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. 2025 Jul 1;23(1):363.
doi: 10.1186/s12916-025-04175-y.

Cross-national differences in the association between estimated cardiorespiratory fitness and depressive symptoms among older adults: findings from three nationwide cohort studies

Xue He #  1   2 , Cong Li #  2 , GuangYao Hua  3 , Yan Wang  2 , Lijun Zhang #  4   5 , Chingyu Cheng  6 , Jinghua Jiao  7 , Honghua Yu  8 , Xiaohong Yang  9 , Lei Liu  10   11   12   13
Affiliations

Cross-national differences in the association between estimated cardiorespiratory fitness and depressive symptoms among older adults: findings from three nationwide cohort studies

Xue He et al. BMC Med. .

Abstract

Background: Cardiorespiratory fitness (CRF) is a modifiable risk factor for chronic diseases, but its association with depressive symptoms remains unclear, particularly across different populations. We aimed to investigate the link between estimated CRF (eCRF) and incident depressive symptoms among individuals over 50 years old, and to explore potential cross-country variations in this association.

Methods: Data were retrieved from three national cohorts: the Health and Retirement Study (HRS, United States), the English Longitudinal Study of Ageing (ELSA, England), and the China Health and Retirement Longitudinal Study (CHARLS, China). eCRF was estimated using sex-specific algorithms and categorized into low (quintiles 1), moderate (quintiles 2-3), and high (quintiles 4-5) levels. Depressive symptoms were measured using the 8-item Center for Epidemiological Studies Depression Scale (CESD-8) (cutoff ≥ 3) in HRS and ELSA, and the 10-item version (CESD-10) (cutoff ≥ 10) in CHARLS. Cox proportional hazard models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for potential confounders.

Results: This study included 13,680 participants (4195 from HRS, 5421 from ELSA, and 4064 from CHARLS) with median follow-ups of 9.78, 12.11, and 5.73 years, respectively. Depressive symptoms incidence was 22.79% in HRS, 22.15% in ELSA, and 40.58% in CHARLS. Per 1-SD increase in eCRF was associated with 9% lower risk of depressive symptoms in HRS (HR = 0.91; 95% CI, 0.87-0.96), 8% lower in ELSA (HR = 0.92; 95% CI, 0.87-0.97), but 6% higher in CHARLS (HR = 1.06; 95% CI, 1.01-1.16). Compared with the low eCRF level group, high eCRF level was associated with decreased risk of depressive symptoms in HRS (HR = 0.69; 95% CI, 0.55-0.85) and ELSA (HR = 0.62; 95% CI, 0.48-0.79), but increased risk in CHARLS (HR = 1.27; 95% CI, 1.01-1.61). Subgroup analyses revealed that the associations were modified by smoking status (HRS), by gender and presence of diabetes (ELSA), and by the presence of hypertension (CHARLS) (P for interaction < 0.05).

Conclusions: A higher level of eCRF was associated with reduced depressive symptoms risk in the US (HRS) and England (ELSA) older adults but with increased risk in China (CHARLS), emphasizing the need for nation-specific public health strategies.

Keywords: Cardiorespiratory fitness; Depressive symptoms; Nationwide cohort studies; Older adults.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The Health and Retirement Study is sponsored by the National Institute on Aging (grant number NIA U01 AG009740) and is conducted by the University of Michigan (IRB Protocol: HUM00061128 approved through 10/18/2018). Ethical approval for all the English Longitudinal Study of Ageing waves was granted from NHS Research Ethics Committees under the National Research and Ethics Service (NRES): wave 2 and wave 3 received ethical approval from the London Multi-Centre Research Ethics Committee on 12 th August 2004 (MREC/04/2/006) and 27 th October 2005 (05/MRE02/63); wave 4 received ethical approval from the National Hospital for Neurology and Neurosurgery & Institute of Neurology Joint Research Ethics Committee on 12 th October 2007 (07/H0716/48); wave 5 received ethical approval from the Berkshire Research Ethics Committee on 21 st December 2009 (09/H0505/124); wave 6 and wave 7 received ethical approval from the NRES Committee South Central—Berkshire on 28 th November 2012 (11/SC/0374) and 28 th November 2013 (13/SC/0532); wave 8 and wave 9 received ethical approval from the South Central – Berkshire Research Ethics Committee on 23rd September 2015 (15/SC/0526) and 10 th May 2018 (17/SC/0588). The China Health and Retirement Longitudinal Study was approved by the Biomedical Ethics Review Committee of Peking University (IRB00001052-14010). All participants provided written consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
The flowchart of study participants
Fig. 2
Fig. 2
Restricted cubic spline analyses for the association of eCRF with the risk of depressive symptoms. Abbreviations: HRS, Health and Retirement Study; ELSA, English Longitudinal Study of Ageing; CHARLS, China Health and Retirement Longitudinal Study; e-CRF, estimated cardiorespiratory fitness; HR, hazard ratio; CI, confidence interval. The model adjusted age, sex, marital status, educational level, smoking status, drinking status, systolic blood pressure, glycated haemoglobin, and total cholesterol
Fig. 3
Fig. 3
Subgroup analyses on the association of eCRF with the risk of depressive symptoms. Abbreviations: HRS, Health and Retirement Study; ELSA, English Longitudinal Study of Ageing; CHARLS, China Health and Retirement Longitudinal Study; e-CRF, estimated cardiorespiratory fitness; BMI, body mass index; HR, hazard ratio; CI, confidence interval. The model adjusted age, sex, marital status, educational level, smoking status, drinking status, systolic blood pressure, glycated haemoglobin, and total cholesterol
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