers facing the significant brunt.
  • Identifying those likely to get sick is critical as our resource-strapped healthcare system should focus on those likely to become the most significant burden to the system.
  • VO2 max is a crucial longevity indicator that can also accurately predict healthcare expenses.

The rampant chronic disease epidemic and the resulting surge in medical expenses is one of the most dire problems of modern societies, probably only second to climate change. Healthcare inflation is on a meteoric rise, and for those with limited or no healthcare coverage, a medical emergency is the equivalent of personal bankruptcy.  


A dire problem for employers

In the US, employers and consumers who face rising health insurance premiums and astronomical out-of-pocket medical expenses feel the brunt of rising healthcare costs. Such is the problem that even large, well-capitalized corporations choose to send employees overseas for specific medical procedures since the cost of traveling and treatment in a foreign country is lower than the cost of care in the US. Another startling example is the infamous “northern caravan,” a term that describes people with diabetes in the northern states who travel to Canada to secure their insulin supply. According to McKinsey, a survey conducted among over 300 employers highlighted that the average increase in the cost of health benefits over the past three years has been within the range of 6 to 7 percent. This survey also indicated that any rate increases exceeding 4 to 5 percent were deemed unsustainable. Interestingly, 95 percent of the surveyed employers expressed willingness to contemplate reducing benefits if costs surged by 4 percent or more. The primary cost-control measures that these employers indicated they might explore included elevating the portion of premium costs covered by employees and a potential transition to high-deductible health plans.


Why is Breath Analysis relevant?

Vis-a-vis this problem, the early and accurate estimation of who will get sick and how much they will cost is as critical as the treatment itself. The reason is that no other method of accurately identifying at-risk populations exists; it helps focus our scarce prevention resources and attention on those most in need. Breath analysis, AKA VO2max or metabolic testing, is an assessment that reveals two key biomarkers that provide significant predictive value for one’s likelihood of developing costly chronic conditions. These two biomarkers are VO2max and the Respiratory Exchange Ratio. In this article, we will dive into VO2max to understand why it’s a critical reflection of our overall health and, consequently, a window into our future healthcare spend.   


What is VO2max?

Let’s start with the basics. What is VO2max? VO2 max is the maximum amount of oxygen the human body can absorb. It is measured in terms of milliliters of oxygen consumed per kilogram of body weight. The below formula below indicates how VO2max is calculated:

The numerator indicates the volume of oxygen your heart, lungs, and cells can absorb, expressed in milliliters per minute. The denominator indicates the weight of the individual represented in kilograms.

How is VO2max measured?

VO2 max is measured by analyzing the total amount of oxygen consumed by a person’s body while exercising at maximal or near-maximal conditions. As our body begins to move, working muscles need to break down more nutrients (i.e., fats and carbohydrates) to cover the increased demand for energy. Since the oxidation (i.e., breakdown) of nutrients requires oxygen, our heart, lungs, and blood circulation will begin to work more intensely to deliver the necessary oxygen. As the intensity of exercise increases, so does the need for oxygen by the working muscles, and the more our cardio-respiratory system works harder. This is what we all experience when we start to exercise and continue increasing the intensity. Consequently, when we exercise at our peak, we consume the most significant amount of oxygen. This is our VO2max. A VO2max assessment is typically conducted on a stationary bicycle or treadmill. 


The Oxygen Chain

Because of the fundamental nature of oxygen supply to our cells, a large part of our body specifically evolved to sustain this process. Our heart, lungs, and blood circulation’s main task is to facilitate oxygen delivery clearance of carbon dioxide, in other words, to maintain the ongoing operation of aerobic metabolism. All these systems comprise the Oxygen Chain.  

The oxygen chain is the bedrock of human longevity. This is manifested by the fact that nearly all chronic conditions likely to kill you or reduce your quality of life are either caused or displayed by a reduction in oxygen throughput in the respective system. For example, the reduced ability of the cells to absorb oxygen has been proven to be one of the most potent predictors of metabolic disorder and type II diabetes. A reduced ability of your heart to pump oxygen-rich blood is a reliable indicator of Coronary Artery Disease. The VO2max test is the only scientific assessment known to analyze the health of your oxygen chain and assess how effectively its parts operate individually and in unison in circulating oxygen and powering aerobic metabolism. VO2 max is the metric that summarizes the health of the oxygen chain most comprehensively. This is why decades-long longitudinal studies have established it as the most potent predictor of how long and well one will live. The range of scientific data supporting the power of VO2 max to predict mortality and morbidity led the American Heart Association to call for the institution of VO2 max testing as part of every person’s annual physical examination.


Healthcare cost prediction


VO2max is a metric that has been extensively analyzed in its ability to predict the likelihood of mortality and morbidity and its ability to predict healthcare costs directly. Specifically, a landmark study published by The Mayo Clinic analyzes the correlation between healthcare expenses and Cardio-Respiratory Fitness (CRF), an alternate description of VO2 max. The study comprised 9,942 participants with a mean age of 59.11 years who underwent a maximal exercise test for clinical purposes from January 2005 to December 2012. Cardiorespiratory fitness was divided into four categories or quartiles, measured as a percentage of age-predicted peak metabolic equivalents (METs) attained. Data were obtained from the Veterans Administration Allocated Resource Center to analyze total and annualized healthcare expenses. Multiple regression techniques were employed to compare these costs while accounting for demographic and clinical factors.


An inverse relationship between cardiorespiratory fitness (CRF) and healthcare costs was observed. Those in the least-fit quartile had approximately $14,662 higher overall costs per patient per year compared to the fittest quartile, even after accounting for potential confounding variables (P<.001). Furthermore, for each 1-MET increase in fitness, there was a corresponding annual reduction of $1,592 in healthcare costs (equating to a 5.6% lower cost per MET). Additionally, moving up to a higher quartile of fitness resulted in a $4,163 annual reduction in costs per patient.

Interestingly, the impact of CRF on costs was more pronounced in subjects without cardiovascular disease (CVD), indicating that these findings were not driven by the possibility that less-fit individuals had a higher prevalence of CVD. The cost savings attributed to greater fitness were most significant in overweight and obese subjects, with lower savings observed among those with a body mass index of less than 25 kg/m². When considering historical, clinical, and exercise test data, heart failure emerged as the most influential predictor of healthcare costs, followed by CRF





The vast amount of scientific evidence behind the relationship among VO2 max mortality, morbidity, and healthcare cost is a powerful tool to help providers and stakeholders in health and wellness contain the chronic disease pandemic. It’s undeniable that our healthcare system is resource-strapped as providers face the most challenging time in modern times recruiting the necessary personnel. As such, targeting our limited resources where it matters most can make the difference between success and failure in mitigating healthcare costs.

Metabolic Health