Artigos

INTRODUCTION
A dichotomous perspective exists between the beneficial effects of physical exercise and the risks of strenuous efforts. Prospective studies have demonstrated that additional increases in exercise, starting from moderate levels i.e., 3600 metabolic equivalents (MET) per minutes/week1 can be beneficial for health and longevity, thus suggesting that the more physical activity practiced, the better these outcomes2. However, other studies have identified a greater cardiac risk related to frequent strenuous efforts3.
Athletes are a select population who may yield insights into the associations between high levels of physical training over time and longevity. In the last two decades, an increasing number of studies have addressed the question of whether elite athletes live longer than the general population4–10. The results from the majority of previous studies4,6–10 confirmed the survival advantage of being an Olympic athlete, regardless of country and sex.
However, it may be premature to make conclusions about the survival advantage of being an Olympic athlete in all countries, since the majority of studies on this topic were conducted with athletes from developed countries5,6. The four reviews on this topic Teramoto and Bungum9, Garatachea et al.6, Lemez; Baker7, and Runacres Mackintosh; Mcnarry8, all included studies that analyzed samples of Olympians from Europe, North America, Oceania, and Asia, such as the USA, France, Italy, Belgium, Norway, Sweden, Finland, New Zealand, the Netherlands, Germany, Japan, Poland, and the UK. As far as we know, no studies have been performed on this topic with athletes from developing countries. Despite being the 12th largest economy in the World in 2020 (according to the Austin Rating), Brazil has a lower socioeconomic profile and life expectancy when compared to countries from Europe and the US11. This could be an important consideration, as studies performed in Brazil may clarify whether the expected advantage of being an Olympian is influenced by the social, economic, geographical, and cultural factors of the country, when compared to developed countries.
On the other hand, it should be noted that lower mortality rates were observed for endurance but not for power athletes in some previous studies7–10, and it is unknown whether this pattern will be observed in Brazilian Olympians, given the important differences in sports training methods and cultures between countries. Therefore, differences in longevity in terms of sport modality remain to be elucidated in developing countries with different socioeconomic and cultural contexts.
Thus, the aims of this study were: (1) to investigate whether former Brazilian Olympic athletes live longer than an age matched sample of the general population; and (2) to describe whether the sport type is related to greater longevity.

METHODS
This is a retrospective cohort study of Brazilian male and female Olympic athletes. We used publicly available data from the Brazilian Olympic Committee (COB) website (https://www.cob.org.br/) to identify all the Brazilian women and men who participated, at least once, in the Summer Olympic Games between 1920 (Antwerp, Belgium) and 1992 (Barcelona, Spain). The sex, dates of birth and death, date(s) of Olympic Games participation, and sports competed in of all the athletes were obtained from both the COB website and the book: “Atletas Olímpicos Brasileiros”12. Athletes with a missing date of birth were excluded from the analyses (Figure 1).

No ethical approval was needed. According to the National Health Council (CNS, acronym in Portuguese), Resolution nº 466/2012 (https://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf), no approval or ethical review by the CEP-CONEP system (Research Ethics Committee - National Research Ethics Commission) was needed as all data are available in the scientific literature and on the COB site. All data were anonymized before use.
(Figure 1 here)
The data from the Brazilian population were obtained from the Brazilian Institute of Geography and Statistics (IBGE) life tables (Supplementary file). In our study the athletes were matched by year of birth and age when they participated in the Summer Olympic Games.
For the sport type comparison, the athletes were categorized into two distinct groups: Strength/Power and Endurance/Mixed. The two types of sports are described in Table 1. A similar criterion has previously been used8, in which Strength and Power (SP) athletes were those from predominantly anaerobic or technical sports; and Endurance and Mixed (EM) athletes were those from continuous or intermittent sports lasting ?10 min.
(Table 1 here)
Data were inserted into an Excel spreadsheet and statistical analyses were performed using R software. As the main interest is the years lived by the athlete (Ti), we defined Ti = Fi?Ni / 365 as the years lived of the i-th athlete (in years), where Ni is the birth date and Fi is the death date for dead athletes; we set Fi = 31/05/2020 for the living athletes, for i = 1, ..., n.
For the analyses, we considered descriptive analysis and an adjusted survival model. In this context, we present the summary measures referring to the athletes’ lifetime using a boxplot. With the aid of the Akaike Information criterion (AIC) selection criteria, in addition to the Kaplan-Meier curve, a model was formulated to adjust the lifetime of the athletes under analysis. Considering the adjusted model, we calculated how much longer an athlete lives in relation to their compatriots.
As the database is composed of the years lived of dead and alive athletes, for the adjustment of the survival model, we assumed that the longevity of living athletes are right-censored observations of type I13, which means that our study had a set number of athletes and ended on 31/05/2020 (i.e., before the death of many athletes had occurred). Additionally, we considered that the years lived (Ti) came from a weibull distribution, which showed the lowest value of the AIC criterion. To estimate the parameters, we considered the maximum likelihood method14.
For comparisons of the life expectancy of Olympic athletes and the general population we present two approaches:
(1) Let Ei be the life expectancy of the population in the year in which the i-th athlete competed in an Olympiad for the first time and Ii the age at which the athlete competed in an Olympiad for the first time, for i = 1, .... n. In this way, we calculated the survival model for the two sport groups, in order to compare the survival of athletes according to the sport they practiced. The log rank test was used to verify the differences in the survival curves between the sport categories
(2) The average lifetime of the athletes (according to their sport category) was compared to the average life expectancy of the age matched general population using t-tests. The alpha level for statistical significance was set at p < 0.05.



RESULTS
A total of 523 (465 men) Olympian athletes were included in this study, among which 167 had died (32%; 159 men, 8 women) and 354 were alive (68%; 306 men) on May, 31th, 2020 (the study end point). Figure 2 presents the boxplot of the lifetime of deceased and alive athletes. Among the deceased athletes, the shortest lifetime recorded was 28 years and the longest was 104 years, with a median lifetime of 73 years, ranging from 50y (1stQuartile) to 82y (3rdQuartile). Among the living athletes, the shortest and longest lifetimes were 46 and 100 years, respectively, with a median lifetime of 65 years, ranging from 57y (1stQuartile) to 80y (3rdQuartile). The median lifetime of dead female athletes was greater than that of male athletes. For living athletes, the median lifetime of male athletes was significantly greater than that of female athletes.
(Figure 2 here)
Figure 3(a) shows the Kaplan-Meier survival models with confidence intervals, while Figure 3(b) shows the survival curves of the Weibull model. There was no difference between the survival of the two groups, according to the log rank test, that is, the estimation indicates a consistently equal survival function between EM and SP athletes.
(Figure 3 here)
The average lifespans of SP and EM athletes were 68.8 and 68.9 years, respectively. However, the life expectancies of the population in the year of their respective competitions were 60.5 and 60.2 years, which shows that SP and EM athletes live 8.38± 2.16 years and 8.82± 1.67 respectively longer than their compatriots, as shown in Figure 4.
(Figure 4 here)
DISCUSSION
This study is the first to investigate longevity among Brazilian athletes. The results suggest that Brazilian Olympic athletes live nearly 8 years longer than the expected lifespan for the age matched general population. Additionally, in our sample, the longevity of SP athletes was not significantly different to that of EM athletes, which differs from previous reports in studies from developed countries.
Our findings confirm previous reports that elite athletes live longer than the general population5,10–13,15. Specifically, two previous studies5,8 provide strong evidence of the greater longevity of Olympic athletes compared to the general population. Clarke et al.5 examined 15,174 Olympic medalists from 9 developed countries and showed that athletes lived ~2.8 years longer than the general population. In a recent meta-analysis including nearly 165,000 former elite athletes of both sexes from different sport types, Runacres et al.8 confirmed the current knowledge, while refuting the ‘J’ shaped hypothesis for vigorous exercise and mortality by showing greater longevity for the athletes when compared to the general population.
To achieve Olympic status, an athlete invests in many years of physical training, thus it is expected that some physiological mechanisms associated with cardiovascular, neuromuscular, and immune systems triggered by systematic vigorous physical exercise can influence physical and psychological health and, consequently, increase longevity by decelerating the aging process16. For instance, maximum oxygen consumption (VO2max) during adulthood has previously been associated with lower mortality rates. This association may be explained by the higher starting point of individuals with higher VO2max values at younger ages, which may lead to greater health and functional capacity when they become older16.
Unfortunately, we were not able to record the cause of death of most of the athletes in the current sample. The reduction in mortality from chronic non-communicable diseases may be the main explanatory factor for the greater longevity of Olympians observed in our study, in accordance with recent findings from 8,124 US athletes17. Antero et al.17 showed that the longevity advantage for US athletes compared to the general population was primarily attributed to the lower risk of death from cardiovascular diseases followed by cancer, respiratory diseases, external causes, endocrine and metabolic diseases, and digestive system diseases. However, mortality rates due to nervous system disorders and mental illnesses were not different from the general population17.
When we consider the epidemiological transition that Brazil experienced in the middle of the 20th century, with important changes in the mortality profile, moving from infectious diseases to non-communicable diseases as the main causes of death18, we can suggest that the deaths in our sample were mainly due to non-communicable diseases and senility, as most Olympians died after 1970.
It is noteworthy that the positive effects of vigorous systematic exercise are reversible after a period of detraining, depending on physiological adaptations, with different rates of decline19. In this regard, little is known about the potential "legacy" effect of systematic vigorous exercise during young adulthood on the morbidity and mortality of athletes after retirement. The majority of studies with longevity as the outcome did not assess lifestyle habits after the end of the athletic career5,9,20, thus, the question on how much exercise and its characteristics before retirement influence athletes’ longevity remains largely unknown, as part of this outcome may be due to positive behavioral facets of lifestyle after retirement.
It has been reported that former athletes who later adopt a sedentary lifestyle present an increased risk of developing chronic diseases, such as diabetes and cardiovascular disease21. On the other hand, former athletes with a physically active lifestyle after retirement have better body composition and a lower risk for cardiovascular disease, metabolic syndrome, and non-alcoholic fatty liver disease22. These findings highlight the impact of an athlete’s post-retirement lifestyle on morbidity and mortality. However, longevity also has other environmental (e.g., access to health services, nutrition, socioeconomic characteristics and wealth) and genetic5 components. Socioeconomic status - measured as a combination of education, income, and occupation - is a well-known factor that may influence human longevity. For former athletes with a higher income for example, medical care and technology accessibility, healthier nutrition, and physical activity facilities are probably more easily available7. Higher socioeconomic status could also expose athletes to a lower risk of violence and homicide17. Despite these “potential” but speculative relationships between socioeconomic status and longevity in athletes, mortality remains lower in athletes compared to controls, even after accounting for socioeconomic status23, highlighting the influence of other factors in longevity. We cannot exclude the hypothesis that our athletes are part of a select group of individuals genetically predisposed to live longer. However, this hypothesis has not been confirmed24. Meanwhile, different to our hypothesis, the expected negative effect of being a citizen of a developing country on the aforementioned environmental factors does not seem to play a role.
Interestingly, there was no statistically significant difference in longevity between the SP and EM groups, which is a different outcome from previous studies5,7–9,25,26. The literature more frequently shows greater longevity for endurance athletes (e.g., marathon runners, cyclists), with gains of 4 to 8 years of lifespan when compared to the general population5,8,22,27. However, other previous evidence17, does not confirm differences between sport types, except for some specific sports (i.e., fencing, shooting) which present a similar risk of death to the general population.
Some explanations for the greater survival of EM athletes have been previously suggested, including more vigorous physical activity levels22,28 a higher proportion of slow-twitch fibers conferring metabolic and cardiovascular protection9,22 and higher aerobic fitness associated with a lower risk of several cardiovascular, inflammatory, and pulmonary diseases and some types of cancer7,9.
Meanwhile, SP athletes tend to have a higher body mass and body mass index (BMI), both factors independently associated with mortality7,25. Furthermore, the use of anabolic steroids is more frequent in SP athletes making them more vulnerable to mental disorders, suicide29, and cardiovascular and liver diseases30. Thus, it could be speculated that, in our sample, some of these factors did not exert their influence.
Alternatively, it is possible that the low number of athletes and the limited statistical power of our study did not allow other comparisons between SP and EM8. Moreover, the differences between studies for sport type classification also deserve consideration. For example, the study by Kujala et al.22 assigned endurance runners and cross country skiers to the “endurance” athlete group; sprinters, weightlifters, and track and field throwers were assigned to the “power/speed” group; while a third group named “other” comprised soccer, ice hockey, basketball players, boxers, wrestlers, and other track and field subdisciplines. Meanwhile, in our study, we grouped endurance and team sport athletes into the EM group, thus including athletes from different sports with diverse aerobic fitness levels. This is an important aspect that should be considered when comparing studies on this topic. We decided to create only two groups with apparently different metabolic demands because of the reduced sample available for comparisons. Of note, we initially assigned volleyball athletes to the EM and later to the SP group because of the reduced levels of intense activity during matches. The non-significant difference between groups was maintained in both analyses, thus confirming the consistency of our criteria.
Interestingly, the study by Lee-Heidenreich et al.25 including the top 20 former male and female Olympic high jumpers, discus throwers, and marathon and 100-m runners showed that life-expectancy of high-jumpers and marathon runners was longer than that of throwers and sprinters, which may be explained by the lower body mass of the first group. These findings suggest that differences in athletes’ longevity may be attributed to factors (e.g., body mass) other than the metabolic profile of the sport. Further studies should verify the relative effect of different facets of physical fitness, including aerobic fitness and body composition.
This is the first study to assess the longevity of Brazilian Olympic athletes. However, some limitations should be highlighted: (1) We were unable to find information about the date of birth of some athletes, and thus, 165 athletes were excluded from our sample, which may have implied less statistical power. However, most previous studies have exhibited similar limitations5,17 although in our study these 165 would represent 23.98% of the total sample. (2) Since socioeconomic characteristics of most Brazilian athletes were not available, we did not control our analysis for these factors. However, as we believe Brazilian Olympians have a similar ethnic and social profile to the general population, we can disregard this potential influence. In contrast, this may represent an important difference with other studies with diverse socioeconomic characteristics of samples from developed countries. (3) Given the low representation of female athletes in this study when compared to previous studies6,8, the analyses were not performed by sex. Assuming that male and female elite athletes share common determinants for greater longevity17, this may not represent a limitation.

CONCLUSION
Brazilian Olympic athletes live about 8 years longer than the general population matched for sex and age. However, there are no differences in longevity between athletes in strength and power sports when compared to those in endurance and mixed sports.

















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