ORIGINAL ARTICLE

Elite Athletes Live Longer Than the General

Population: A Meta-Analysis
Nuria Garatachea, PhD; Alejandro Santos-Lozano, PhD;
Fabian Sanchis-Gomar, MD, PhD; Carmen Fiuza-Luces, PhD;
Helios Pareja-Galeano, MSc; Enzo Emanuele, MD, PhD;
and Alejandro Lucia, MD, PhD
Abstract

Objective: To perform a meta-analysis of cohort studies aimed at providing an accurate overview of

mortality in elite athletes.
Patients and Methods: We reviewed English-language scientific articles available in Medline and Web of
Science databases following the recommendations of the Meta-analyses Of Observational Studies in
Epidemiology group. We searched for publications on longevity and professional or elite athletes (with no
restriction on the starting date and up to March 31, 2014).
Results: Ten studies, including data from a total of 42,807 athletes (707 women), met all inclusion criteria.
The all-cause pooled standard mortality ratio (SMR) was 0.67 (95% CI, 0.55-0.81; P<.001) with no evi-
dence of publication bias (P¼.24) but with significant heterogeneity among studies (I2¼96%; Q¼224.46;
P<.001). Six studies provided data on cardiovascular disease (CVD) and 5 on cancer (in a total of 35,920
and 12,119 athletes, respectively). When only CVD was considered as a cause of mortality, the pooled SMR
was 0.73 (95% CI, 0.65-0.82; P<.001) with no evidence of bias (P¼.68) or heterogenity among studies
(I2=38%; Q¼8.07; P¼.15). The SMR for cancer was 0.60 (95% CI, 0.38-0.94; P¼.03) with no evidence of
bias (P¼.20) despite a significant heterogeneity (I2¼91%; Q¼44.21; P<.001).
Conclusion: The evidence available indicates that top-level athletes live longer than the general population
and have a lower risk of 2 major causes of mortality, namely, CVD and cancer.
ª 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;89(9):1195-1200

and ventricular arrhythmia.7 Accordingly, a

T
here is strong epidemiological evidence
that regular physical activity (eg, brisk certain tolerance “threshold” has been proposed
walking and jogging) has great poten- after which exercise would no longer be bene- For editorial
tial in the management and rehabilitation of ficial and might be even harmful to the heart.5,6 comment, see page
various diseases1,2 and is associated with lower Some authors recently postulated that stren- 1171; for a related
risk of all-cause mortality, cardiovascular dis- uous endurance exercise (eg, running) for article, see page
ease (CVD), hypertension, stroke, metabolic more than approximately 1 h/d might induce 1187
syndrome, type 2 diabetes, breast and colon deleterious effects on the human heart.8
From the Department of
cancer, depression, and falling.3,4 However, To determine whether the health benefits Physiotherapy and
whether the repeated exposure to the highest of exercise are actually confined (or not) to Nursing, University of
exercise levels, such as those required in profes- noncompetitive, moderate (or recreational) Zaragoza, Huesca, Spain
(N.G.); Research Institute
sional sports participation, affects human practice is of broad medical interest and might of Hospital 12 de Octubre
longevity and disease risk remains an open help clinicians have more evidence-based data (‘i+12’), Madrid, Spain
question.5,6 There is growing evidence on the on exercise benefits. Thus, we conducted a (N.G., A.S.-L., C.F.-L., A.L.),
Department of Biomedical
potential arrhythmogenic effects of intense meta-analysis of cohort studies comparing Sciences, University of
endurance exercise, such as marathon running, mortality in elite athletes with mortality in León, León, Spain (A.S.-L.);
in previously healthy people.3-14 The debate is the general population. We hypothesized Department of Physiology,
University of Valencia and
fueled by news media reports of sudden death that the overall health benefits of competitive Fundación Investigación
in young athletes and by recent provocative exercise would counteract any potential detri- Hospital Clínico Universi-
murine research establishing a cause-effect rela- mental effect, resulting in higher longevity and tario/INCLIVA, Valencia,

tionship between long-term forced treadmill lower disease risk in elite athletes than in the Affiliations continued at
training and the development of cardiac fibrosis general population. the end of this article.

Mayo Clin Proc. n September 2014;89(9):1195-1200 n http://dx.doi.org/10.1016/j.mayocp.2014.06.004 1195

www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research

PATIENTS AND METHODS
Data Sources and Searches
We followed the recommendations of the
Meta-analyses Of Observational Studies in
Epidemiology group9 [see the checklist in
Supplemental Appendix 1 (available online at
http://www.mayoclinicproceedings.org)]. We
searched for publications on longevity and pro-
fessional or elite athletes (with no restriction on
the starting date and up to March 31, 2014).
The search terms longevity or survival and pro-
fessional, elite, or Olympic athletes were used, or
combinations of 1 or more of these terms,
with restrictions to English-language scientific
articles (excluding congress abstracts) indexed
in the Medline and Web of Science databases.
We also extended the search spectrum to the
“related articles” and the bibliographies of all
retrieved studies. Once potentially relevant ar-
ticles were identified, their reference lists and
abstracts were retrieved. Two authors inde-
pendently assessed the records obtained by
the search results.
Study Selection
The criteria for including a study in the meta-
analysis were as follows: (1) available informa-
tion on the evaluation of the longevity or
survival; (2) athletic cohort composed solely
of professional athletes or elite athletes (with
the latter implying having experience in inter-
national competitions, eg, Olympic Games11);
(3) using a cohort study design; and (4)
providing standard mortality ratio (SMR) with
95% CI or, alternatively, providing sufficient
observed and expected death data to allow
this variable to be calculated.
Data Extraction
When the SMR and its 95% CI were not pro-
vided directly, they were calculated from the re-
ported observed and expected deaths as SMR ¼
observed death/expected death and its 95%
CI ¼ SMR  1.96 (observed death/expected
death)1/2. We also calculated the inverse vari-
ance weighted pooled summary estimates of
SMRs (meta-SMRs). The meta-SMR (or “pooled
SMR”) represents a summary estimate of the
increased risk of death in elite athletes than in
the general population, weighted by the inverse
of the log variance of SMRs of each study. We
used the Newcastle-Ottawa Quality Assessment
n n
1196 Mayo Clin Proc. September 2014;89(9):1195-1200
MAYO CLINIC PROCEEDINGS
Scale12 to assess the quality of each study
included in the meta-analysis.
Statistical Analyses
All analyses were performed with the Stata statis-
tical software package (version 13, StataCorp,
2010). The meta-SMR was computed using a
random effects model, and heterogeneity was
tested using the Q and I2 statistics. Calculations
were performed on the log of SMRs from the in-
dividual studies, and the resulting pooled values
were then transformed back to the SMR scale.
Separate meta-SMRs were calculated for CVD
and cancer. Because heterogeneity is expected to
exist in meta-analyses of observational studies,
meta-regression analysis was performed to ac-
count for sources of heterogeneity on the basis
of causes of mortality. Egger’s tests were used to
assess evidence of publication bias. The signifi-
cance level was set at P<.05.
RESULTS
From an initial identification of 88,192 studies,
88,138 were excluded (ie, not potentially rele-
vant studies, congress abstracts, and duplicated
material). From the remaining 54 potentially
relevant studies, 44 studies were excluded
with reasons, namely, not written in English
(n¼3), SMR not reported (n¼38), and dupli-
cated or nonelite athletic population (n¼3).
Ten studies,13-22 including a total of 42,807
athletes (707 women), met all the inclusion
criteria (Table). Of a maximum 9-point score, 2
studies had a quality score of 7, 6 had a quality
score of 8, and 2 had a quality score of 9. Thus,
this meta-analysis included data on (1) profes-
sional team sport athletes (85.2% of the total),
for example, North American and African Amer-
ican football and baseball players and Italian pro-
fessional soccer players; (2) Finnish and Polish
Olympic athletes of various disciplines (9.6%),
namely, power, “mixed,” and endurance events;
(3) track and field athletes from Italy (2.7%); (4)
European road cyclists, that is, participants in
the Tour de France (1.8%); and (5) Olympic (inter-
national) level athletes from Denmark partici-
pating in heterogeneous disciplines, including
team, power, and endurance sports (0.7%).
The all-cause pooled SMR was 0.67 (95% CI,
0.55-0.81; P<.001) with no evidence of publica-
tion bias (P¼.23) but with significant heteroge-
neity among studies (I2¼96%; Q¼224.46;
P<.001; Figure 1). Six studies provided data
http://dx.doi.org/10.1016/j.mayocp.2014.06.004
www.mayoclinicproceedings.org
ELITE ATHLETES AND MORTALITY

TABLE. Main Characteristics of the Studies Entered in the Meta-Analysis

All-cause SMR SMR due to CVD SMR due to cancer
Reference, year Cases (95% CI) only (95% CI) only (95% CI)
Baron et al,13 n¼3439 0.53 (0.48-0.59) 0.68 (0.56-0.81) 0.58 (0.46-0.72)
2012 National Football League players with >5 pension-credited playing
seasons from 1959 to 1988
Belli et al,14 n¼24,000 1.00 (0.90-1.10) 0.83 (0.69-1.00) NA
2005 Italian professional soccer players active during 1960-1996 in the 3 top
leagues (A, B, and C)
Gajewski n¼2113 (424 women) 0.51 (0.45-0.57) NA NA
et al,15 2008 All Polish participants in all Olympic Games held in the 20th century
Kalist and n¼2641 0.31 (0.23-0.39) NA NA
Peng,16 Major US league baseball players who were born between 1945 and
2007 1964
Kujala et al,17 n¼2009 0.74 (0.69-0.79) 0.72 (0.64-0.82) 0.36 (0.24-0.52)
2001 Athletes who had represented Finland in international competitions
during 1920-1965 and were alive in January 1971
Marijon et al,18 n¼786 0.59 (0.51-0.68) 0.67 (0.50-0.88) NA
2013 French cyclists who competed in 1 or more editions of the Tour de
France during 1947-2012
Menotti et al,19 n¼1148 (283 women) 0.70 (0.47-0.93) NA NA
1990 Track and field athletes who had participated in international events as
members of the Italian national team from 1940 until now
Taioli,21 2007 n¼5389 0.68 (0.52-0.86) 0.41 (0.20-0.73) 0.31 (0.15-0.55)
Soccer players who were enrolled in the Italian professional leagues A
and B for at least 1 season between 1975 and 2003
Waterbor n¼985 0.94 (0.88-1.00) NA 1.05 (0.89-1.22)
et al,22 1988 All baseball players who played their first games for a professional
major league baseball team in the United States between 1911 and
1915 and who survived until 1925
Schnohr,20 n¼297 1.00 (0.80-1.20) 0.95 (0.63-1.26) 0.94 (0.56-1.32)
1971 Athletic champions (world record holders; medalists at Olympic
Games and World, European, or Nordic championships; members
of Olympic teams; Danish champions, record holders, and members
of national teams) born in Denmark between 1880 and 1910
CVD ¼ cardiovascular disease; NA ¼ not available; SMR ¼ standard mortality ratio.

on CVD13,14,17,18,20,21 and 5 on cancer (in a total
of 35,920 and 12,119 athletes, respec-
tively).13,17,20-22 The pooled SMR for CVD was
only 0.73 (95% CI, 0.65-0.82; P<.001) with
no evidence of bias (P¼.68) or heterogeneity
among studies (I2¼38%; Q¼8.07; P¼.15;
Figure 2). The SMR for cancer was 0.60 (95%
CI, 0.38-0.94; P¼.03) with no evidence of bias
(P¼.20) but with significant heterogeneity
among studies (I2¼91%; Q¼44.21; P<.001;
Figure 3).
DISCUSSION
The results of this meta-analysis indicate that elite
athletes live longer than the general population.
Such a powerful effect on human longevity is
comparable, if not higher, to that reported for
vigorous but less competitive exercise. For
instance, the all-cause SMR of well-trained recre-
ational athletes (Dutch endurance ice-skaters)
was 0.76 (95% CI, 0.68-0.85).23
Growing evidence indicates that intense
endurance exercise might produce cardiac al-
terations (mainly increased risk of atrial fibril-
lation),5-7 and a “safety threshold” has been
postulated to exist in competitive sports, espe-
cially in endurance events.5,6 However, the
studies analyzed here as well as other pub-
lished articles do not support that such type
of exercise is overall harmful to the human
heart. Recent data indicated 58% lower overall
mortality and 57% lower CVD risk in a large
cohort of participants in a 90-km cross-
country ski race,24 which was accompanied

Mayo Clin Proc. n September 2014;89(9):1195-1200 n http://dx.doi.org/10.1016/j.mayocp.2014.06.004 1197

www.mayoclinicproceedings.org
 MAYO CLINIC PROCEEDINGS

be equal to approximately 10 years.29 Such

Reference, year Measure (95% CI) Weight P value continuous intense exercise loads are unrealistic
Baron et al,13 2012 0.53 (0.48-0.59) 11% <.001 for most athletes, including those participating
Belli et al,14 2005 1.00 (0.90-1.11) 11% >.99
in the Tour de France.30 Former participants
Gajewski et al,15 2008 0.51 (0.45-0.57) 11% <.001
Kallist and Peng,16 2007 0.31 (0.24-0.40) 9% <.001 in the Tour de France live longer than the gen-
Kujala et al,17 2001 0.74 (0.69-0.79) 11% <.001 eral population as indicated by a study
Marijon et al,18 2013 0.59 (0.51-0.68) 10% <.001
Menotti et al,19 1990 0.70 (0.50-0.98) 8% .04 included in our meta-analysis18 as well as by
Taioli,21 2007 0.68 (0.53-0.87) 9% <.001 a previous report.31 Particularly strong epide-
Waterbor et al,22 1988 0.94 (0.88-1.00) 11% .06
Schnohr,20 1971 1.00 (0.82-1.22) 10% >.99
miological evidence supporting the benefits of
Synthesis 0.67 (0.55-0.81) 100% <.001
strenuous endurance exercise on life expec-
tancy and health comes from Finish male
0.12 0.25 0.50 1.00 2.00 population-based cohort studies with elite ath-
SMR letes of various disciplines who were Olym-
pians between 1920 and 1965.17,32 Athletes,
FIGURE 1. Main results of the meta-analysis. SMR ¼ standard mortality ratio. especially endurance athletes, had higher
mean life expectancies than did controls32; in
by a rather mild increase in atrial fibrillation addition, they had lower mortality rates owing
risk (hazard ratio, 1.2).25 Veteran athletes to CVD than did controls.17 Consequently,
with arrhythmias have higher heart rate vari- former elite athletes had a lower risk of medica-
ability, which has a cardioprotective effect.26 tion for chronic diseases.33
Some evidence also starts to accumulate against Our meta-results have several limitations,
the notion that exercise benefits are confined to particularly regarding the differences between
“moderate” doses, at least in terms of total exer- studies in the duration of the selected time inter-
cise time, with higher moderate-to-vigorous vals used to calculate SMR. In addition, the
physical exercise (eg, brisk walking and apparent survival advantage conferred by
running) levels (450 min/wk), which are elite sports participation during a period of an in-
clearly above the minimum international rec- dividual’s life might be inflated by potential
ommendations of 150 min/wk,27 being associ- confounders, including lifestyle habits (indepen-
ated with longer life expectancy.28 On the dent from intense exercise) during or after retire-
other hand, caution is needed when extrapo- ment from competition. For instance, former
lating provocative data from animal studies to Finnish elite athletes were more physically active
humans.7 Benito et al7 reported a cause-effect during leisure time, smoked less, consumed less
relationship between long-term forced treadmill alcohol, and had a healthier diet than their refer-
training and the development of right ventricu- ents.34 Another important limitation arises from
lar remodeling in rats. The authors trained rats the absence of information on specific cause of
at approximately 90% of maximum heart rate, death in 3 studies15,16,19 (accounting for
1 h/d, 5 d/wk for 16 weeks; when translated w14% of the total meta-analysis sample) and,
to the human life span, this time period would especially, from the observed heterogeneity
among studies for all-cause pooled SMR as well
as for SMR due to cancer. A reason explaining
Reference, year Measure (95% CI) Weight P value such heterogeneity may be the large variability
Baron et al,13 2012 0.68 (0.57-0.82) 22% <.001 among studies in the sports phenotype of the co-
Belli et al,14 2005 0.83 (0.69-1.00) 22% .05
Kujala et al,17 2001 0.72 (0.64-0.81) 31% <.001
horts, which included athletes participating in
Marijon et al,18 2013 0.67 (0.51-0.89) 13% <.001 quite different sports specialties, that is, ranging
Taioli,21 2007 0.41 (0.21-0.78) 3% .01 from team sports with little aerobic component
Schnohr,20 1971 0.95 (0.67-1.34) 9% .75
Synthesis 0.73 (0.65-0.82) 100% <.001
such as baseball to extreme endurance events
such as Tour de France. In addition, the global
0.12 0.25 0.50 1.00 2.00 term cancer includes numerous cancer types
SMR that differ in etiology (ie, genetic vs lifestyle
factors) whereas only 1 study13 reported suba-
FIGURE 2. Results of the meta-analysis when only cardiovascular disease nalyses based on different cancer categories.
was considered as the cause of mortality. SMR ¼ standard mortality ratio. In contrast, only 2 studies reported SMR for
death due to musculoskeletal/connective tissue
n n
1198 Mayo Clin Proc. September 2014;89(9):1195-1200 http://dx.doi.org/10.1016/j.mayocp.2014.06.004
www.mayoclinicproceedings.org
ELITE ATHLETES AND MORTALITY
diseases; that is, SMR¼0.90 (95% CI, 0.02-
5.02) in participants in the Tour de France18 vs
SMR¼3 (95% CI, 0.97-7) in football players.13
Whether this type of disease was specifically
caused by sports participation and might nega-
tively affect the mortality of former athletes
remains to be determined in studies with high
statistical power. In addition, there is a lack of
information on fatal accidents during sports
participation. Because female athletes accounted
for less than 2% of the total athletes’ sample
assessed in this meta-analysis, it is not possible
to determine whether there is a sex effect on
the association between elite sports participation
and mortality. Finally, the comparatively high
weightage of studies performed by Kujala
et al17 in Finnish Olympic athletes and by Baron
et al13 and Taioli et al21 in football and soccer
players, respectively, may have skewed the
results toward a favorable effect on CVD. In
fact, the combined weight of the 3 above-
mentioned studies was approximately 68%
(Figure 2) despite accounting for only approxi-
mately 25% of the total meta-analysis population.
CONCLUSION
Although more research is needed using more
homogeneous cohorts and a more proportional
representation of both sexes, the evidence avail-
able indicates that elite athletes (mostly men)
live longer than the general population, which
suggests that the beneficial health effects of ex-
ercise, particularly in decreasing CVD and can-
cer risk, are not necessarily confined to
moderate doses. Future studies might elucidate
whether the present high demands of profes-
sional sports participation also translate into
an actual longevity and health benefit.
ACKNOWLEDGMENTS
The authors would like to thank Dr Pedro J.
Marín for his advice and thoughtful comments.
SUPPLEMENTAL ONLINE MATERIAL
Supplemental material can be found online at
http://www.mayoclinicproceedings.org.
Abbreviations and Acronyms: CVD = cardiovascular dis-
ease; SMR = standard mortality rate
Affiliations (Continued from the first page of this
article.): Spain (F.S.-G., H.P.-G.); European University,
Madrid, Spain (C.F.-L., A.L.); and Department of Health Sci-
ences, University of Pavia, Pavia, Italy (E.E.).
Mayo Clin Proc. n September 2014;89(9):1195-1200 n http://dx.doi.org/10.1016/j.mayocp.2014.06.004
www.mayoclinicproceedings.org
Reference, year Measure (95% CI) Weight P value
Baron et al,13 2012 0.58 (0.46-0.73) 22% <.001
Kujala et al,17 2001 0.36 (0.24-0.53) 20% <.001
Taioli,21 2007 0.31 (0.16-0.59) 16% <.001
Waterbor et al,22 1988 1.05 (0.90-1.23) 23% .54
Schnohr,20 1971 0.94 (0.61-1.44) 19% .78
Synthesis 0.60 (0.38-0.94) 100% .03
0.12 0.25 0.50 1.00 2.00
SMR
FIGURE 3. Results of the meta-analysis when only cancer was considered as
the cause of mortality. SMR ¼ standard mortality ratio.
Correspondence: Address to Alejandro Lucía, MD, PhD,
Universidad Europea de Madrid, 28670 Villaviciosa de
Odón, Madrid, Spain (alejandro.lucia@uem.es).
REFERENCES
1. Franklin BA, Lavie CJ, Squires RW, Milani RV. Exercise-based
cardiac rehabilitation and improvements in cardiorespiratory
fitness: implications regarding patient benefit. Mayo Clin Proc.
2013;88(5):431-437.
2. Vuori IM, Lavie CJ, Blair SN. Physical activity promotion in the
health care system. Mayo Clin Proc. 2013;88(12):1446-1461.
3. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT;
Lancet Physical Activity Series Working Group. Effect of phys-
ical inactivity on major non-communicable diseases worldwide:
an analysis of burden of disease and life expectancy. Lancet.
2012;380(9838):219-229.
4. Teramoto M, Bungum TJ. Mortality and longevity of elite ath-
letes. J Sci Med Sport. 2010;13(4):410-416.
5. Zaidi A, Sharma S. Reduced mortality in former Tour de France
participants: the benefits from intensive exercise or a select ge-
netic tour de force? Eur Heart J. 2013;34(40):3106-3108.
6. O’Keefe JH, Schnohr P, Lavie CJ. The dose of running that best
confers longevity. Heart. 2013;99(8):588-590.
7. Benito B, Gay-Jordi G, Serrano-Mollar A, et al. Cardiac arrhyth-
mogenic remodeling in a rat model of long-term intensive ex-
ercise training. Circulation. 2011;123(1):13-22.
8. O’Keefe JH, Patil HR, Lavie CJ, Magalski A, Vogel RA,
McCullough PA. Potential adverse cardiovascular effects from
excessive endurance exercise [published correction appears
in Mayo Clin Proc. 2012;87(7):704]. Mayo Clin Proc. 2012;
87(6):587-595.
9. Stroup DF, Berlin JA, Morton SC, et al; Meta-analysis Of Obser-
vational Studies in Epidemiology (MOOSE) Group. Meta-anal-
ysis of observational studies in epidemiology: a proposal for
reporting. JAMA. 2000;283(15):2008-2012.
10. Jüni P, Holenstein F, Sterne J, Bartlett C, Egger M. Direction and
impact of language bias in meta-analyses of controlled trials:
empirical study. Int J Epidemiol. 2002;31(1):115-123.
11. Druzhevskaya AM, Ahmetov II, Astratenkova IV, Rogozkin VA.
Association of the ACTN3 R577X polymorphism with power
athlete status in Russians. Eur J Appl Physiol. 2008;103(6):631-634.
12. Wells GA, Shea B, O’Connell D, et al. Newcastle-Ottawa Scale
(NOS) for assessing the quality of non-randomized studies
in meta-analysis. Countway Library of Medicine website. http://
guides.library.harvard.edu/meta-analysis. Accessed June 3, 2014.
13. Baron SL, Hein MJ, Lehman E, Gersic CM. Body mass index,
playing position, race, and the cardiovascular mortality of
retired professional football players. Am J Cardiol. 2012;
109(6):889-896.
1199

14. Belli S, Vanacore N. Proportionate mortality of Italian soccer
players: is amyotrophic lateral sclerosis an occupational disease?
Eur J Epidemiol. 2005;20(3):237-242.
15. Gajewski AK, Poznanska A. Mortality of top athletes, actors
and clergy in Poland: 1924-2000 follow-up study of the
long term effect of physical activity. Eur J Epidemiol. 2008;
23(5):335-340.
16. Kalist DE, Peng Y. Does education matter? Major League Base-
ball players and longevity. Death Stud. 2007;31(7):653-670.
17. Kujala UM, Tikkanen HO, Sarna S, Pukkala E, Kaprio J,
Koskenvuo M. Disease-specific mortality among elite athletes.
JAMA. 2001;285(1):44-45.
18. Marijon E, Tafflet M, Antero-Jacquemin J, et al. Mortality of
French participants in the Tour de France (1947-2012). Eur
Heart J. 2013;34(40):3145-3150.
19. Menotti A, Amici E, Gambelli GC, et al. Life expectancy in
Italian track and field athletes. Eur J Epidemiol. 1990;6(3):
257-260.
20. Schnohr P. Longevity and causes of death in male athletic
champions. Lancet. 1971;2(7738):1364-1366.
21. Taioli E. All causes of mortality in male professional soccer
players. Eur J Public Health. 2007;17(6):600-604.
22. Waterbor J, Cole P, Delzell E, Andjelkovich D. The mortality
experience of major-league baseball players. N Engl J Med.
1988;318(19):1278-1280.
23. van Saase JL, Noteboom WM, Vandenbroucke JP. Longevity of
men capable of prolonged vigorous physical exercise: a 32 year
follow up of 2259 participants in the Dutch eleven cities ice
skating tour. BMJ. 1990;301(6766):1409-1411.
24. Farahmand BY, Ahlbom A, Ekblom O, et al. Mortality amongst
participants in Vasaloppet: a classical long-distance ski race in
Sweden. J Intern Med. 2003;253(3):276-283.
n n
1200 Mayo Clin Proc. September 2014;89(9):1195-1200
MAYO CLINIC PROCEEDINGS
25. Andersen K, Farahmand B, Ahlbom A, et al. Risk of arrhythmias
in 52 755 long-distance cross-country skiers: a cohort study. Eur
Heart J. 2013;34(47):3624-3631.
26. Jensen-Urstad K, Bouvier F, Saltin B, Jensen-Urstad M. High
prevalence of arrhythmias in elderly male athletes with a life-
long history of regular strenuous exercise. Heart. 1998;79(2):
161-164.
27. Rogers NH, Perfield JW II, Strissel KJ, Obin MS, Greenberg AS.
Loss of ovarian function in mice results in abrogated skeletal
muscle PPARdelta and FoxO1-mediated gene expression.
Biochem Biophys Res Commun. 2010;392(1):1-3.
28. Moore SC, Patel AV, Matthews CE, et al. Leisure time physical
activity of moderate to vigorous intensity and mortality: a large
pooled cohort analysis. PLoS Med. 2012;9(11):e1001335.
29. Ruiz JR, Joyner MJ, Lucia A. Letter by Ruiz et al regarding article,
“Cardiac arrhythmogenic remodeling in a rat model of long-
term intensive exercise training.” Circulation. 2011;124(9):
e250; author reply e251.
30. Lucia A, Earnest C, Arribas C. The Tour de France: a physiolog-
ical review. Scand J Med Sci Sports. 2003;13(5):275-283.
31. Sanchis-Gomar F, Olaso-Gonzalez G, Corella D, Gomez-
Cabrera MC, Vina J. Increased average longevity among the
“Tour de France” cyclists. Int J Sports Med. 2011;32(8):644-647.
32. Sarna S, Sahi T, Koskenvuo M, Kaprio J. Increased life expec-
tancy of world class male athletes. Med Sci Sports Exerc.
1993;25(2):237-244.
33. Kujala UM, Sarna S, Kaprio J. Use of medications and dietary
supplements in later years among male former top-level ath-
letes. Arch Intern Med. 2003;163(9):1064-1068.
34. Fogelholm M, Kaprio J, Sarna S. Healthy lifestyles of former
Finnish world class athletes. Med Sci Sports Exerc. 1994;26(2):
224-229.
http://dx.doi.org/10.1016/j.mayocp.2014.06.004
www.mayoclinicproceedings.org