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Sports Med 2001; 31 (8): 571-576

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Physical Fitness and Changes

in Mortality
The Survival of the Fittest
Gunnar Erikssen
Medical Department, Central Hospital of Akershus, Nordbyhagen, Norway


Physical fitness is a term describing maximal aerobic capacity adjusted for

body size and composition, and is an integrated measure of cardiorespiratory and
neuromusculo-skeletal function, oxygen transport and delivery, and psychological drive. Accordingly, high physical fitness requires that all these important body
functions function normally, while low physical fitness suggests malfunction of
one or more of them.
High levels of physical fitness maintained through heavy daily exercise
has probably been a necessary requirement for survival in the earlier history of
humans. In modern, industrialised countries the demand for physical activity to
sustain life is declining, and a decline in physical fitness is observed in many
Epidemiological studies over the past 50 years have unanimously shown that
low physical activity and physical fitness is associated with high cardiovascular
and total mortality. Recent data also suggest that low physical activity and physical fitness is followed by an increased incidence of diabetes mellitus and nonfatal
cardiovascular diseases. A number of unfavourable biochemical and physiological aberrations following physical inactivity probably explain these observations. However, recent studies also indicate that changes in physical activity, and
especially changes that bring increases in physical fitness, can reverse this rather
pessimistic scenario.
The Global Burden of Disease Study initiated by the World Health Organization included physical inactivity among the most important risk factors threatening global health. A sedentary life style may be as detrimental to health as smoking.
Encouragement of physical activity is an important and difficult task, as society
is becoming increasingly successful in reducing our need to move.

In their struggle for survival primordial humans

had to maintain a high level of physical fitness. In
their struggle for longevity, modern day humans
are dying because of lack of physical exercise. In
1990, physical inactivity was among the top 10 risk
factors for global health according to The Global

Burden of Disease Study.[1] The modern, sedentary

life style probably represents a serious violation of
biological principles to which humans have genetically adapted, and it is hardly surprising that fitness and the will and ability to stay fit is associated
with health and survival.


The present article presents a synopsis of what

is currently known about the relationships between
fitness and various body functions, factors influencing fitness and the impact of fitness and changes
in fitness on long term health outcome.
1. Measurements of Physical Fitness
The term physical fitness refers to maximal
aerobic capacity [maximal oxygen uptake (VO2max)]
adjusted for body composition and size. VO2max
can be measured directly by gas exchange measurements during maximal exercise; usually on a
bicycle ergometer or a treadmill.[2] In practice, more
simple techniques are often used. The currently most
common alternative is determination of the work
performed at the time of exhaustion adjusted for
body dimensions. This measure has shown a very
high correlation with VO2max, and is sufficiently
simple for epidemiologic purposes.[2] Determinations of work capacity when a certain heart rate is
reached or other indirect methods represent cruder
assessments of fitness.
2. Determinants of Physical Fitness
Physical fitness is an integrated measure of cardiorespiratory function, oxygen transport and delivery, neuromusculo-skeletal function and psychological drive.[2] Disorders in any of these functions
besides poor nutritional status influence fitness
negatively. Physical fitness is of course also a function of age.
In healthy individuals, about a third of the variation in physical fitness is caused by genetic factors.[3] Otherwise, apart from quitting smoking, the
only way for healthy people to increase their fitness
from any level is to increase their physical activity.
Thus, physical activity and fitness are inseparable.
2.1 Smoking and Fitness

Apart from the short term smoking-related reduction in oxygen binding and delivery caused by carbon
monoxide, chronic exposure to smoking causes reduced ventilatory capacity and eventually chronic
obstructive lung disease, in addition to unfavour Adis International Limited. All rights reserved.


able effects on the cardiovascular system.[4] All these

factors, in the early stages at least partly reversible,
have unfavourable effects on fitness.
2.2 Assessment and Effects of
Physical Activity

Exact assessments of physical activity in test populations using current methods (self-reports, physical activity questionnaires, structured interviews)
are difficult and these methods have not been fully
standardised. Recently, experimental use of doubly
radioactively labelled water has improved the precision in measuring energy expenditure during physical activity, as have computerised motion detectors.[5]
A high level of physical activity, necessary to
maintain high fitness, has favourable effects on serum lipids, fibrinolysis, glucose tolerance and insulin
sensitivity, platelet function, blood pressure, autonomic nervous system function, myocardial electric
stability, endothelial function and endotheliumdependent vasodilation in coronary arteries, and
the immune system.[6,7] Physical activity level also
influences aspects of mental health related to risk
of cardiovascular disease (CVD).[8]
3. Associations Between Physical
Fitness and Coronary Heart Disease
Risk Factors
In addition to physical activity level and smoking status, age-adjusted physical fitness is closely
associated with coronary heart disease (CHD) risk
factors such as systolic blood pressure, triglycerides, high and low density lipoproteins, resting heart
rate and body mass index. Such associations have
been demonstrated in both genders.[9]
Associations between physical activity level and
CHD risk factors are similar to those of physical
fitness, but generally weaker.[10] Part of this difference may be related to imprecision of measuring
activity levels, but it remains that fitness has an
important genetic component and is not a direct
mirror of activity level. However, improvements in
fitness are followed by a more favourable risk factor pattern.[6] This suggests that CHD risk factors
Sports Med 2001; 31 (8)

Physical Fitness and Changes in Mortality

can be modified through improvements in fitness

regardless of genetic influences.
4. Relationships Between Physical
Activity, Physical Fitness and Risk of
Death: Epidemiological Studies
Since Morris et al.[11] in 1953 and Pfaffenbarger
et al.[12] in 1970 first demonstrated inverse relationships between point estimates of physical activity level and CVD mortality independent of conventional risk factors, these observations have been
confirmed and extended to also include all-cause
mortality in both men and women,[13-16] and individuals with various chronic diseases. More recently,
similar relationships have been demonstrated for
physical fitness.[17-20] The significance of physical
activity and physical fitness as predictors of death
has been further amplified by recent studies which
consistently demonstrate inverse associations between changes in physical activity, changes in fitness and changes in mortality.[6,21-23]
Few long term follow-up studies have included
physical fitness and physical activity level in the
same analyses. Two such studies[6,18] demonstrated
considerably stronger inverse relationships between
fitness and mortality than between activity and mortality. One study showed that high fitness was not
associated with decreased risk of CHD if activity
was low, whereas low fitness was associated with
lowest risk if activity was high.[24] Recent levels of
physical activity may be particularly important in
reducing mortality risk.[25] Comparing studies on
relationships between fitness and mortality versus
studies on activity and mortality suggest that fitness is the strongest predictor of the two. However,
such differences could be related to the possibility
that fitness reflects physical activity levels better
than other indirect assessments of activity.[19]
Regular exercise has favourable effects on progression of coronary atherosclerosis and mortality
in CHD prevention studies.[26-28] Conversely, short
bouts of intense physical activity in sedentary individuals both with and without recognised heart
disease may increase the risk of acute myocardial
infarction and sudden death.[29,30]
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Virtually all studies of physical activity and fitness have only dealt with all-cause and CVD mortality, whereas little attention has been paid to their
association with disease development before death.
In our long term observational study of 2014 initially healthy, middle-aged men we have also had
the opportunity to study long term incidence of various diseases in relation to fitness, as reported earlier.[6] Table I shows data on the combined incidence of CVD, diabetes mellitus and cancer 8, 16
and 21 years after the baseline examinations in 1972
to 1975 among quartiles of age-adjusted physical
fitness. A virtually identical association is seen between fitness and disease as for mortality.[20] The
influence of changes in fitness and disease development is similar to that of changes in fitness and
changes in mortality (data not shown). Accordingly,
fitness appears to influence mortality and morbidity in a similar way.
5. Discussion
Reductions in mortality associated with increased
physical activity and fitness have never been demonstrated in randomised trials, and such trials are
hardly possible in free living populations. However, extensive experimental and epidemiological
research during the past 5 decades strongly indicates that this hypothesis holds true, because:
There are strong and inverse associations between physical activity/fitness and long term
cardiovascular and all-cause mortality
Physical activity has several favourable short
and long term biochemical and physiological
effects in the body
High physical fitness a state that can only be
achieved through regular physical exercise, is
favourably associated with a number of cardiovascular risk factors
Increases in fitness are associated with favourable changes in cardiovascular risk factors
Changes in physical fitness are strongly and inversely related to reductions in long term mortality.
According to common epidemiological principles,[31] it can therefore be concluded beyond reaSports Med 2001; 31 (8)



Table I. Mortality and prevalence of cardiovascular disease (CVD)a, diabetes mellitus (DM) or cancer within age-adjusted quartiles of physical
fitness (PF) determined at baseline between 1972 to 1975 among 2014 initially healthy men aged 40 to 60 years: 8, 16 and 21 years of
Length of follow-up

Quartile of
age-adjusted PF



















Alive with CVD,

DM or cancer (%)

Alive with no CVD,

DM or cancer (%)





























CVD includes angina pectoris, myocardial infarction, stroke, aortic aneurysm or intermittent claudication.

sonable doubt that physical fitness and changes in

fitness are causally related to long term health.
5.1 Significance of Exercise Testing

Exercise testing is a time consuming procedure,

and cost effectiveness in various clinical settings is
an important issue. Such testing is established as
an integral part of follow-up among patients with
CHD. In 1983, Bruce et al.[32] suggested that in apparently healthy individuals, exercise testing should
be reserved for those with known increased CHD
risk. However, recent results from repeated exercise testing have shown that changes in fitness are
strongly associated with changes in mortality,[6] suggesting that measures of fitness and changes in fitness may unveil integrated measures of important
body functions that carry long term impact on health.
Exercise blood pressure, heart rate acceleration during exercise and deceleration after termination of
exercise have, for example, also recently been identified as strong predictors of CHD death.[33-35] In
view of the wealth of important information which
can be derived from careful exercise testing, costeffectiveness estimates of exercise testing should
be reconsidered.
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5.2 Exercise Prescriptions

There exists considerable controversy regarding

the types and amounts of physical activity needed
to obtain health benefits,[36] although there is general consensus that exercise must be taken and administered with a clear understanding of both the
benefits and the risks.[37] Our studies in apparently
healthy, middle-aged men indicate that among the
least fit, substantial reductions in mortality can be
achieved through modest improvements in fitness.
These data to be generalised with caution, seem to
support the recent official US recommendations[36]
if these are applied on very sedentary populations.
However, our data also indicate that the will and
ability to stay moderately or highly fit is associated
with additional reductions in mortality. Since the
amount of exercise required to maintain or improve
fitness depends on baseline fitness, a dose-response
relationship between changes in fitness and changes
in mortality may exist; at least within the normal
range of fitness.
5.3 Physical Fitness, Disease and Disability

Discussions on fitness, changes in fitness and

implications for long term health outcomes mainly
Sports Med 2001; 31 (8)

Physical Fitness and Changes in Mortality

focus on mortality. However, favourable psychological effects of exercise and the strong associations
between fitness and nonfatal disease manifestations
should also be emphasised. Increased physical
activity is a key factor in enabling people to attain
old age without disability or becoming institutionalised the fear of which may be greater than the fear
of death.[38] This and not only prolonging life
may be the most important benefit from physical
activity in older age groups.[39]
5.4 A Public Health Perspective

In the US it was estimated in 1986 that the number of CHD deaths attributable to never or irregularly engaging in physical activity and elevated serum cholesterol were of the same magnitude, and
clearly higher than CHD deaths associated with
smoking.[40] Far from improving since 1986, the
proportion of Americans having adequate physical
activity appears to be declining,[38] as in most industrialised countries. Thus, society is becoming
increasingly successful at reducing our need to move.
In developing countries, a decline in physical activity appears to follow in the wake of economic
All the studies referred to above demonstrating
inverse associations between physical fitness/physical activity and mortality have concluded that physicians and authorities should encourage people
to become more physically active. The question
remains whether such messages will have the desired effects. Experience from various anti-smoking
campaigns is discouraging in this regard. In many
countries, authorities are now enforcing laws and
regulations to prevent people from smoking. Application of similar measures to force people to become
more physically active which might be equally important in a public health perspective, is difficult
to conceive. Convenience and necessity are the main
determinants of our everyday actions, and the development of, for example, electronic communication media does not support any drive towards exercising. Encouragement of physical movement,
therefore, is an increasingly challenging task.
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Disregarding these rather pessimistic considerations, the fact still remains that each individual
regardless of any genetic component has a decisive influence on their own fitness. Scientific evidence strongly indicates that improvements in fitness particularly among those who are least fit,
are associated with substantial health gains. Even
in this rather unusual context, Darwins idea of the
survival of the fittest[42] may not be far from the
6. Conclusion
Extensive research during the past 50 years
strongly indicates that physical fitness and changes
in fitness are causally related to long term health.
The apparently inevitable decline in physical activity
followed by industrialisation will undoubtedly
have grave impact on global health unless countermeasures are taken. Creation of drives towards exercising in the community is an increasingly important and difficult task.
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Correspondence and offprints: Gunnar Erikssen, Medical

Department, Central Hospital of Akershus, N-1474
Nordbyhagen, Norway.

Sports Med 2001; 31 (8)