Editorials
thinks about the balance of sedentary
behaviour and activity in all aspects of
daily life, including transport, occupa-
tional settings, domestic work and leisure,
especially around obesity management
and the role of total physical activity in
the prevention of further weight gain.
This involves some re-orienting of the
physical activity and health field from its
well-established focus on LTPA to a
comprehensive programme of research to
understand the determinants of sedentary
behaviour and both LIPA and MVPA. It
will also involve studying the effects on
health outcomes of shifting the balance of
these behaviours towards more activity in
all domains of daily life.
CLINICAL IMPLICATIONS
Given the recent recognition of this
phenomenon of too much sitting, there
are not yet any recommended clinical
guidelines. Commonsense might suggest
that it may be prudent to try to minimise
prolonged sitting with 5 minute breaks
every hour. However, more specific advice
will require dose-response relationships
between sitting and health outcomes to
be defined using controlled studies. Many
of the possible interventions that encou-
rage movement may well be undertaken
in settings in which prolonged periods of
sedentary behaviours are the norm.
CONCLUSIONS
Research, policy and practice on physical
activity and population health has
focussed largely on increasing the time
that adults spend doing moderate to
vigorous intensity activities; 30 minutes
a day is generally the target. However,
recent evidence from biomarker studies
and objective-measurement studies (and
also from some prospective epidemiologi-
cal studies) highlights the importance of
focusing on the balance of light-intensity
activities and sedentary behaviours—par-
ticularly the high volumes of time that
Is the measurement of maximal
oxygen intake passé?
Roy J Shephard
A recent and controversial review1 sug-
gests that the measurement of maximal
Correspondence to: Roy J Shephard, PO Box 521,
Brackendale, Canada BC V0N 1H0; royjshep@shaw.ca
Br J Sports Med February 2009 Vol 43 No 2
adults in industrialised and developing
countries spend sitting in their 15.5 ‘‘non-
exercise’’ waking hours. A particular con-
cern for this new research agenda is how
to approach reducing or breaking-up
prolonged sitting time, and how this
might relate to increasing light intensity
and moderate to vigorous intensity phy-
sical activities. Other research opportu-
nities include carrying out studies on how
best to promote higher volumes of overall
physical activity (light intensity activities
in addition to moderate to vigorous
intensity activities), in the context of the
ubiquitous environmental and social dri-
vers of sitting time in occupational,
transportation, recreational and domestic
settings.
Particular concerns for exercise science
research agenda include identifying why
sedentary behaviour and the associated
health relationships seem to be particu-
larly strong for women and examining the
effects of interventions for reducing or
breaking-up sitting time. The issue of too
much sitting has challenging implications
for future healthcare practice and will
require development of new kinds of
clinical and public health guidelines.18
Funding: NO, AB WB are supported by NHMRC
Program Grant funding (#301200); NO is also supported
by a Queensland Health Core Research Infrastructure
grant.
Competing interests: None.
Accepted 24 October 2008
Published Online First 28 November 2008
Br J Sports Med 2009;43:81–83.
doi:10.1136/bjsm.2008.055269
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1. Daar AS, Singer PA, Persad DL, et al. Grand
challenges in chronic non-communicable diseases.
Nature 2007;450:494–6.
2. Bauman A, Bellew B, Vita P, et al. Getting Australia
active: Best practice for the promotion of physical
activity. Melbourne: National Public Health
Partnership, 2002.
3. Bauman A, Allman-Farinelli M, Huxley R, et al.
Leisure-time physical activity alone may not be a
oxygen intake is passé. The author con-
cludes (p. 554) ‘‘It is now time to develop
novel testing methods....That the measured
VO2max is a relatively poor predictor of both
the performance potential of athletes with
sufficient public health approach to prevent obesity—
a focus on China. Obes Rev 2008;9:119–26.
4. Healy GN, Dunstan DW, Salmon J, et al. Objectively
measured light-intensity physical activity is
independently associated with 2-h plasma glucose.
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5. Anderssen SA, Engeland A, Sogaard AJ, et al.
Changes in physical activity behavior and the
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6. Levine JA. Nonexercise activity thermogenesis—
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exercise and too much sitting: Inactivity physiology
and the need for new recommendations on sedentary
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2008;2:292–8.
similar athletic ability and of the changes in
performance that occur with continued train-
ing should encourage both basic and applied
sports scientists to reconsider the real value of
this iconic test.’’
A number of the arguments that are
advanced in this review seem to need
correction or refutation. Specifically, this
riposte will examine whether a maximal
treadmill test is an unrealistic procedure for
athletes, whether a unimodal approach to
testing is appropriate in sports medicine,
and whether an alternative laboratory test
83
 Editorials
will be developed to categorise the perfor-
mance of individual athletes. Comments
will also be made on the place of maximal
oxygen intake assessment in various areas
of science, sports medicine and clinical
medicine.
IS THE MAXIMAL TREADMILL TEST AN
UNREALISTIC PROCEDURE FOR
ATHLETES?
Noakes argues1 that the treadmill test is
an unrealistic approach to the testing of
athletes for three reasons: the duration of
the exercise is not known to the subject,
there is a steep and progressive increase in
the intensity of exercise, and the person
who is tested has no control over the
ultimate intensity of effort. All of these
criticisms may be true of the test protocol
used in some laboratories. However, the
standard recommendation is for a tread-
mill test lasting 9–11 minutes, and this
should be explained to the subject. The
appropriate treadmill slope and speed
should be ascertained by preliminary
submaximal testing; this allows the defi-
nitive test to commence close to maximal
steady-state effort, thereby avoiding a
steep ramp of intensity. Moreover, the
maximal value can be determined by
carrying out a series of tests on successive
days, although the values obtained in this
manner do not differ materially from those
seen with an appropriately conducted
continuous test protocol.2 Finally, proto-
cols are available that allow the subject to
regulate the speed of the treadmill himself
or herself as the test proceeds.
There are thus ways of dealing with the
problems cited by Noakes. However, there
remain some important differences
between a laboratory treadmill test and
athletic performance that Noakes does
not discuss. Most treadmills cannot
match the speed of short-distance run-
ners. While on a treadmill, an athlete does
not encounter wind resistance3 and can-
not profit from ‘‘drafting’’.4 Few labora-
tories simulate radiant heating or cooling
by cross-winds, and the running surface
of the treadmill differs substantially from
the usual track. However, these various
limitations apply only to laboratory mea-
surements, and do not negate the value of
maximal oxygen intake testing, since it is
quite practicable to measure oxygen con-
sumption when an athlete is running on a
standard track.5
Other factors affecting athletic perfor-
mance include an appropriate choice of
tactics (including selection of clothing),
motivation of the individual, and the
mechanical efficiency of movement. No
laboratory test seems likely to evaluate
84
tactical skills. The motivating power of
the observer is important to the reaching
of an oxygen consumption ‘‘plateau’’, and
laboratories that have difficulty in
demonstrating this phenomenon6 prob-
ably need to upgrade their motivational
skills. Mechanical efficiency can be esti-
mated roughly from treadmill data,
although other forms of ergometer pro-
vide more precise values.7
IS A UNIMODAL APPROACH TO TESTING
APPROPRIATE?
Another puzzling feature of the recent
review1 is the apparent assumption that
everyone will be tested on a treadmill. The
International Working Party that standar-
dised procedures for the measurement of
maximal oxygen intake suggested that
three possible modes of testing were suita-
ble for ordinary, non-athletic individuals,
based on a treadmill, a double step and a
cycle ergometer.8 In non-athletic indivi-
duals, the largest values were obtained on
the treadmill; step test readings were on
average 4 per cent smaller, and cycle
ergometer values 7 per cent smaller.
Intermodal differences in maximal oxy-
gen intake are thought to reflect the
differing proportions of the total muscle
mass that are used in the different
protocols9; intermodal differences are
much larger in athletes who have trained
one particular group of muscles. For
athletes, it is thus critical to select a test
modality that allows use of the muscles
engaged in their chosen sport; for a
cyclist, the natural choice would be a
cycle ergometer or a racing bicycle
mounted on rollers,10 for the oarsperson
a rowing ergometer or the collection of
gas samples during actual rowing,11 for the
cross-country skier a skiing ergometer or
uphill skiing,12 and for the swimmer a
flume or the collection of gas samples
during swimming in a pool.13 14 Plainly, for
many categories of athlete, the treadmill
is an inappropriate test modality.
CAN LABORATORY TESTS OFFER A
USEFUL PREDICTION OF ATHLETIC
ABILITY?
Given the various constraints noted
above, it seems unlikely that any labora-
tory test can be devised that will categor-
ise athletes of similar ability with useful
accuracy. Rather, athletes should be
ranked based on the actual performances
achieved over several recent competitions.
Here, tactics, motivation and mechanical
efficiency all come into play, and the
mode of exercise is entirely natural.
Moreover, individual performances can
be determined to a small fraction of a
second. This compares very favourably
with the laboratory treadmill, since even
careful determinations of maximal oxy-
gen intake have an experimental error of
2–4 per cent, and superimposed upon this
is an intraindividual biological variation of
10–20 per cent.15
WHAT ARE APPROPRIATE USES OF
MAXIMAL OXYGEN INTAKE
DETERMINATION?
Maximal oxygen intake tests are of little
help in ranking athletes of similar ability.
However, this does not imply that such
measurements are passé. On the contrary,
the testing of maximal oxygen intake has
many appropriate and important applica-
tions. This concluding section highlights
just a few such applications, in integrative
biology, sports medicine, doping control,
epidemiology and clinical medicine.
Integrative biology
Analysis of the oxygen conductance equa-
tion under conditions of maximal aerobic
effort16 provides helpful insights into the
factors limiting various types of physical
performance.9 In activities that involve
large muscle groups, oxygen transport is
determined almost entirely by maximal
cardiac output, and, taken together with
determinations of heart rate, the measure-
ment of maximal oxygen intake offers a
useful method of examining cardiac
stroke volume during maximal aerobic
exercise. If the external work is measured,
the mechanical efficiency of various types
of activity can also be determined.7
Sports medicine
Grouped data on the maximal oxygen
intake of top competitors provide insights
into the extent of aerobic demands in
various forms of sport.17 Comparisons of
the grouped physiological profile with the
individual’s personal data may suggest
how large an emphasis the individual
should place upon enhancing his or her
aerobic power. Careful records of an
individual’s maximal oxygen intake are
also helpful in evaluating the extent of
any deterioration in aerobic function
following injury or overtraining, and in
monitoring the recovery of aerobic func-
tion following such episodes.18
Doping control
A variety of drugs19 and manipulations such
as blood transfusions20 can induce small
increments of maximal oxygen intake
that have an important influence on the
outcome of endurance competitions.
Br J Sports Med February 2009 Vol 43 No 2

Measurements of maximal oxygen intake
under carefully controlled double-blind
trials are thus important in distinguishing
medications that are acceptable (for
instance, certain drugs used in the treat-
ment of bronchospasm induced by exercise
or cold) from those which would give
athletes an unfair advantage.
Epidemiology
It is widely agreed that the majority of
the population in developed countries
currently takes insufficient physical activ-
ity, with adverse consequences for many
facets of health.21 Nevertheless, the deter-
mination of the physical activity of a
population, whether by questionnaire or
by use of accelerometers, is unreliable, and
the mass testing of maximal oxygen
intake provides a helpful alternative
approach when assessing the extent of
endurance activity within a population.2
Maximal oxygen intake data can also be
used to demonstrate secular trends in
habitual physical activity; for instance,
repeated measurements in a Canadian
circumpolar community have shown a
progressive decrease of maximal oxygen
intake as the community has adopted the
sedentary lifestyle typical of their peers in
southern Canada.22
Clinical medicine
In many clinical situations, the oxygen
intake is limited by warning symptoms or
signs before a ‘‘plateau’’ is reached. The
value thus reported is termed the peak
rather than the maximal oxygen intake.
The peak aerobic power provides a useful
indication of prognosis in patients with
various types of cardiac disorder.23 Such
Br J Sports Med February 2009 Vol 43 No 2
observations also provide an optimal basis
for the setting of a safe and effective
intensity of training in programmes of
cardiac rehabilitation.24 Clinical informa-
tion can be derived from the extent of ST
depression at various fractions of an
individual’s maximal oxygen intake.25
Finally, determinations of maximal oxy-
gen intake are helpful in gauging recovery
following bed rest, injury, and exposure to
zero gravity environments.
Competing interests: None.
Accepted 7 August 2008
Published Online First 21 August 2008
Br J Sports Med 2009;43:83–85.
doi:10.1136/bjsm.2008.052506
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85