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Development of Global Reference Standards for Directly Measured Cardiorespiratory Fitness: A Report From the Fitness Registry and Importance of Exercise National Database (FRIEND)

Published:December 26, 2019DOI:



      To begin the process of developing global reference standards for adults from directly measured cardiorespiratory fitness (CRF).


      Percentiles of maximal oxygen consumption (VO 2max) for men and women were determined for each decade from 20 through 79 years of age using International data from the Fitness Registry and Importance of Exercise: A National Database (FRIEND-I) along with previously published data from seven studies. FRIEND-I data from January 1, 2014, through January 1, 2019, included 11,678 maximal treadmill tests from three countries, whereas the previously published reports included 32,329 maximal treadmill tests from six countries.


      FRIEND-I data revealed significant differences between sex and age groups for VO 2max ( P<0.01). For the 20- to 29-years of age group, the 50 th percentile VO 2max in men and women were 49.5 mLO 2⋅kg -1⋅min -1 and 40.6 mLO 2⋅kg -1⋅min -1, respectively. VO 2max declined an average of 9% per decade with the 50 th percentile for the 70- to 79-years of age group having a VO 2max of 30.8 mLO 2⋅kg -1⋅min -1 in men and 25.0 mLO 2⋅kg -1⋅min -1 in women. These results were similar in magnitude and direction to the previously published literature. Within both the FRIEND-I and previously published data there were CRF differences between countries.


      This report begins to establish global reference standards for CRF. Continued development of FRIEND-I will increase global representation providing an improved ability to identify and stratify CRF risk categories.

      Abbbreviations and Acronyms:

      AHA ( American Heart Association), CRF ( cardiorespiratory fitness), CVD ( cardiovascular disease), CPX ( cardiopulmonary exercise testing), FRIEND ( Fitness Registry and the Importance of Exercise: A National Database), FRIEND-I ( International data from the Fitness Registry and the Importance of Exercise: A National Database ), MET ( metabolic equivalent), VO2max ( maximal oxygen consumption)
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        • Imboden M.T.
        • Harber M.P.
        • Whaley M.H.
        • Finch W.H.
        • Bishop D.L.
        • Kaminsky L.A.
        Cardiorespiratory fitness and mortality in healthy men and women.
        J Am Coll Cardiol. 2018; 72: 2283-2292
        • Blair S.N.
        • Kohl 3rd, H.W.
        • Paffenbarger Jr., R.S.
        • Clark D.G.
        • Cooper K.H.
        • Gibbons L.W.
        Physical fitness and all-cause mortality. A prospective study of healthy men and women.
        JAMA. 1989; 262: 2395-2401
        • Wei M.
        • Kampert J.B.
        • Barlow C.E.
        • et al.
        Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men.
        JAMA. 1999; 282: 1547-1553
        • Ozemek C.
        • Laddu D.R.
        • Lavie C.J.
        • et al.
        An update on the role of cardiorespiratory fitness, structured exercise and lifestyle physical activity in preventing cardiovascular disease and health risk.
        Prog Cardiovasc Dis. 2018; 61: 484-490
        • de Lannoy L.
        • Sui X.
        • Lavie C.J.
        • Blair S.N.
        • Ross R.
        Change in submaximal cardiorespiratory fitness and all-cause mortality.
        Mayo Clin Proc. 2018; 93: 184-190
        • Sui X.
        • Ott Jr., J.
        • Becofsky K.
        • et al.
        Cardiorespiratory fitness and all-cause mortality in men with emotional distress.
        Mayo Clin Proc. 2017; 92: 918-924
        • Nauman J.
        • Nes B.M.
        • Lavie C.J.
        • et al.
        Prediction of cardiovascular mortality by estimated cardiorespiratory fitness independent of traditional risk factors: the HUNT study.
        Mayo Clin Proc. 2017; 92: 218-227
        • Pedersen B.K.
        • Saltin B.
        Exercise as medicine — evidence for prescribing exercise as therapy in 26 different chronic diseases.
        Scand J Med Sci Sports. 2015; 25: 1-72
        • Kokkinos P.F.
        • Faselis C.
        • Myers J.
        • et al.
        Cardiorespiratory fitness and incidence of major adverse cardiovascular events in US veterans: a cohort study.
        Mayo Clin Proc. 2017; 92: 39-48
        • Ross R.
        • Blair S.N.
        • Arena R.
        • et al.
        Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.
        Circulation. 2016; 134: e653-e699
        • Kaminsky L.A.
        • Arena R.
        • Beckie T.M.
        • et al.
        The importance of cardiorespiratory fitness in the United States: the need for a national registry: a policy statement from the American Heart Association.
        Circulation. 2013; 127: 652-662
        • Kaminsky L.A.
        • Arena R.
        • Myers J.
        Reference Standards for cardiorespiratory fitness measured with cardiopulmonary exercise testing: data from the Fitness Registry and the Importance of Exercise National Database.
        Mayo Clin Proc. 2015; 90: 1515-1523
        • Kaminsky L.A.
        • Imboden M.T.
        • Arena R.
        • Myers J.
        Reference standards for cardiorespiratory fitness measured with cardiopulmonary exercise testing using cycle ergometry: data from the Fitness Registry and the Importance of Exercise National Database (FRIEND) registry.
        Mayo Clin Proc. 2017; 92: 228-233
        • Loe H.
        • Rognmo O.
        • Saltin B.
        • Wisloff U.
        Aerobic capacity reference data in 3816 healthy men and women 20-90 years.
        PLoS One. 2013; 8: e64319
        • Edvardsen E.
        • Hansen B.H.
        • Holme I.M.
        • Dyrstad S.M.
        • Anderssen S.A.
        Reference values for cardiorespiratory response and fitness on the treadmill in a 20- to 85-year-old population.
        Chest. 2013; 144: 241-248
        • Hakola L.
        • Komulainen P.
        • Hassinen M.
        • et al.
        Cardiorespiratory fitness in aging men and women: the DR's EXTRA study.
        Scand J Med Sci Sports. 2011; 21: 679-687
        • Grigaliuniene A.
        • Ramonas A.
        • Celutkiene J.
        • et al.
        Cardiorespiratory parameters of exercise capacity in a healthy Lithuanian population: the pilot study.
        Hellenic J Cardiol. 2013; 54: 107-118
        • Rossi Neto J.M.
        • Tebexreni A.S.
        • Alves A.N.F.
        • et al.
        Cardiorespiratory fitness data from 18,189 participants who underwent treadmill cardiopulmonary exercise testing in a Brazilian population.
        PLoS One. 2019; 14: e0209897
        • de Souza E.S.C.G.
        • Kaminsky L.A.
        • Arena R.
        • et al.
        A reference equation for maximal aerobic power for treadmill and cycle ergometer exercise testing: Analysis from the FRIEND registry.
        Eur J Prev Cardiol. 2018; 25: 742-750
        • Nauman J.
        • Tauschek L.C.
        • Kaminsky L.A.
        • Nes B.M.
        • Wisloff U.
        Global fitness levels: findings from a web-based surveillance report.
        Prog Cardiovasc Dis. 2017; 60: 78-88
        • Nelson M.D.
        • Petersen S.R.
        • Dlin R.A.
        Effects of age and counseling on the cardiorespiratory response to graded exercise.
        Med Sci Sports Exerc. 2010; 42: 255-264
        • Itoh H.
        • Ajisaka R.
        • Koike A.
        • et al.
        Heart rate and blood pressure response to ramp exercise and exercise capacity in relation to age, gender, and mode of exercise in a healthy population.
        J Cardiol. 2013; 61: 71-78
        • Inbar O.
        • Oren A.
        • Scheinowitz M.
        • Rotstein A.
        • Dlin R.
        • Casaburi R.
        Normal cardiopulmonary responses during incremental exercise in 20- to 70-yr-old men.
        Med Sci Sports Exerc. 1994; 26: 538-546
        • Whaley M.H.
        • Kaminsky L.A.
        • Dwyer G.B.
        • Getchell L.H.
        Failure of predicted VO2peak to discriminate physical fitness in epidemiological studies.
        Med Sci Sports Exerc. 1995; 27: 85-91
        • Myers J.
        • Kaminsky L.A.
        • Lima R.
        • Christle J.W.
        • Ashley E.
        • Arena R.
        A Reference equation for normal standards for VO2 max: analysis from the Fitness Registry and the Importance of Exercise National Database (FRIEND registry).
        Prog Cardiovasc Dis. 2017; 60: 21-29
        • Myers J.
        • Arena R.
        • Franklin B.
        • et al.
        Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association.
        Circulation. 2009; 119: 3144-3161
        • Riebe D.E.J.K.
        • Liguori G.
        • Magal M.
        ACSM’s Guidelines for Exercise Testing and Prescription.
        10th ed. Wolters Kluwer, Philadelphia, PA2018
        • Fitzgerald M.D.
        • Tanaka H.
        • Tran Z.V.
        • Seals D.R.
        Age-related declines in maximal aerobic capacity in regularly exercising vs. sedentary women: a meta-analysis.
        J Appl Physiol (1985). 1997; 83: 160-165
        • Shvartz E.
        • Reibold R.C.
        Aerobic fitness norms for males and females aged 6 to 75 years: a review.
        Aviat Space Environ Med. 1990; 61: 3-11
        • Garber C.E.
        • Blissmer B.
        • Deschenes M.R.
        • et al.
        American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
        Med Sci Sports Exerc. 2011; 43: 1334-1359
        • Guthold R.
        • Stevens G.A.
        • Riley L.M.
        • Bull F.C.
        Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants.
        Lancet Glob Health. 2018; 6: e1077-e1086
        • Kokkinos P.
        • Myers J.
        • Franklin B.
        • Narayan P.
        • Lavie C.J.
        • Faselis C.
        Cardiorespiratory fitness and health outcomes: a call to standardize fitness categories.
        Mayo Clin Proc. 2018; 93: 333-336
        • Myers J.
        • Doom R.
        • King R.
        • et al.
        Association between cardiorespiratory fitness and health care costs: the Veterans Exercise Testing Study.
        Mayo Clinic Proc. 2018; 93: 48-55
        • Mandsager K.
        • Harb S.
        • Cremer P.
        • Phelan D.
        • Nissen S.E.
        • Jaber W.
        Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults Undergoing Exercise Treadmill Testing.
        JAMA Netw Open. 2018; 1: e183605
        • Wang Y.
        • Chen S.
        • Zhang J.
        • et al.
        Nonexercise Estimated Cardiorespiratory Fitness and All-Cancer Mortality: the NHANES III study.
        Mayo Clin Proc. 2018; 93: 848-856
        • McAuley P.A.
        • Keteyian S.J.
        • Brawner C.A.
        • et al.
        Exercise capacity and the obesity paradox in heart failure: the FIT (Henry Ford Exercise Testing) project.
        Mayo Clinic Proc. 2018; 93: 701-708
        • World Health Organization
        Global Status Report on Noncommunicable Diseases 2014.
        World Health Organization, Geneva, Switzerland2014
        • Letnes J.M.
        • Dalen H.
        • Vesterbekkmo E.K.
        • Wisloff U.
        • Nes B.M.
        Peak oxygen uptake and incident coronary heart disease in a healthy population: the HUNT Fitness Study.
        Eur Heart J. 2019; 40: 1633-1639