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Characterizing Differences in Mortality at the Low End of the Fitness Spectrum


Medicine & Science in Sports & Exercise: August 2009 - Volume 41 - Issue 8 - p 1573-1579
doi: 10.1249/MSS.0b013e31819ca063
Basic Sciences

Purpose: A graded nonlinear relationship exists between fitness and mortality with the most remarkable difference in mortality rates observed between the least-fit (first, Q1) and the next-least-fit (second, Q2) quintile of fitness. The purpose of this study was to compare clinical characteristics, exercise test responses, and physical activity patterns in Q1 versus Q2 in apparently healthy individuals.

Methods: A total of 4384 subjects referred for clinical treadmill testing from 1986 to 2006 were followed for a mean ± SD period of 8.7 ± 5.3 yr. All subjects had normal exercise ECG responses and no history of cardiovascular disease. Subjects were classified into quintiles of exercise capacity measured in METs. Clinical characteristics, physical activity patterns, and treadmill test results were compared between the first two quintiles (Q1: METs <5.9 (n = 693); Q2: METs 6.0-7.9 (n = 842)).

Results: Small differences in age (64 ± 11 vs 60 ± 10 yr, P < 0.001), use of antihypertensive medications, prevalence of diabetes (21% vs 16%, P = 0.02), and dyslipidemia (43% vs 49%, P = 0.04) were observed between Q1 and Q2. When the Cox proportional hazards model was adjusted for age and other clinical characteristics, the relative risk of mortality remained almost two times greater in Q1 versus Q2 (cardiovascular mortality: HR: 4.01 vs 2.01, P < 0.001; reference group: fittest subjects (Q5)). In a subset of 802 subjects, recent recreational physical activity was significantly lower in Q1 versus Q2.

Conclusions: Reduced physical activity patterns rather than differences in clinical characteristics contribute to the striking difference in mortality rates between the least-fit and the next-least-fit quintile of fitness in healthy individuals.

1Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; 2Stanford School of Medicine, Palo Alto, CA; and 3School of Physical Education, University of Otago, Dunedin, NEW ZEALAND

Address for correspondence: Sandra Mandic, Ph.D., Exercise Physiology, School of Physical Education, University of Otago, PO Box 56, Dunedin, New Zealand; E-mail:

Submitted for publication October 2008.

Accepted for publication January 2009.

© 2009 American College of Sports Medicine