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Data for this study are from the combined cycles 1 (March 2007 to February 2009) and 2 (August 2009 to November 2011) of the Canadian Health Measures Survey (CHMS). The CHMS covers 96% of the Canadian population aged 6 to 79. It excludes people living on reserves and in other Aboriginal settlements, full-time members of the Canadian Forces, institutionalized individuals, and residents of certain remote areas.^Note8,Note9 Data collection was completed in two steps: an interview at the respondent’s home and a visit to the CHMS mobile examination centre where physical measurements and blood and urine samples were taken.

The overall response rate for both cycles was 53.5% of selected households.^Note10 Ethics approval for the CHMS was obtained from Health Canada’s Research Ethics Board; informed, written consent was obtained from all participants aged 14 or older.^Note11 This study is based on 7,605 respondents aged 15 to 69 (mean age = 40; 47% male, 53% female) for whom various fitness measurements and health outcomes were obtained. This age range was chosen based on the validity of exercise pre-screening and exercise testing protocols.

Cardiorespiratory fitness (modified Canadian Aerobic Fitness Test, mCAFT), flexibility (sit-and-reach), muscle endurance (partial curl-ups) and strength (grip strength) assessments were performed using protocols outlined in the Canadian Physical Activity, Fitness and Lifestyle Approach (CPAFLA) of the Canadian Society for Exercise Physiology (CSEP).^Note12 The CSEP has since published an updated, evidence-based manual that will be used to guide future data collection.^Note4 Test eligibility for the musculoskeletal measures was established based on medication use, the presence of acute and chronic conditions, pregnancy, and failure to adhere to pre-testing guidelines.^Note8,Note10

The CHMS used strict screening criteria for the various fitness tests, particularly, the mCAFT and partial curl-up, in which respondents with high blood pressure or who were taking blood pressure medication or who had had a heart attack did not participate. Consequently, people who participated in some of the fitness tests were inherently healthier than those who did not.

Waist circumference was measured at the highest lateral point of the iliac crest, as described in the National Institutes of Health protocols.^Note13

Composite scores for back fitness and for musculoskeletal fitness were calculated according to the CPAFLA. Waist circumference and partial curl-ups were used for back fitness. Grip strength, sit-and-reach and partial curl-ups were used for musculoskeletal fitness. In the updated CSEP manual, composite scores are no longer used.^Note4

For each respondent, an automated device (BPTru™ BP-300 device, BpTRU Medical Devices Ltd., Coquitlam, British Columbia) recorded a minimum of six blood pressure and heart rate measurements taken at one-minute intervals following a five-minute rest period. Resting averages were then calculated based on the last five of these measurements.

Up to eight trials of a full inspiration followed by a full and forceful expiration through a Koko spirometer (nSpire Health, Inc., 908 Main Street, Louisville, CO 80027 USA) were used to measure lung function. The best forced vital capacity (FVC) and the best forced expiratory volume in one second (FEV₁) from trials meeting the American Thoracic Society standards for within- and between-manoeuvre criteria^Note14 were maintained for each respondent. The FEV₁/FVC ratio was then calculated.

Venous blood samples were collected. Total cholesterol (TC) and high-density lipoprotein (HDL) were measured in serum. The total cholesterol-to-high-density lipoprotein (TC/HDL) ratio was used for analysis. Glycated hemoglobin (HbA1c) was measured in whole blood.

As part of the household interview, respondents were asked to rate their general health (excellent, very good, good, fair or poor) and their level of life satisfaction (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied or very dissatisfied). Those who selected excellent, very good or good for their general health were considered to have a positive view; those who selected very satisfied or satisfied for their level of life satisfaction were categorized as being generally satisfied with their life.

Respondents were asked if they had physician-diagnosed chronic health conditions: arthritis, cardiovascular disease (heart disease or stroke), hypertension, chronic obstructive pulmonary disease, and diabetes.

Respondents were asked what prescription and over-the-counter medications they had taken in the last month.^Note8,Note10 Drug identification numbers were used to find the corresponding code in the Anatomical Therapeutic Chemical (ATC) classification system^Note15 to identify medication use related to each selected health outcome. Reported chronic conditions and medication use were used in conjunction with directly measured values to determine the presence of a chronic condition or health risk:  cardiovascular (self-reported heart disease, hypertension or stroke; medication for blood pressure  or blood lipids; or systolic BP ≥ 130 mmHg or diastolic BP ≥ 85 mmHg); respiratory (self-reported asthma, emphysema, chronic obstructive pulmonary disease, chronic bronchitis; medication for respiratory conditions; or FEV₁/FVC < 70%); metabolic (self-reported diabetes; medication for diabetes; or HbA1c ≥ 7.0%); and musculoskeletal (self-reported arthritis or arthritis medications). A variable was also created to identify respondents who had at least one of these chronic conditions/risks.

Linear regression was used to assess whether higher fitness categories were independently associated with better health outcomes, adjusting first for age group and sex (Table 1), and then for waist circumference (Table 2), which was significantly associated with the exposures (fitness measures) and also with the health outcomes. Finally, t-tests were run to determine differences in adjusted estimates across fitness categories.

The analyses were completed with SAS v9.2 and SUDAAN v10. Results were weighted using the full sample weights for the combined cycle 1 and 2 data. Confidence intervals were calculated with the bootstrap technique. Differences between estimates were based on a reference value of p < 0.005. The combined cycle 1 and 2 CHMS study design requires that 24 degrees of freedom be specified in the software (11 degrees of freedom in cycle 1 plus 13 degrees of freedom in cycle 2).^Note8-10 Differences across fitness categories were not assessed for minimal clinically important differences; these data do not exist for CPAFLA measures.