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Tesis Doctoral Europea / European Doctoral Thesis
EVALUACIN DE LA FUERZA MUSCULAR Y LA
CAPACIDAD AERBICA EN ADOLESCENTES
ASPECTOS METODOLGICOS Y RELACIN CON LA SALUD
MUSCULAR AND CARDIORESPIRATORY FITNESS
ASSESSMENT IN ADOLESCENTS
METHODOLOGICAL ISSUES AND HEALTH IMPLICATIONS
DEPARTAMENTO DE FISIOLOGA
FACULTAD DE MEDICINA
UNIVERSIDAD DE GRANADA
ENRIQUE GARCA ARTERO
2010
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Editor: Editorial de la Universidad de GranadaAutor: Enrique Garca ArteroD.L.: GR 2686-2010ISBN: 978-84-693-2017-4
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A mis padres, mi hermano y toda mi familia
To my parents, my brother and my whole family
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DEPARTAMENTO DE FISIOLOGA
FACULTAD DE MEDICINA
UNIVERSIDAD DE GRANADA
EVALUACIN DE LA FUERZA MUSCULAR Y LA CAPACIDAD
AERBICA EN ADOLESCENTES
ASPECTOS METODOLGICOS Y RELACIN CON LA SALUD
MUSCULAR AND CARDIORESPIRATORY FITNESS
ASSESSMENT IN ADOLESCENTS METHODOLOGICAL ISSUES AND HEALTH IMPLICATIONS
ENRIQUE GARCA ARTERO
Directores de Tesis [Thesis Supervisors]
Manuel J. Castillo Garzn Stefaan De Henauw Francisco B. Ortega Porcel MD, PhD MD, PhD PhD Catedrtico de Universidad Senior Lecturer Investigador Posdoctoral Universidad de Granada Ghent University, Belgium Universidad de Granada Miembros del Tribunal [Members of the Jury]
Jos A. Lpez Calbet Pekka Oja Alejandro Luca Mulas MD, PhD PhD MD, PhD Catedrtico de Universidad UKK Institute for Health Catedrtico de Universidad Universidad de Las Palmas Promotion Research Universidad Europea de Madrid de Gran Canaria Tampere, Finland Esteban Gorostiaga Ayestarn Jess Rodrguez Huertas PhD PhD Centro de Estudios, Investigacin Profesor Titular de Universidad y Medicina del Deporte Universidad de Granada Gobierno de Navarra
Granada, 15 de enero de 2010
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Prof. Dr. Manuel J. CASTILLO GARZON
Catedrtico de Universidad ---
Departamento de Fisiologa FACULTAD DE MEDICINA
Universidad de Granada
MANUEL J. CASTILLO GARZN, CATEDRTICO DE FISIOLOGA MDICA EN LA FACULTAD DE MEDICINA DE LA UNIVERSIDAD DE GRANADA
CERTIFICA:
Que la Tesis Doctoral titulada Evaluacin de la fuerza muscular y la capacidad aerbica en
adolescentes. Aspectos metodolgicos y relacin con la salud que presenta D. ENRIQUE
GARCA ARTERO al superior juicio del Tribunal que designe la Universidad de Granada,
ha sido realizada bajo mi direccin durante los aos 2005-2010, siendo expresin de la
capacidad tcnica e interpretativa de su autor en condiciones tan aventajadas que le hacen
merecedor del Ttulo de Doctor, siempre y cuando as lo considere el citado Tribunal.
Fdo. Manuel J. Castillo Garzn
En Granada, 5 de diciembre de 2009
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Prof. Dr. Stefaan DE HENAUW
Senior Lecturer ---
Department of Public Health UNIVERSITY HOSPITAL
Ghent University
STEFAAN DE HENAUW, SENIOR LECTURER IN THE DEPARTMENT OF PUBLIC HEALTH, GHENT UNIVERSITY, BELGIUM
CERTIFY:
That the Doctoral Thesis entitled Muscular and cardiorespiratory fitness assessment in
adolescents. Methodological issues and health implications presented by ENRIQUE
GARCA ARTERO has been done under my tutelage from 2005 to 2010. This Doctoral
Thesis proves that the PhD candidate has gained expertise through the process in both the
field work as well as reporting data in a scientific manner. Therefore, I firmly believe that
Enrique Garca Artero is an excellent candidate for a PhD award.
Stefaan De Henauw
In Ghent, Belgium, December 5th 2009
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Dr. Francisco B. ORTEGA PORCEL
Investigador Post-Doctoral ---
Departamento de Fisiologa FACULTAD DE MEDICINA
Universidad de Granada
FRANCISCO B. ORTEGA PORCEL, INVESTIGADOR POSDOCTORAL DEL MINISTERIO DE CIENCIA E INNOVACIN
CERTIFICA:
Que la Tesis Doctoral titulada Evaluacin de la fuerza muscular y la capacidad aerbica en
adolescentes. Aspectos metodolgicos y relacin con la salud que presenta D. ENRIQUE
GARCA ARTERO al superior juicio del Tribunal que designe la Universidad de Granada,
ha sido realizada bajo mi direccin durante los aos 2005-2010, siendo expresin de la
capacidad tcnica e interpretativa de su autor en condiciones tan aventajadas que le hacen
merecedor del Ttulo de Doctor, siempre y cuando as lo considere el citado Tribunal.
Fdo. Francisco B. Ortega Porcel
En Granada, 5 de Diciembre de 2009
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CONTENIDOS [CONTENTS]
Proyectos de Investigacin [Research Projects].. 8
Becas y Financiacin [Grants and Funding].... 9
Lista de publicaciones [List of Publications]... 10
Resumen [Summary].... 11
Abreviaturas [Abbreviations]....... 19
Introduccin [Introduction].. 23
Bibliografa [References]..... 27
Objetivos [Aims]...... 33
Material y Mtodos [Material and Methods]....... 35
Resultados y Discusin [Results and Discussion]... 41
1. Aspectos metodolgicos en la evaluacin de la condicin fsica [Methodological
issues of fitness assessment]
1.1 Validez [Criterion-related validity] (Artculos I y II)..... 43
1.2 Fiabilidad [Reliability] (Artculos III y IV).......... 119
2. Condicin fsica y salud [Physical fitness and health]
2.1 Factores de riesgo cardiovascular [Cardiovascular disease risk factors]
(Artculo V)...... 177
2.2 Composicin corporal [Body composition] (Artculo VI) 199
2.3 Determinantes tempranos de la condicin fsica [Early determinants of
physical fitness] (Artculo VII).... 215
Conclusiones [Conclusions]....... 245
Anexo [Annex]... 247
Curriculum Vitae abreviado [Short CV].... 253
Agradecimientos [Acknowledgements]. 257
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PROYECTOS DE INVESTIGACIN [RESEARCH PROJECTS]
El trabajo desarrollado y los artculos que componen la presente memoria de Tesis Doctoral
estn basados en los siguientes proyectos de investigacin:
Estudio AVENA (Alimentacin y Valoracin del Estado Nutricional de los
Adolescentes Espaoles). Proyecto Nacional multicntrico financiado por el
Instituto de Salud Carlos III con Fondos de Investigacin Sanitaria, Ministerio de
Sanidad y Consumo (n 00/0015), y por varias empresas privadas: Panrico S.A.,
Madaus S.A., y Procter and Gamble S.A.
Pgina web: www.estudioavena.com
Estudio HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence).
Proyecto financiado por la Unin Europea: European Union Sixth RTD Framework
Programme (Contract FOOD-CT-2005-007034).
Pgina web: www.helenastudy.com
Estudio ALPHA (Assessing Levels of Physical Activity and Fitness). Proyecto
financiado por la Unin Europea: Public Health Executive Agency, DG SANCO,
Health Information Strand (Ref. 2006120).
Pgina web: www.thealphaproject.eu
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BECAS Y FINANCIACIN [GRANTS AND FUNDING]
La presente memoria de Tesis Doctoral ha sido posible tambin gracias a las siguientes
subvenciones:
Beca de Iniciacin a la Investigacin. Vicerrectorado de Poltica Cientfica e
Investigacin, Universidad de Granada. Departamento de Fisiologa, Facultad de
Medicina.
Ayudas a Grupos de Investigacin de la Junta de Andaluca. Grupo de Investigacin en
Evaluacin Funcional y Fisiologa del Ejercicio CTS 262. Universidad de Granada.
Beca de Formacin de Profesorado Universitario (FPU) del Ministerio de Educacin
y Ciencia (AP2005-4358). Departamento de Fisiologa, Facultad de Medicina,
Universidad de Granada.
Ayudas para estancias breves del Programa Nacional de Formacin de Profesorado
Universitario:
Departamento de Salud Pblica, Universidad de Gante, Blgica (agosto -
diciembre 2008).
Departamento de Ciencias del Ejercicio, Centro de Investigacin en Salud
Pblica, Universidad de Carolina del Sur, EEUU (septiembre - diciembre 2009).
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LISTA DE PUBLICACIONES [LIST OF PUBLICATIONS]
La presente memoria de Tesis Doctoral est compuesta por los siguientes artculos cientficos:
I. Castro-Piero J, Artero EG, Espaa-Romero V, Ortega FB, Sjstrm M, Suni J, Ruiz JR. Criterion-related validity of field-based fitness tests in youth: A systematic review. Br J Sports Med 2009 Apr 12. [Epub ahead of print]
II. Artero EG, Espaa-Romero V, Castro-Piero J, Ruiz JR, Jimnez-Pavn D, Aparicio VA, Gatto-Cardia MC, Baena PA, Vicente-Rodrguez G, Castillo MJ, Ortega FB. Criterion-related validity of field-based muscular fitness tests in youth. Submitted.
III. Artero EG, Espaa-Romero V, Castro-Piero J, Ortega FB, Suni J, Castillo MJ, Ruiz JR. Reliability of field-based fitness tests in youth: A systematic review. Revised version submitted to J Sports Sci.
IV. Ortega FB, Artero EG, Ruiz JR, Vicente-Rodrguez G, Bergman P, Hagstrmer M, Ottevaere C, Nagy E, Konsta O, Rey-Lpez JP, Polito A, Dietrich S, Plada M, Beghin L, Manios Y, Sjstrom M, Castillo MJ, on behalf of the Helena Study Group. Reliability of health-related physical fitness tests in European adolescents. The HELENA Study. Int J Obes (London) 2008; 32(5): s49-s57.
V. Garca-Artero E, Ortega FB, Ruiz JR, Mesa JL, Delgado M, Gonzlez-Gross M, Garca-Fuentes M, Vicente-Rodrguez G, Gutirrez A, Castillo MJ. [Lipid and metabolic profiles in adolescents are affected more by physical fitness than by physical activity (AVENA Study)]. Rev Esp Cardiol 2007; 60 (6): 581-8.
VI. Artero EG, Espaa-Romero V, Ortega FB, Jimnez-Pavn D, Ruiz JR, Vicente-Rodrguez G, Bueno M, Marcos A, Gmez-Martnez S, Urzanqui A, Gonzlez-Gross M, Moreno LA, Gutirrez A, Castillo MJ. Health-related fitness in adolescents: underweight, and not only overweight, as an influencing factor. The AVENA Study. Scand J Med Sci Sports 2009 Jun 23. [Epub ahead of print]
VII. Artero EG, Ortega FB, Espaa-Romero V, Labayen I, Huybrechts I, Papadaki A, Rodrguez G, Mauro B, Widhalm K, Kersting M, Manios Y, Molnar D, Moreno LA, Sjstrm M, Gottrand F, Castillo MJ, De Henauw S, on behalf of the HELENA study group. Longer breastfeeding duration is associated with increased lower body muscular fitness in adolescence. The HELENA Study. Submitted.
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RESUMEN
En personas adultas, el nivel de condicin fsica se considera hoy da un importante
predictor de morbilidad y mortalidad tanto general como cardiovascular. La evidencia
cientfica ms reciente indica adems que el nivel de condicin fsica puede ser considerado
un potente indicador de salud tambin en la infancia y adolescencia. Sin embargo, no existe
an consenso sobre la metodologa a emplear para su evaluacin, lo cual dificulta la
identificacin de aquellos jvenes que presentan un bajo nivel de condicin fsica y, por tanto,
un mayor riesgo de enfermedad.
La presente memoria de Tesis Doctoral tiene como objetivo analizar aspectos
metodolgicos relacionados con la evaluacin de la condicin fsica en adolescentes, as
como estudiar la relacin entre el nivel de condicin fsica (especialmente fuerza muscular y
capacidad aerbica) y diversos parmetros de salud en estas edades.
Los trabajos que componen esta memoria de Tesis Doctoral estn basados en datos
procedentes de los proyectos AVENA, HELENA y ALPHA. Un total de 2474 adolescentes
espaoles de cinco ciudades diferentes, 2567 adolescentes de nueve pases europeos, y una
muestra adicional de 126 adolescentes de la provincia de Granada, han sido analizados en esta
investigacin.
Los principales resultados de este trabajo indican que: a) el test de 20m de ida y
vuelta, la fuerza de prensin manual, el salto en longitud con pies juntos, el ndice de masa
corporal, el permetro de cintura y los pliegues cutneos son los test ms vlidos y fiables para
evaluar la capacidad aerbica, la fuerza muscular y la composicin corporal en nios y
adolescentes. b) Tanto la capacidad aerbica como la fuerza muscular se asocian de manera
independiente con factores de riesgo cardiovascular en adolescentes. c) No slo el sobrepeso
y la obesidad sino tambin un bajo peso corporal afectan al nivel de condicin fsica de los
adolescentes. d) Un perodo de lactancia materna de mayor duracin podra estar asociado con
una mayor capacidad muscular del tren inferior durante la adolescencia.
La presente memoria de Tesis Doctoral propone una batera de test vlida y fiable para
evaluar la condicin fsica en nios y adolescentes. Adems, aporta nuevas perspectivas sobre
la relacin entre el nivel de condicin fsica y diversos parmetros de salud durante la
adolescencia.
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Qu se sabe en este mbito? Qu aade esta Tesis Doctoral?
Existen diversas bateras de test para evaluar la
condicin fsica en nios y adolescentes.
Validez y fiabilidad son dos aspectos
fundamentales en cualquier instrumento de
medida. La validez de un test se define por la
capacidad del mismo para evaluar aquello para
lo que ha sido diseado. Sin embargo, el test
no ser apropiado si no es adems lo
suficientemente fiable.
Una propuesta de batera de condicin fsica
vlida y fiable, compuesta por los siguientes
test:
Test de 20m ida y vuelta para la capacidad
aerbica; fuerza de prensin manual y salto en
longitud con pies juntos para la fuerza
muscular; e ndice de masa corporal, permetro
de cintura y pliegues cutneos para la
composicin corporal.
La actividad fsica, la capacidad aerbica y la
fuerza muscular se han asociado con factores
de riesgo cardiovascular durante la
adolescencia. Sin embargo, en pocas ocasiones
se ha analizado de manera conjunta la
influencia independiente de esos parmetros.
La capacidad aerbica y la fuerza muscular se
asocian de manera independiente con factores
de riesgo cardiovascular, mientras que la
actividad fsica evaluada mediante
cuestionario podra no estar asociada con
dichos factores.
La condicin fsica de los adolescentes con
sobrepeso ha sido objeto de estudio en
numerosas ocasiones. Sin embargo, se ha
prestado una menor atencin a aquellos
adolescentes con bajo peso corporal y se
desconoce el efecto particular de la masa grasa
y la masa libre de grasa.
Aquellos adolescentes con un bajo peso
corporal presentan menos masa libre de grasa
y menos fuerza de prensin manual.
En adolescentes con sobrepeso y obesidad, el
exceso de masa grasa supone un menor
rendimiento en aquellos test que requieren
transportar o mantener la masa corporal.
Se ha sugerido que la lactancia materna no
influye sobre la capacidad aerbica que el
recin nacido pueda tener aos ms tarde. Sin
embargo, se desconoce la posible influencia
sobre otros componentes de la condicin fsica.
Una lactancia materna de mayor duracin
podra asociarse con un incremento en la
fuerza muscular del tren inferior durante la
adolescencia.
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SUMMARY
In adults, physical fitness is nowadays considered a strong predictor of cardiovascular
disease and all-cause morbidity and mortality. The increasing evidence during the last years
suggests that physical fitness can also be considered as a powerful marker of health already at
childhood and adolescence. However, there is still no comparable testing methodology agreed
upon internationally, which hinders the identification of young people with a low fitness level
and, therefore, at risk for future disease.
In this context, the overall aim of this PhD Thesis was to analyze methodological
issues of physical fitness assessment during adolescence, as well as to study the relation of
fitness level (especially muscular and cardiorespiratory fitness) with several health indicators
at these ages.
The current PhD Thesis is based on data from three multicentre research projects:
AVENA, HELENA and ALPHA studies. A total of 2474 Spanish adolescents from five
different cities, 2567 adolescents from nine European countries, and an additional sample of
126 adolescents from Granada, were involved in the present work.
The main findings and conclusions were: a) 20m shuttle run test, handgrip strength,
standing broad jump, body mass index, waist circumference and skinfold thickness are the
most valid and reliable field tests to measure cardiorespiratory fitness, muscular fitness and
body composition in children and adolescents. b) Both cardiorespiratory and muscular fitness
are independently associated with cardiovascular disease risk factors in adolescents. c) Not
only overweight and obesity but also underweight seem to be determinants of physical fitness
level in adolescents. d) Longer breastfeeding duration could be associated with increased
lower body muscular fitness during adolescence.
The present PhD Thesis formulates an evidence-based proposal of a valid and reliable
test battery to measure physical fitness in children and adolescents. Furthermore, it highlights
novel associations between physical fitness and several health indicators during the
adolescence.
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What is already known on this topic? What does this PhD Thesis add?
Numerous test batteries have been developed
to assess fitness in children and adolescents.
Validity and reliability are two characteristics
that need to be considered in any measurement
tool. Criterion-related validity refers to the
extent to which a field test correlates with the
criterion measure. However the test will never
be appropriate if it is not adequately reliable.
A valid and reliable health-related fitness test
battery is proposed:
20m shuttle run test to measure
cardiorespiratory fitness; handgrip strength
and standing broad jump for muscular fitness;
and body mass index, waist circumference and
skinfold thickness to estimate body
composition.
Physical activity, cardiorespiratory fitness and
muscular fitness have been associated with
cardiovascular disease risk factors during
adolescence. However, the independent
influence of each parameter has been rarely
analyzed.
Cardiorespiratory and muscular fitness are
independently associated with cardiovascular
disease risk factors, while self-reported
physical activity could not be associated.
The fitness levels of overweight and obese
adolescents have been widely analyzed.
However, underweight youths have received
less attention and the influence of fat mass and
fat-free mass remains unclear.
Underweight adolescents present lower fat-
free mass and handgrip strength.
In overweight and obese adolescents, excess
body fat determines a lower performance in
tests that require propulsion or lifting of body
mass.
A lack of association between breastfeeding
duration and later cardiorespiratory fitness has
been suggested, but there is no evidence
regarding other fitness components.
Longer breastfeeding duration may be
associated with an increased lower body
muscular fitness during adolescence.
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ABREVIATURAS [ABBREVIATIONS]
AAUTB Amateur Athletic Union Test Battery
ABA Abalakov jump
AFEA Australian Fitness Education Award. The Australian Council
for Health, Education and Recreation
ALPHA Assessing Levels of Physical Activity and Fitness
ANCOVA Analysis of covariance
ANN Artificial neural network
ANOVA Analysis of variance
AVENA Alimentacin y Valoracin del Estado Nutricional de los
Adolescentes [Feeding and assessment of nutritional status of
Spanish adolescents]
BIA Bioelectrical impedance analysis
BMI Body mass index
CAHPER-FPT II Canadian Association for Health, Physical Education and
Recreation. Fitness Performance Test II
CI Confidence interval
CMJ Countermovement jump
CPAFLA Canadian Physical Activity, Fitness & Lifestyle Approach.
Canadian Society for Exercise Physiology
CV Coefficient of variation
DT Desviacin tpica
DXA Dual-energy X-ray absorptiometry
E Error
EUROFIT Council of Europe Committee for the Development of Sport
FFM Fat-free mass
FITNESSGRAM Fitness program for children
FM Fat mass
HC Hip circumference
HDL-c High density lipoprotein cholesterol [Colesterol unido a
lipoprotena de alta densidad]
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HELENA Healthy Lifestyle in Europe by Nutrition in Adolescence
HRFT Health-Related Fitness Test. American Association for Health,
Physical Education, and Recreation
IAAT Intra-abdominal adipose tissue
ICC Intraclass correlation coefficient
IFG ndice de fuerza general [GSI: General Strength Index]
IOTF International obesity task force
IPFT International Physical Fitness Test. United States Sports
Academic / General Organization of Youth and Sport of
Bahrain
LDL-c Low density lipoprotein cholesterol [Colesterol unido a
lipoprotena de baja densidad]
MET Metabolic equivalents
MSE Mean squared error
NFTP-PRC National Fitness Test Program in the Popular Republic China.
Chinas National Sport and Physical Education Committee
NSCA National Strength and Conditioning Association
NYPFP National Youth Physical Program. The United States Marines
Youth Foundation
NZFT New Zealand Fitness Test. Rusell/Department of Education
PCHF Presidents Challenge: Health Fitness. American Association
for Health, Physical Education, and Recreation
PCPF Presidents Challenge: Physical Fitness. American Association
for Health, Physical Education, and Recreation
RMSE Root mean squared error
ROC Receiver operating characteristics
SAAT Subcutaneous adipose tissue
SD Standard deviation
SE Standard error
SEE Standard error of estimate
SEM Standard error of the measure
SJ Squat jump
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SLJ Standing long jump
SPSS Statistical package for the social sciences
SSE Sum of squared errors
TE Total error
TEM Technical error of measurement
VO2max Maximal oxygen consumption
VO2peak Peak oxygen consumption
WC Waist circumference
WHR Waist-to-hip ratio
YMCAYFT YMCA Youth Fitness Test
% BF Percentage body fat
1RM 1 repetition maximum
4x10m SRT 4 x 10 meters shuttle run test
20m-SRT 20 meters shuttle run test
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INTRODUCCIN [INTRODUCTION]
Physical activity, physical exercise and physical fitness are different but inter-related
concepts. Physical activity refers to any bodily movement produced by skeletal muscles that
results in energy expenditure [1]. Exercise is a subcategory of physical activity that refers to
planned, structured, repetitive, and purposeful physical activity; and physical fitness is
considered an integrated measurement of all functions (skeletomuscular, cardiorespiratory,
hematocirculatory, psychoneurological, and endocrine-metabolic) and structures involved in
the performance of physical activity and/or physical exercise [2]. In other words, physical
activity and exercise are related to the movements that people perform, while physical fitness
is a set of attributes that people have or achieve [1].
Physical fitness is typically defined with focus on two goals: performance or health.
Performance-related fitness refers to those components of fitness that are necessary for
optimal work or sports performance [3]. This is defined in terms of the individuals ability in
athletic competition, a performance test or occupational work. Health-related physical fitness
is considered as the ability to perform daily activities with vigour and without undue fatigue,
as well as traits and capacities that are associated with a low risk of chronic diseases and
premature death [1]. The present PhD Thesis focuses on health-related physical fitness in
young people.
Methodological issues of fitness assessment in children and adolescents
In recent years, the interest in physical fitness assessment in young people has
increased. Within the paediatric population, physical fitness can be objectively and accurately
measured through different laboratory methods, such as treadmill test [4], cycle ergometer
[5], isokinetic dynamometry [6] or 1 repetition maximum [7]. However, these tests are not
feasible for field use due to the high costs, necessity of sophisticated instruments, qualified
technicians, and time constraints.
Field tests are commonly used in population based-studies, especially in the school
setting. During the last two decades numerous field-based test batteries have been developed
to assess fitness in children and adolescents [8-12]. However, validity and reliability are two
characteristics that need to be considered in any measurement tool [13]. Validity refers to the
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ability of the test to reflect what it is designed to measure. Field-based fitness measurement
depends on the prediction techniques, and thus is prone to error. Criterion-related validity
refers to the extent to which a field test correlates with a criterion measure [14]. Nevertheless,
the test will never be appropriate if it is not adequately consistent in whatever value it
indicates from repeated measurements [15]. Reliability refers to the reproducibility of values
of a test in repeated trials on the same individual/s. In other words, an individual doing a test
on two occasions under the same conditions and close proximity in time should obtain similar
results [16]. In spite of the increased scientific interest on physical fitness assessment in
young people, there is a substantial lack of consensus in designing and reporting validity and
reliability studies. Ideally, comparable testing methodology has to be developed, tested and
agreed upon internationally.
Physical fitness and health in young people
In recent years, an increasing amount of research on physical fitness and health in
adolescence has been published. Adolescence is a crucial period of life, since dramatic
physiological and psychological changes take place at these ages. Likewise, lifestyle and
healthy/unhealthy behaviours are established during these years, which may influence adult
behaviour and health status [17].
Cardiovascular disease risk factors
Although the clinical manifestations of cardiovascular disease normally appear in
middle adulthood, their pathogenic origin is likely to have ocurred in adolescence and even
childhood [18-20]. High cardiorespiratory fitness during childhood and adolescence has
been associated with a healthier cardiovascular profile during these years [21, 22]. Negative
associations between cardiorespiratory fitness and features of the metabolic syndrome have
been reported in children [23] and adolescents [21, 24]. Furthermore, increased
cardiorespiratory fitness has been associated with a favourable metabolic profile in both
overweight and non-overweight adolescents [21, 25]. Interestingly, cardiorespiratory fitness
levels during childhood and adolescence can be considered a powerful marker of health not
only during these ages, but throughout life. Several prospective studies have reported that low
cardiorespiratory fitness during childhood and adolescence is a predictor of abnormal blood
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lipids, high blood pressure, excess of overall and central adiposity, metabolic syndrome, and
arterial stiffness later in life [26].
Cardiorespiratory fitness is a direct marker of physiological status and reflects the
overall capacity of the cardiovascular and respiratory systems to supply oxygen to the tissues
during sustained physical activity [27]. This is the main reason why cardiorespiratory fitness
is considered one of the most important health markers. Cardiorespiratory fitness,
cardiovascular fitness, cardiorespiratory endurance, aerobic fitness, aerobic capacity, aerobic
power, maximal aerobic power, aerobic work capacity, physical work capacity, and VO2max
are used interchangeably in the literature.
In addition to cardiorespiratory fitness, muscular fitness is emerging as an important
marker of health throughout life [28]. During childhood and adolescence, muscular fitness
level has been inversely associated with cardiovascular disease risk factors such as insulin
sensitivity [29], inflammatory proteins [30] and traits of the metabolic syndrome [31].
Muscular fitness improvements from childhood to adolescence are negatively associated with
changes in overall and central adiposity, systolic blood pressure, blood lipids and lipoproteins
[26]. Healthy functioning of the musculoskeletal system requires that a specific muscle or
muscle group to be able to generate maximum force or torque (measured as muscular
strength); to resist repeated contractions over time or to maintain a maximal voluntary
contraction for a prolonged period of time (measured as muscular endurance); and to carry out
a maximal, dynamic contraction of a single muscle or muscle group in a short period of time
(measured as explosive strength, also called power) [1].
As health-related physical fitness reflects an overall physiological status, the different
components are generally correlated with each other in a given person [32]. It is therefore
necessary to better understand the independent association of cardiorespiratory and muscular
fitness with cardiovascular disease risk factors.
Body composition
Together with cardiorespiratory and muscular fitness, body composition is another
key concept that merits special attention. It relates to the relative amount of muscle, fat, bone
and other vital parts of the body, and has been traditionally considered a health indicator
given the relevance of obesity-associated comorbidities such as type 2 diabetes, hypertension
or dyslipidemia [33]. However, body composition is also considered another component of
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health-related physical fitness, also called morphological fitness [34]. Cardiorespiratory
fitness, muscular fitness and body composition are so strongly linked to each other that
whenever possible they should be analyzed together in relation to health status. Several
studies have examined the fitness level of overweight and obese adolescents, reporting a
decrease in fitness with increasing body mass index [32, 35-40]. In contrast, physical fitness
in underweight youths has been by far less studied [32], and the particular influence of fat
mass and fat-free mass remains unclear [41].
Early determinants of physical fitness
Given the public health importance of physical fitness, it is necessary to gain a better
understanding of what determines a persons fitness level. Non-modifiable factors such as
genetics, gender and age greatly influence physical fitness [42, 43]. Nonetheless, there is little
doubt that environmental factors also play an important role. Physical activity is a major
determinant of physical fitness [44], and different types of physical exercise programs have
been shown to successfully improve cardiorespiratory and muscular fitness in children and
adolescents [45, 46].
Nevertheless, not only current but also early characteristics and behaviours can
influence the child or adolescent fitness level. Both physical fitness and body composition
during adolescence seem to be influenced by perinatal factors such as birth weight [47-49] or
breastfeeding [50]. Birth weight has been associated with handgrip strength [47], fat mass and
fat-free mass [49] in adolescents. The association of breastfeeding with body composition
throughout life has been widely studied, but the relationship is not yet fully understood [51].
On the other hand, there is little evidence examining the role of breastfeeding in later physical
fitness [52]. A lack of association between breastfeeding duration and cardiorespiratory
fitness during childhood has been reported [52], but there is no evidence regarding other
fitness components.
Based on the aforementioned evidence, the present PhD Thesis provides new insights
on field-based physical fitness assessment in adolescents and the association with health at
these ages.
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12. Chinas National Sports and Physical Education Committee. The national fitness
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13. Currell K. and Jeukendrup A.E. Validity, reliability and sensitivity of measures of
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17. Gonzalez-Gross M., Castillo M.J., Moreno L., et al. [Feeding and assessment of
nutritional status of Spanish adolescents (AVENA study). Evaluation of risks and
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18. Berenson G.S., Srinivasan S.R., Bao W., Newman W.P., 3rd, Tracy R.E., and
Wattigney W.A. Association between multiple cardiovascular risk factors and
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1998; 338(23): 1650-6.
19. Strong J.P., Malcom G.T., Mcmahan C.A., et al. Prevalence and extent of
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727-35.
20. Srinivasan S.R. and Berenson G.S. Childhood lipoprotein profiles and implications for
adult coronary artery disease: the Bogalusa Heart Study. Am J Med Sci 1995; 310
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21. Mesa J.L., Ruiz J.R., Ortega F.B., et al. Aerobic physical fitness in relation to blood
lipids and fasting glycaemia in adolescents: influence of weight status. Nutr Metab
Cardiovasc Dis 2006; 16(4): 285-93.
22. Mesa J.L., Ortega F.B., Ruiz J.R., et al. The importance of cardiorespiratory fitness for
healthy metabolic traits in children and adolescents: the AVENA Study [notification].
Journal of Public Health 2006; 14(3): 178-80.
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23. Ruiz J.R., Ortega F.B., Meusel D., Harro M., Oja P., and Sjstrm M.
Cardiorespiratory fitness is associated with features of metabolic risk factors in
children. Should cardiorespiratory fitness be assessed in a European health monitoring
system? The European Youth Heart Study. J Public Health 2006; 14(2): 94-102.
24. Gonzalez-Gross M., Ruiz J.R., Moreno L.A., et al. Body composition and physical
performance of Spanish adolescents: the AVENA pilot study. Acta Diabetologica
2003; 40 Suppl 1: S299-301.
25. Klasson-Heggebo L., Andersen L.B., Wennlof A.H., et al. Graded associations
between cardiorespiratory fitness, fatness, and blood pressure in children and
adolescents. Br J Sports Med 2006; 40(1): 25-9.
26. Ruiz J.R., Castro-Pinero J., Artero E.G., et al. Predictive Validity of Health-Related
Fitness in Youth: A Systematic Review. Br J Sports Med 2009: In press.
27. Taylor H.L., Buskirk E., and Henschel A. Maximal oxygen intake as an objective
measure of cardio-respiratory performance. J Appl Physiol 1955; 8(1): 73-80.
28. Wolfe R.R. The underappreciated role of muscle in health and disease. Am J Clin Nutr
2006; 84(3): 475-82.
29. Benson A.C., Torode M.E., and Singh M.A. Muscular strength and cardiorespiratory
fitness is associated with higher insulin sensitivity in children and adolescents. Int J
Pediatr Obes 2006; 1(4): 222-31.
30. Ruiz J.R., Ortega F.B., Warnberg J., et al. Inflammatory proteins and muscle strength
in adolescents: the Avena study. Arch Pediatr Adolesc Med 2008; 162(5): 462-8.
31. Steene-Johannessen J., Anderssen S.A., Kolle E., and Andersen L.B. Low muscle
fitness is associated with metabolic risk in youth. Med Sci Sports Exerc 2009; 41(7):
1361-7.
32. Huang Y.C. and Malina R.M. BMI and health-related physical fitness in Taiwanese
youth 9-18 years. Med Sci Sports Exerc 2007; 39(4): 701-8.
33. Lawrence V.J. and Kopelman P.G. Medical consequences of obesity. Clin Dermatol
2004; 22(4): 296-302.
34. Bouchard C., Blair S.N., and Haskell W.L. Why study physical activity and health?, in
Physical activity and health, C. Bouchard, S.N. Blair, and W.L. Haskell, Editors.
2007, Human Kinetics Books: Champaign, IL. p. 3-22.
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35. Deforche B., Lefevre J., De Bourdeaudhuij I., Hills A.P., Duquet W., and Bouckaert J.
Physical fitness and physical activity in obese and nonobese Flemish youth. Obes Res
2003; 11(3): 434-41.
36. Prista A., Maia J.A., Damasceno A., and Beunen G. Anthropometric indicators of
nutritional status: implications for fitness, activity, and health in school-age children
and adolescents from Maputo, Mozambique. Am J Clin Nutr 2003; 77(4): 952-9.
37. Graf C., Koch B., Kretschmann-Kandel E., et al. Correlation between BMI, leisure
habits and motor abilities in childhood (CHILT-project). Int J Obes Relat Metab
Disord 2004; 28(1): 22-6.
38. Kim J., Must A., Fitzmaurice G.M., et al. Relationship of physical fitness to
prevalence and incidence of overweight among schoolchildren. Obes Res 2005; 13(7):
1246-54.
39. Brunet M., Chaput J.P., and Tremblay A. The association between low physical fitness
and high body mass index or waist circumference is increasing with age in children:
the 'Quebec en Forme' Project. Int J Obes (Lond) 2007; 31(4): 637-43.
40. Fogelholm M., Stigman S., Huisman T., and Metsamuuronen J. Physical fitness in
adolescents with normal weight and overweight. Scand J Med Sci Sports 2008; 18(2):
162-70.
41. Ekelund U., Franks P.W., Wareham N.J., and Aman J. Oxygen uptakes adjusted for
body composition in normal-weight and obese adolescents. Obes Res 2004; 12(3):
513-20.
42. Bray M.S., Hagberg J.M., Perusse L., et al. The human gene map for performance and
health-related fitness phenotypes: the 2006-2007 update. Med Sci Sports Exerc 2009;
41(1): 35-73.
43. Bouchard C., Blair S.N., and Haskell W.L. Physical Activity and health, ed. H.
Kinetics. 2007, Champaign, IL.
44. Ortega F.B., Ruiz J.R., Hurtig-Wennlof A., and Sjostrom M. [Physically active
adolescents are more likely to have a healthier cardiovascular fitness level
independently of their adiposity status. The European youth heart study]. Rev Esp
Cardiol 2008; 61(2): 123-9.
45. Baquet G., Van Praagh E., and Berthoin S. Endurance training and aerobic fitness in
young people. Sports Med 2003; 33(15): 1127-43.
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46. Faigenbaum A.D., Kraemer W.J., Blimkie C.J., et al. Youth resistance training:
updated position statement paper from the national strength and conditioning
association. J Strength Cond Res 2009; 23(5 Suppl): S60-79.
47. Ortega F.B., Labayen I., Ruiz J.R., et al. Are muscular and cardiovascular fitness
partially programmed at birth? Role of body composition. J Pediatr 2009; 154(1): 61-
6 e1.
48. Labayen I., Moreno L.A., Blay M.G., et al. Early programming of body composition
and fat distribution in adolescents. J Nutr 2006; 136(1): 147-52.
49. Ortega F.B., Ruiz J.R., Labayen I., et al. High fitness is associated with a healthier
programming of body composition at adolescence. Am J Hum Biol 2008; 20(6): 732-4.
50. Arenz S., Ruckerl R., Koletzko B., and Von Kries R. Breast-feeding and childhood
obesity-a systematic review. Int J Obes Relat Metab Disord 2004; 28(10): 1247-56.
51. Cope M.B. and Allison D.B. Critical review of the World Health Organization's
(WHO) 2007 report on 'evidence of the long-term effects of breastfeeding: systematic
reviews and meta-analysis' with respect to obesity. Obes Rev 2008; 9(6): 594-605.
52. Lawlor D.A., Cooper A.R., Bain C., et al. Associations of birth size and duration of
breast feeding with cardiorespiratory fitness in childhood: findings from the Avon
Longitudinal Study of Parents and Children (ALSPAC). Eur J Epidemiol 2008; 23(6):
411-22.
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OBJETIVOS
General:
El objetivo general de esta Tesis Doctoral ha sido analizar aspectos metodolgicos
relacionados con la evaluacin de la condicin fsica en adolescentes, as como estudiar la
relacin entre el nivel de condicin fsica (especialmente fuerza muscular y capacidad
aerbica) y diversos parmetros de salud en estas edades.
Especficos:
Analizar la validez y fiabilidad de los test de campo existentes para evaluar la condicin fsica en nios y adolescentes (Artculos I a IV).
Estudiar de manera conjunta la influencia de la actividad fsica, la capacidad aerbica y la fuerza muscular sobre factores de riesgo cardiovascular en
adolescentes (Artculo V).
Analizar el nivel de condicin fsica de los adolescentes en funcin de la categora de peso corporal (Artculo VI).
Estudiar la relacin entre la duracin de la lactancia materna y el posterior nivel de condicin fsica durante la adolescencia (Artculo VII).
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AIMS
Overall:
The overall aim of this PhD Thesis was to analyze methodological issues of physical fitness
assessment during adolescence, as well as to study the relation of fitness level (especially
muscular and cardiorespiratory fitness) with several health indicators at these ages.
Specific:
To analyze the validity and reliability of the existing field-based fitness tests used in children and adolescents (Papers I to IV).
To examine the independent associations of physical activity, cardiorespiratory fitness and muscular fitness with cardiovascular disease risk factors in adolescents
(Paper V).
To analyze the physical fitness levels of adolescents according to their weight status (Paper VI).
To examine the association between breastfeeding duration in early life and later physical fitness during adolescence (Paper VII).
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MATERIAL Y MTODOS [MATERIAL AND METHODS]
The current PhD Thesis is based on data from the AVENA, HELENA and ALPHA
studies. A copy of the abstract of the methodological paper for each study is provided. In
addition, the most relevant methodological information for papers I to VII has been
summarized in Table 1.
Alimentacin y valoracin del estado nutricional de los adolescentes espaoles (Estudio AVENA). Evaluacin de riesgos y propuesta de intervencin. I. Descripcin metodolgica del proyecto [Feeding and assessment of nutritional status of Spanish adolescents (AVENA study). Evaluation of risks and interventional proposal. I. Methodology].
Gonzlez-Gross M, Castillo MJ, Moreno L, Nova E, Gonzlez-Lamuo D, Prez-Llamas F, Gutirrez A, Garaulet M, Joyanes M, Leiva A, Marcos A. Nutr Hosp 2003; 18(1): 15-28.
BACKGROUND: Adolescence is a decisive period in human life due to the multiple physiological and psychological changes that take place. These changes will condition both nutritional requirements and eating/physical activity behavior. It has been demonstrated that these "adolescence" factors are of significant influence in health status during adult life. Due to its importance and adequate development the project has been granted by the Fondo de Investigacin Sanitaria of the Institute of Health Carlos III.
OBJECTIVE: To develop a methodology to evaluate the health and nutritional status of a representative population of Spanish adolescents. Specific attention is paid to three specific health problems: obesity, anorexia nervosa/bulimia, dislipidemia.
METHODOLOGY: The following magnitudes will be studied: 1) dietary intake, food habits and nutrition knowledge; 2) daily physical activity and personal approach; 3) physical condition; 4) anthropometry and body composition; 5) hematobiochemical study: plasma lipid phenotypic and metabolic profile, blood cell counts; 6) genotipic profile of cardiovascular risk lipid factors; 7) immune function profile related to nutritional status; 8) psychological profile.
CONCLUSION: This project includes the co-ordinate activity of five Spanish centers of five different cities (Granada, Madrid, Murcia, Santander, Zaragoza). Each center is specialized in a specific area and will be responsible for the corresponding part of the study. From the data obtained, we will elaborate a specific intervention program in order to improve nutrition and neutralize the risk for nutritional related problems in adolescence. By this, we will contribute to improve the health status of the Spanish population in the new millennium.
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Design and implementation of the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Cross-Sectional Study. LA Moreno, S De Henauw, M Gonzlez-Gross, M Kersting, D Molnr, F Gottrand, L Barrios, M Sjstrm, Y Manios, CC Gilbert, C Leclercq, K Widhalm, A Kafatos and A Marcos, on behalf of the HELENA Study Group. Int J Obes (Lond) 2008; 32 Suppl 5: S4-11.
OBJECTIVE: To provide an overview of the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) design, with particular attention to its quality control procedures. Other important methodological aspects are described in detail throughout this supplement.
DESIGN: Description of the HELENA-CSS sampling and recruitment approaches, standardization and harmonization processes, data collection and analysis strategies and quality control activities.
RESULTS: The HELENA-CSS is a multi-centre collaborative study conducted in European adolescents located in urban settings. The data management systems, quality assurance monitoring activities, standardized manuals of operating procedures and training and study management are addressed in this paper. Various quality controls to ensure collection of valid and reliable data will be discussed in this supplement, as well as quantitative estimates of measurement error.
CONCLUSION: The great advantage of the HELENA-CSS is the strict standardization of the fieldwork and the blood analyses, which precludes to a great extent the kind of immeasurable confounding bias that often interferes when comparing results from isolated studies.
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Assessing Levels of Physical Activity in the European Population the ALPHA Project. D. Meusel, J.R. Ruiz, F.B. Ortega, M. Hagstrmer, P Bergman, M. Sjstrm. Seleccin 2007; 16 (1): 9-12.
Although our understanding of the positive relationship between physical activity and health is increasing daily, our knowledge of the patterns and levels of physical activity in the general population is still poor. This is due to the gap in comparable data, resulting from non-standardised instruments.
The project ALPHA is being initialized to develop and find consensus for a comprehensive set of assessment methodology for physical activity levels in European Member States and their underlying key factors. These methodologies include: physical activity questionnaire, accelerometry, Geographical Information Systems data, and health-related fitness tests.
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Table 1. Summary table of the methodology used in the current PhD Thesis.
Project Paper Study design Participants Main variables studied Methods
ALPHA I. Criterion-related validity of field-based fitness tests in youth: A systematic review
Review Children and adolescents
Cardiorespiratory fitness, muscular fitness, motor fitness and body composition
Systematic review and comprehensive description of the main findings
HELENA,
ALPHA
II. Criterion-related validity of field-based muscular fitness tests in youth
Cross-sectional : 74 : 52 Age: 12-18 y
Muscular fitness, body weight and fat-free mass
Isokinetic dynamometry. Handgrip strength, bent arm hang, extended arm hang, standing broad jump, Bosco jumps (SJ, CMJ, ABA). Standard anthropometric procedure
ALPHA III. Reliability of field-based fitness tests in youth: A systematic review
Review Children and adolescents
Cardiorespiratory fitness, muscular fitness, motor fitness and body composition
Systematic review and comprehensive description of the main findings
HELENA IV. Reliability of health-related fitness tests in European adolescents
Cross-sectional : 69 : 54 Age: 12-14 y
Cardiorespiratory fitness, muscular fitness and motor fitness
20m SRT, handgrip strength, standing broad jump, Bosco jumps (SJ, CMJ, ABA), bent arm hang, 4x10m SRT, back-saver sit and reach
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European PhD Thesis
Table 1 (cont). Summary table of the methodology used in the current PhD Thesis.
Project Paper Study design Participants Main variables studied Methods
AVENA V. Lipid and metabolic profiles in adolescents are affected more by physical fitness than by physical activity
Cross-sectional : 248 : 212 Age: 13-18.5 y
Cardiorespiratory fitness, muscular fitness, physical activity, triglycerids, LDL-cholesterol, HDL-cholesterol and glucose
20m SRT, handgrip strength, standing broad jump, bent arm hang. Physical activity questionnaire. Blood sampling
AVENA VI. Health-related fitness in adolescence: underweight, and not only overweight, as an influencing factor
Cross-sectional : 1,196 : 1,278 Age: 13-18.5 y
Weight status, fat mass, fat-free mass, cardiorespiratory fitness, muscular fitness and motor fitness
Standard anthropometric procedure. 20m SRT, handgrip strength, standing broad jump, bent arm hang, 4x10m SRT, sit and reach
HELENA VII. Longer breastfeeding duration is associated with increased lower body muscular fitness in adolescence
Cross-sectional : 1,141 : 1,426 Age: 12.5-17.5 y
Breastfeeding duration, cardiorespiratory fitness, muscular fitness, birth weight, fat mass, fat-free mass, height and maternal education
Parental questionnaire. 20mSRT, handgrip strength, standing broad jump. Standard anthropometric procedure
ABA: Abalakov jump; ALPHA: Assessing Levels of Physical Activity and Fitness; AVENA: Alimentacin y Valoracin del Estado Nutricional
de los Adolescentes; CMJ: countermovement jump; HDL: high-density lipoprotein; HELENA: Healthy Lifestyle in Europe by Nutrition in
Adolescence; LDL: low-density lipoprotein; SJ: squat jump; SRT: shuttle run test. SRT: shuttle run test; boys; girls.
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RESULTADOS Y DISCUSIN [RESULTS AND DISCUSSION]
The results and discussion of the present PhD Thesis are shown as a compilation of
scientific papers. They are enclosed in the form they have been published or submitted.
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1. METHODOLOGICAL ISSUES OF FITNESS ASSESSMENT
1.1. CRITERION-RELATED VALIDITY
(Papers I and II)
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45
Qu se sabe en este mbito? Qu aaden estos estudios?
Existen diversas bateras de test para evaluar la
condicin fsica en nios y adolescentes.
Como consecuencia, para algunos
componentes de la condicin fsica existen ms
de 10 posibles pruebas diferentes.
La validez de un test se define por la capacidad
del mismo para evaluar aquello para lo que ha
sido diseado.
El test de 20 m de ida y vuelta es un test
vlido para evaluar la capacidad aerbica.
La fuerza de prensin manual y el salto en
longitud con pies juntos son test vlidos para
evaluar la fuerza muscular.
Los pliegues cutneos (trceps y subescapular)
y el ndice de masa corporal son estimadores
vlidos de la composicin corporal, mientras
que el permetro de cintura es una medida
vlida para estimar la adiposidad central.
What is already known on this topic? What do these studies add?
Numerous test batteries have been developed
to assess fitness in children and adolescents.
As a consequence, there are more than 10
different tests available for some fitness
dimensions.
Criterion-related validity refers to the extent to
which a field test correlates with the criterion
measure.
The 20m shuttle run is a valid test to measure
cardiorespiratory fitness.
Handgrip strength and standing broad jump
are valid tests to measure muscular fitness.
Skinfold thickness (triceps and subscapular)
and body mass index are valid estimates of
body composition, while waist circumference
is a valid measure to estimate central body fat.
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47
I
CRITERION-RELATED VALIDITY OF FIELD-BASED FITNESS
TESTS IN YOUTH: A SYSTEMATIC REVIEW
Castro-Piero J, Artero EG, Espaa-Romero V, Ortega FB,
Sjstrm M, Suni J, Ruiz JR
Br J Sports Med 2009 Apr 12 [Epub ahead of print]
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Criterion-related validity of field-based fitness tests inyouth: a systematic review
J Castro-Pinero,1 E G Artero,2 V Espana-Romero,2,3 F B Ortega,2,3 M Sjostrom,3 J Suni,4
J R Ruiz3
c Additional data(Supplementary information) arepublished online only at http://bjsm.bmj.com/content/volXX/issueX
1 Department of PhysicalEducation, School of Education,University of Cadiz, Puerto Real,Spain; 2 Department ofPhysiology, School of Medicine,University of Granada, Granada,Spain; 3 Department ofBiosciences and Nutrition atNOVUM, Unit for PreventiveNutrition, Karolinska Institutet,Huddinge, Sweden; 4 UKKInstitute for Health PromotionResearch, Tampere, Finland
Correspondence to:J R Ruiz, Department ofBiosciences and Nutrition, Unitfor Preventive Nutrition,NOVUM, 14157, Huddinge,Sweden; [email protected]
Accepted 2 April 2009Published Online First12 April 2009
ABSTRACTThe objective of this systematic review was tocomprehensively study the criterion-related validity of theexisting field-based fitness tests used in children andadolescents. The studies were scored according to thenumber of subjects, description of the study populationand statistical analysis. Each study was classified as high,low and very low quality. Three levels of evidence wereconstructed: strong evidence, when consistent findingswere observed in three or more high quality studies;moderate evidence, when consistent findings wereobserved in two high quality studies; and limited evidencewhen consistency of findings and/or the number ofstudies did not achieve the criteria for moderate. Theresults of 73 studies (50 of high quality) addressing thecriterion-related validity of field-based fitness tests inchildren and adolescents indicate the following: that thereis strong evidence indicating that the 20 m shuttle runtest is a valid test to estimate cardiorespiratory fitness,that the hand-grip strength test is a valid measure ofmusculoskeletal fitness, that skin fold thickness and bodymass index are good estimates of body composition, andthat waist circumference is a valid measure to estimatecentral body fat. Moderate evidence was found that the1-mile run/walk test is a valid test to estimate cardior-espiratory fitness. A large number of other field-basedfitness tests presented limited evidence, mainly due to alimited number of studies (one for each test). The results ofthe present systematic review should be interpreted withcaution due to the substantial lack of consistency inreporting and designing the existing validity studies.
Physical fitness refers to the full range of physicalqualities (ie, cardiorespiratory fitness, muscularstrength, agility, coordination and flexibility).1 Itcan be understood as an integrated measurementof all functions (skeletomuscular, cardiorespira-tory, haematocirculatory, psychoneurological andendocrine/metabolic) and structures involved inthe performance of physical activity and/or physi-cal exercise.2 Physical fitness, especially cardiore-spiratory fitness and muscular strength, isconsidered an important marker of health inadults,3 4 as well as in young people.5 6
Physical fitness can be objectively and accuratelymeasured through laboratory tests. However, dueto their high cost, necessity for sophisticatedinstruments and qualified technicians, and timeconstraints, their use is limited in school settingsand in population-based studies. Field-based testsprovide a reasonable alternative since they aretime-efficient, low in cost and equipment require-ments and can be easily administered to a largenumber of people simultaneously.
Field-based fitness assessment depends on theprediction techniques, and thus is prone to error. Inorder for a test or a fitness test battery to beconsidered good, it should measure what it issupposed to measure (ie, validity).7 Criterion-related validity refers to the extent to which afield test of a fitness component correlates with thecriterion measure (ie, the gold standard).8 Indeciding whether or not to use a test, the usershould be satisfied that the test has establishedvalidity. In the 1990s, Safrit9 summarised thecriterion-related validity of several fitness tests;yet, despite the growing interest in this area, noother attempt has been made to summarise thecriterion-related validity of the existing field-basedfitness tests in youth.
During the last two decades a great deal ofattention has been devoted to the fitness ofchildren and adolescents. As a result, numerousfield-based fitness test batteries have been devel-oped to assess fitness in this population (table 1).
The objective of the present systematic reviewwas to comprehensively study the validity of theexisting field-based fitness tests used in childrenand adolescents. To better understand whether ornot a field-based test has established validity willhelp physical educators, exercise scientists, healthagencies and private organisations dealing withsport, fitness and health to decide which field testshould be used to assess physical fitness.
METHODSThe present systematic review is produced as a partof the ALPHA (for instruments for AssessingLevels of PHysical Activity and fitness) study.25
The ALPHA study aims to provide a set ofinstruments for assessing levels of physical activityas well as health-related physical fitness in acomparable way within the European Union.
ProceduresThe electronic databases MEDLINE, SCOPUS andSPORTS DISCUS were screened for criterion-related validity studies in children and adolescentswhere one or more field-based fitness test werecarried out. All the fitness tests from the mostcommonly used fitness test batteries in youth wereincluded (table 1).
The keywords used (in various combinations)were: criterion validity, validity, validation, cross-validation, estimation, prediction, physical fitness,fitness, aerobic capacity, cardiorespiratory fitness,maximum oxygen consumption, strength, flexibil-ity, motor, endurance, speed, agility, balance, body
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:02 Topics:
Review
Br J Sports Med 2009;000:010. doi:10.1136/bjsm.2009.058321 1
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composition, anthropometry, Body Mass Index (BMI), skinfolds and waist circumference. The specific names of the testswere also included. Tables 2 to 5 summarise the field-basedfitness tests used to assess cardiorespiratory fitness, musculos-keletal fitness, motor fitness and body composition, respec-tively.
The computer-based searches were limited to papers pub-lished from January 1990 to December 2008, full reportspublished in English or Spanish, in humans, and all children(018 years). An additional search using adolescents (1318years) was also performed. Additional studies were identifiedfrom reference lists.
The results of the most recent reviews were summarised first,and then the studies potentially relevant for the selected topicswere screened for retrieval. Finally, a snowball search wasperformed, in which reference lists of the selected articles werechecked for titles including validity of physical fitness.
Quality assessment of the studyThe quality of the selected studies was scored using a qualityassessment list. The list included three items based on numberof study subjects, description of the study population andstatistical methods; see table 6. The items were rated from 0 to2, 2 being the best score. For all studies, a total quality score wascalculated by counting up the number of positive items (a totalscore between 0 and 6). Studies were defined as high quality ifthey had a total score of 5 or higher. A total score of 3 or 4 wasdefined as low quality and a score lower than 3 was defined asvery low quality. Two reviewers (JCP and JRR) evaluated thequality of the studies, separately. A consensus meeting wasarranged to sort out differences between both reviewers. Thearticles were not blinded for authors because the reviewers whoperformed the quality assessment were familiar with theliterature.
Levels of evidenceThree levels of evidence were constructed: (1) strong evidence:consistent findings in three or more high quality studies; (2)moderate evidence: consistent findings in two high qualitystudies; (3) limited evidence: consistent findings in multiple lowquality studies, inconsistent results found in multiple highquality studies, or results based on one single study.
The degree of criterion-related validity of the field-basedfitness test will be discussed for those tests on which we havefound strong or moderate evidence that the test is (or not) valid.
Data extractionWe extracted information on fitness quality, population char-acteristics, fitness test, gold standard, statistical methods, mainoutcome and conclusions from studies defined as high quality. Weregarded results with a p(0.05 as statistically significant.
RESULTSQuality assessmentThe literature search identified 73 studies addressing thecriterion-related validity of field-based fitness tests in childrenand adolescents (see supplementary material, table 1). Of these,23 studies were of low quality and were not included in thismanuscript. There were no studies with a score (2, that is,with a very low quality. A total of 31 high quality studies hadthe highest score (score = 6). The overall agreement between thetwo reviewers was 90% (k= 0.813). Disagreement was solved ina consensus meeting.
Levels of evidenceCardiorespiratory fitnessThe 20 m shuttle run test (20mSRT) was investigated in eightstudies,2633 and the 1-mile run/walk test was investigated inthree studies.3436 (see supplementary material, table 2).
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:04 Topics:
Table 1 Existing field-based physical fitness test batteries for children and adolescents
Acronym Society/organisation Country/region Age, years
EUROFIT10 Council of Europe Committee for the Development of Sport Europe 618
FITNESSGRAM11 The Cooper Institute USA 517
PCHF12 Presidents Challenge: Health Fitness. The Presidents Council onPhysical Fitness and Sports/American Association for Health,Physical Education, and Recreation (AAHPER)
USA 617
PCPF13 Presidents Challenge: Physical Fitness. The Presidents Council onPhysical Fitness and Sports/American Association for Health,Physical Education, and Recreation (AAHPER)
USA 617
AAUTB14 Amateur Athletic Union Test Battery. Chrysler Foundation/AmateurAthletic Union
USA 617
YMCAYFT15 YMCA Youth Fitness Test USA 617
NYPFP16 National Youth Physical Program. The United States Marines YouthFoundation
USA 517
HRFT17 Health-Related Fitness Test, American Association for Health,Physical Education, and Recreation (AAHPER)
USA 518
Physical Best18 American Association for Health, Physical Education, andRecreation (AAHPER)
USA 518
IPFT19 International Physical Fitness Test (United States Sports Academic/General Organization of Youth and Sport of Bahrain)
USA 919
CAHPER-FPT II20 Fitness Performance Test II. Canadian Association for Health,Physical Education and Recreation (CAHPER)
Canada 769
CPAFLA21 The Canadian Physical Activity, Fitness & Lifestyle Approach(Canadian Society for Exercise Physiology)
Canada 1569
NFTP-PRC22 National Fitness Test Program in the Popular Republic China(Chinas National Sport and Physical Education Committee)
China 919+
NZFT23 New Zealand Fitness Test. Rusell/Department of Education New Zealand 612
AFEA24 Australian Fitness Education Award. The Australian Council forHealth, Education and Recreation, ACHER
Australia 919
YMCA, Young Mens Christian Association.
Review
2 Br J Sports Med 2009;000:010. doi:10.1136/bjsm.2009.058321
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The Douglas bag method is considered the gold standard toassess maximal oxygen consumption (VO2max),
37 yet there isagreement on that respiratory gas analyser is a valid method toassess oxygen uptake.37 All the studies measured VO2max or peakoxygen consumption (VO2peak) when performing a maximaltreadmill test to measure, except Ruiz et al26 27 that measuredVO2max when performing the 20mSRT.
20mSRTSeveral studies26 28 3032 attempted to develop an equation toestimate VO2max. McVeigh et al
28 showed that the estimation ofVO2peak from the 20mSRT might be improved by including skinfold thickness measurements in the regression model, particu-larly for girls (R2 = 0.85, standard error of estimate (SEE):2.4 ml/kg/min for girls and R2 = 0.68, SEE: 3.23 ml/kg/min forboys), which concurs with others.30 31 In contrast, Mahar et al32
showed that a model including sex, number of laps completedand body weight or BMI was not accurate to estimate VO2peak(R2 = 0.65, SEE: 6.35 ml/kg/min) in boys and girls aged 1214years. More recently, we have developed a new equation toestimate VO2max from 20mSRT performance (stage), sex, age,weight and height in adolescents aged 1319 years using a moreadvance mathematical model, that is, artificial neural networkmodelling (R2 = 0.92, percentage error: 7.30%, SEE: 2.84 ml/kg/min).26
Several studies have cross-validated the mentioned equa-tions.26 27 29 33 Pitteti et al29 cross-validated the Leger and theFernhall equations, and found significant but modest relation-ships between both regression equations and VO2peak (r = 0.57,p,0.01; r = 0.66, p,0.01, respectively). More recently, Ruiz etal27 assessed the validity of five different equations (ie, the Ruizet al,26 Leger et al,38 Barnett et al (a),30 Barnett et al (b)30 andMatsuzaka et al31 equations) for estimating VO2max from the20mSRT test in a relatively small sample of 48 Portugueseadolescents 1319 years of age. They reported that equations toestimate VO2max from the 20mSRT should not be used at anindividual level, and suggested that the equations reported byBarnett (b)30 and Ruiz26 seems to be the most accurate toestimate VO2max in adolescents.
Distance run/walk testsThe most commonly used equation to estimate VO2peak fromthe 1-mile run/walk test is the Cureton equation,34 which wasselected for the FITNESSGRAM battery to estimate VO2peak.
11
We have examined the criterion-related validity of Curetonequation in 66 endurance trained children and adolescents aged817 years.35 We observed that there was a significant meandifference between measured and estimated VO2peak (10.01 ml/kg/min, 95% confidence interval (CI) 9.2 to 11.8, p,0.001). Thefindings did not materially change when the analyses wereperformed by sex, age groups and weight status, which suggeststhat this equation is not accurate for estimating VO2peak inendurance trained children.35 Buono et al36 also developed anequation to estimate VO2peak from the 1-mile run/walk time,and reported a SEE of 4.3 ml/kg/min (R2 = 0.84).
The nature of this test deserves several comments. The 1-milerun/walk test is not a friendly test, especially in young people.One of its major problems is the participants capacity todevelop an appropriate pace. Participants may either start toofast so that they are not able to keep up the speed all throughthe test, or they may start too slow so that when they want toincrease speed, the test is already finished. To ameliorate thisproblem, several versions were developed such us the 1-mile
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:06 Topics:
Tabl
e2
Fiel
d-ba
sed
fitne
sste
sts
used
toas
sess
card
iore
spira
tory
fitne
ss
Fitn
ess
qual
ity
Fitn
ess
test
Fitn
ess
test
batt
ery
(cou
ntry
)
EUR
OFI
T(E
U)
FITN
ESS
GR
AM
(US
A)
PC
HF
(US
A)
PC
PF
(US
A)
AA
UTB
(US
A)
YM
CA
YFT
(US
A)
NY
PFP
(US
A)
HR
FT(U
SA
)P
hysi
cal
Bes
t(U
SA
)IP
FT(U
SA
)C
AH
PER
-FP
TII
(CA
N)
CP
AFL
A(C
AN
)N
FTP
-PR
C(C
HIN
)N
ZFT
(NZ)
AFE
A(A
US
)
Aer
obic
capa
city
20m
shut
tleru
nN
NN
506
8m
shut
tleru
nN
4/3/
2m
in25
msh
uttle
run
N
Hoo
sier
endu
ranc
esh
uttle
run
N
1.5-
mile
run/
wal
kte
stN
N
1-m
ileru
n/w
alk
test
NN
NN
NN
NN
NN
NN
1000
mru
nN
N
1/2-
mile
run/
wal
kte
stN
NN
NN
NN
1/4-
mile
run/
wal
kte
stN
NN
N
Coo
per
test
NN
9-m
inru
nnin
gN
N
1-m
inju
mp
rope
N
Org
anis
atio
nal
abbr
evia
tions
give
nin
tabl
e1.
EU,
Euro
pe;
CA
N,
Can
ada;
CH
IN,
Chi
na;
NZ,
New
Zeal
and;
AU
S,
Aus
tral
ia.
Review
Br J Sports Med 2009;000:010. doi:10.1136/bjsm.2009.058321 3
-
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:08 Topics:
Tabl
e3
Fiel
d-ba
sed
fitne
sste
sts
used
toas
sess
mus
culo
skel
etal
fitne
ss
Fitn
ess
qual
ity
Fitn
ess
test
Fitn
ess
test
batt
ery
(cou
ntry
)
EUR
OFI
T(E
U)
FITN
ESS
GR
AM
(US
A)
PC
HF
(US
A)
PC
PF
(US
A)
AA
UTB
(US
A)
YM
CA
YFT
(US
A)
NY
PFP
(US
A)
HR
FT(U
SA
)
Phy
sica
lB
est
(US
A)
IPFT
(US
A)
CA
HP
ER-
FPT
II(C
AN
)C
PA
FLA
(CA
N)
NFT
P-P
RC
(CH
IN)
NZF
T(N
Z)A
FEA
(AU
S)
Max
imal
isom
etric
stre
ngth
Han
d-gr
ipst
reng
thN
NN
Trun
klif
tN
N
Endu
ranc
est
reng
th:
Upp
erbo
dyB
ent
arm
hang
NN
NN
NN
NN
Pull-
ups
NN
NN
NN
Mod
ified
pull-
ups
NN
NN
Para
llel-b
ars
dips
N
Push
-ups
NN
NN
N
Mod
ified
push
-ups
NN
Isom
etric
push
-ups
N
Trun
kS
it-up
sN
NN
NN
NN
Cur
l-ups
NN
NN
N
Part
ial
curl-
ups
NN
N
Low
erbo
dyPh
anto
mch
air
N
Expl
osiv
est
reng
th:
Upp
erbo
dyB
aske
tbal
lth
row
N
Med
icin
eba
llth
row
N
San
dba
llth
row
(0.2
5kg
)N
Sho
tpu
t(1
,2,
3,4
or5
kg)
N
Bac
kth
row
(8po
unds
)N
Low
erbo
dyS
tand
ing
broa
dju
mp
NN
NN
NN
Ver
tical
jum
pN
N
Flex
ibili
tyS
itan
dre
ach
NN
NN
NN
NN
NN
Vsi
tan
dre
ach
NN
Bac
ksa
ver
sit
and
reac
hN
Sho
ulde
rst
retc
hN
N
Org
anis
atio
nal
abbr
evia
tions
give
nin
tabl
e1.
EU,
Euro
pe;
CA
N,
Can
ada;
CH
IN,
Chi
na;
NZ,
New
Zeal
and;
AU
S,
Aus
tral
ia.
Review
4 Br J Sports Med 2009;000:010. doi:10.1136/bjsm.2009.058321
-
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:12 Topics:
Tabl
e4
Fiel
d-ba
sed
fitne
sste
sts
used
toas
sess
mot
orfit
ness
Fitn
ess
qual
ity
Fitn
ess
test
Fitn
ess
test
batt
ery
(cou
ntry
)
EUR
OFI
T(E
U)
FITN
ESS
GR
AM
(US
A)
PC
HF
(US
A)
PC
PF
(US
A)
AA
UTB
(US
A)
YM
CA
YFT
(US
A)
NY
PFP
(US
A)
HR
FT(U
SA
)
Phy
sica
lB
est
(US
A)
IPFT
(US
A)
CA
HP
ER-F
PT
II(C
AN
)C
PA
FLA
(CA
N)
NFT
P-P
RC
(CH
IN)
NZF
T(N
Z)A
FEA
(AU
S)
Spe
edan
dag
ility
Shu
ttle
run
(106
5m
)N
Shu
ttle
run
with
spon
ges
(106
4m
)
NN
NN
N
10se
c25
msh
uttle
run
N
Spe
ed10
0m
dash
NN
N
50m
dash
NN
NN
Spe
edof
limbs
Plat
eta
ppin
gN
Bal
ance
Flam
ingo
bala
nce
N
Org
anis
atio
nal
abbr
evia
tions
give
nin
tabl
e1.
EU,
Euro
pe;
CA
N,
Can
ada;
CH
IN,
Chi
na;
NZ,
New
Zeal
and;
AU
S,
Aus
tral
ia.
Tabl
e5
Fiel
d-ba
sed
fitne
sste
sts
used
toas
sess
body
com
posi
tion
Fitn
ess
qual
ity
Fitn
ess
test
Fitn
ess
test
batt
ery
(cou
ntry
)
EUR
OFI
T(E
U)
FITN
ESS
GR
AM
(US
A)
PC
HF
(US
A)
PC
PF
(US
A)
AA
UTB
(US
A)
YM
CA
YFT
(US
A)
NY
PFP
(US
A)
HR
FT(U
SA
)
Phy
sica
lB
est
(US
A)
IPFT
(US
A)
CA
HP
ER-
FPT
II(C
AN
)C
PA
FLA
(CA
N)
NFT
P-P
RC
(CH
IN)
NZF
T(N
Z)A
FEA
(AU
S)
Ant
hrop
omet
ricin
dice
sH
eigh
tan
dw
eigh
tN
NN
NN
NN
N
Wai
stci
rcum
fere
nce
N
Hip
circ
umfe
renc
eN
Wai
st-t
o-hi
pra
tioN
Wai
st-t
o-he
ight
ratio
Bod
ym
ass
inde
xN
NN
NN
Ski
nfo
ldth
ickn
ess
NN
NN
NN
NN
Org
anis
atio
nal
abbr
evia
tions
give
nin
tabl
e1.
EU,
Euro
pe;
CA
N,
Can
ada;
CH
IN,
Chi
na;
NZ,
New
Zeal
and;
AU
S,
Aus
tral
ia.
Review
Br J Sports Med 2009;000:010. doi:10.1136/bjsm.2009.058321 5
-
walk,39 the submaximal 1-mile track jog test (pacing test),40 andthe 1/2-mile run/walk test (table 2).41 We assessed the criterion-related validity of the 1/2-mile run/walk test in children aged 617 years, and also examined the criterion-related validity of theFernhall equation in a subgroup of children aged 1017 years.41
We computed a regression equation that was assessed throughseveral error measures and the BlandAltman method. Wefound that the 1/2-mile run/walk time, sex and BMI weresignificantly associated with VO2peak. There was no systematicbias in the validation group nor in the cross-validation group(p.0.1), and the root mean squared error (RMSE) and thepercentage error were 6.5 ml/kg/min and 13.9%, respectively.The newly developed equation had a lower RMSE andpercentage error than the Fernhall equation in the subgroup ofchildren aged 1017 years (7.2 vs 17.7 ml/kg/min and 16.0% vs50.4%, respectively, p,0.001).
In conclusion, there is strong evidence indicating that the20mSRT is a suitable test to estimate cardiorespiratory fitness.From the developed equations, it seems that the Barnett (b) andRuiz equations yielded the most promising results to estimateVO2max. There is moderate evidence in the case of the 1-milerun/walk test, and limited evidence that the 1-mile walk test,the submaximal 1-mile track jog test (pacing test) and the 1/2-run/walk test are valid tests to estimate VO2max (or VO2peak).The Cureton equation seems the best equation to predictVO2peak from the 1-mile run/walk test, but the fitness levels ofthe individuals may affect its validity.
Musculoskeletal fitnessTwo studies examined the criterion-related validity of the hand-grip strength test (maximal isometric strength),42 43 one studyexamined the criterion-related validity of the bent arm hang,push-ups, pull-ups and modified pull-ups tests44 (upper bodyendurance strength) and one examined the criterion-relatedvalidity of the standing broad jump and vertical test.43 Twostudies assessed the criterion-related validity of flexibility: oneanalysed the back saver sit and reach test,45 and the other oneanalysed the trunk lift test46 (see supplementary material,table 2).
There is no established gold standard for most of themusculoskeletal fitness tests, which makes it difficult todetermine the criterion-related validity of these tests. Thespecificity of the type of muscular work performed and the useof different energy systems are both major challenges for
establishing a gold standard method for maximal muscularstrength and endurance strength tests.47 One repetition max-imum (1RM) and repetitions to a certain percentage of 1RM (ie,50% of 1RM or 70% of 1RM) have been used as goldstandards.43 44 Concerning flexibility, radiography seems to bethe best criterion measurement, but goniometry has also beenused as a criterion measure.45 4850
Maximal isometric strengthWe have studied the criterion-related validity of the hand-gripstrength test using Jamar, DynEx and TKK dynamometers ;inadolescents aged 1216 years.42 We used known weights(ranging from 20 to 70 kg) as the criterion measure. Weobserved a negative systematic bias (underestimation) for theJamar and DynEx dynamometers (21.92 and 21.43 kg,respectively, p,0.05), whereas a marginal positive overestima-tion was observed for the TKK dynamometer (0.49 kg, p,0.05).These results concur with those reported in studies performedin adults.5159 We also examined whether the elbow position(extended or flexed at 90 degrees) affects the hand-grip strengthin adolescents. We observed that performing the hand-gripstrength test with the elbow extended seems the mostappropriate protocol to evaluate maximal hand-grip strengthin adolescents when using the TKK dynamometer. We have alsoconducted a series of studies in children60 and adolescents,61 todetermine if there is an optimal grip span for determining themaximum hand-grip strength, and if the optimal grip span wasrelated to hand size. We found that there was an optimal gripspan to which the dynamometer should be adjusted whenmeasuring hand-grip strength in children60 and adolescents.61
We provided sex and age specific equations to adjust the gripspan of the dynamometer to the hand size of the individual inorder to obtain the actual maximal hand-grip strength. Millikenet al43 analysed the association between hand-grip strength(using the TKK dynamometer) and 1RM chest press in childrenaged 712 years. They found that the hand-grip strength test isvalid to assess upper body maximal strength.
Upper body endurance strengthWoods et al44 studied the criterion-related validity of the bentarm hang, push-up, pull-ups and two modified pull-up testsusing 1RM and repetitions at 50% of 1RM as criterion referencein children aged 911 years. They concluded that these tests arenot valid to assess muscular endurance and that body fatpercentage was the main determinant of performance. Weobserved that muscular strength is highly influenced by bodyweight in children aged 617 years,62 especially in relation toweight bearing tests. We showed that out of 2778, a total of1037 (85%) of the girls and 889 (60%) of the boys were not ableto perform a single repetition in the pull-up test. Likewise, atotal of 478 (39%) of the girls and 409 (28%) of the boys werenot able to perform for more than 0 s in the bent arm hang test.Collectively, these findings suggest that these tests are notappropriate to measure upper body endurance strength inchildren and adolescents.
Lower body explosive strengthMilliken et al43 studied the criterion-related validity of thestanding broad jump test and the vertical jump test using 1RMof leg press as criterion measure in children aged 712 years.They reported that the standing broad jump and vertical jumptest, with BMI, accounted for 44.4% and for 40.8% of thevariation in 1RM leg press, respectively.
sm58321 Module 1 British Journal of Sports Medicine 26/6/09 14:17:17 Topics:
Table 6 Quality assessment criteria for criterion-related validity studies
Grading system parameter Grade Criterion
Number of study subjects 0 n(10
1 n = 1150
2 n>51
Description of the study populationwith respect to age, sex, healthstatus, fitness levels, pubertal status,ethnicity, physical activity patterns,body composition, etc.