Tesis Doctoral Europea / European Doctoral Thesis
EVALUACIÓN DE LA FUERZA MUSCULAR Y LA CAPACIDAD AERÓBICA EN ADOLESCENTES ASPECTOS METODOLÓGICOS Y RELACIÓN CON LA SALUD
MUSCULAR AND CARDIORESPIRATORY FITNESS ASSESSMENT IN ADOLESCENTS METHODOLOGICAL ISSUES AND HEALTH IMPLICATIONS
DEPARTAMENTO DE FISIOLOGÍA FACULTAD DE MEDICINA UNIVERSIDAD DE GRANADA
ENRIQUE GARCÍA ARTERO 2010
Editor: Editorial de la Universidad de Granada Autor: Enrique García Artero D.L.: GR 2686-2010 ISBN: 978-84-693-2017-4
γονεῦσιν ἀδελφῷ τε συγγενέσι τε πᾶσιν A mis padres, mi hermano y toda mi familia To my parents, my brother and my whole family
DEPARTAMENTO DE FISIOLOGÍA FACULTAD DE MEDICINA UNIVERSIDAD DE GRANADA
EVALUACIÓN DE LA FUERZA MUSCULAR Y LA CAPACIDAD AERÓBICA EN ADOLESCENTES ASPECTOS METODOLÓGICOS Y RELACIÓN CON LA SALUD
MUSCULAR AND CARDIORESPIRATORY FITNESS ASSESSMENT IN ADOLESCENTS METHODOLOGICAL ISSUES AND HEALTH IMPLICATIONS ENRIQUE GARCÍA ARTERO
Directores de Tesis [Thesis Supervisors] Manuel J. Castillo Garzón MD, PhD Catedrático de Universidad Universidad de Granada
Stefaan De Henauw MD, PhD Senior Lecturer Ghent University, Belgium
Francisco B. Ortega Porcel PhD Investigador Posdoctoral Universidad de Granada
Miembros del Tribunal [Members of the Jury] José A. López Calbet MD, PhD Catedrático de Universidad Universidad de Las Palmas de Gran Canaria
Pekka Oja PhD UKK Institute for Health Promotion Research Tampere, Finland
Esteban Gorostiaga Ayestarán PhD Centro de Estudios, Investigación y Medicina del Deporte Gobierno de Navarra
Alejandro Lucía Mulas MD, PhD Catedrático de Universidad Universidad Europea de Madrid
Jesús Rodríguez Huertas PhD Profesor Titular de Universidad Universidad de Granada
Granada, 15 de enero de 2010
Prof. Dr. Manuel J. CASTILLO GARZON Catedrático de Universidad --Departamento de Fisiología FACULTAD DE MEDICINA Universidad de Granada
MANUEL J. CASTILLO GARZÓN, CATEDRÁTICO DE FISIOLOGÍA MÉDICA EN LA FACULTAD DE MEDICINA DE LA UNIVERSIDAD DE GRANADA
CERTIFICA: Que la Tesis Doctoral titulada “Evaluación de la fuerza muscular y la capacidad aeróbica en adolescentes. Aspectos metodológicos y relación con la salud” que presenta D. ENRIQUE GARCÍA ARTERO al superior juicio del Tribunal que designe la Universidad de Granada, ha sido realizada bajo mi dirección durante los años 2005-2010, siendo expresión de la capacidad técnica e interpretativa de su autor en condiciones tan aventajadas que le hacen merecedor del Título de Doctor, siempre y cuando así lo considere el citado Tribunal.
Fdo. Manuel J. Castillo Garzón
En Granada, 5 de diciembre de 2009
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 GARCÍA 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 García Artero is an excellent candidate for a PhD award.
Stefaan De Henauw
In Ghent, Belgium, December 5th 2009
Dr. Francisco B. ORTEGA PORCEL Investigador Post-Doctoral --Departamento de Fisiología FACULTAD DE MEDICINA Universidad de Granada
FRANCISCO B. ORTEGA PORCEL, INVESTIGADOR MINISTERIO DE CIENCIA E INNOVACIÓN
POSDOCTORAL
DEL
CERTIFICA: Que la Tesis Doctoral titulada “Evaluación de la fuerza muscular y la capacidad aeróbica en adolescentes. Aspectos metodológicos y relación con la salud” que presenta D. ENRIQUE GARCÍA ARTERO al superior juicio del Tribunal que designe la Universidad de Granada, ha sido realizada bajo mi dirección durante los años 2005-2010, siendo expresión de la capacidad técnica e interpretativa de su autor en condiciones tan aventajadas que le hacen merecedor del Título de Doctor, siempre y cuando así lo considere el citado Tribunal.
Fdo. Francisco B. Ortega Porcel
En Granada, 5 de Diciembre de 2009
European PhD Thesis
CONTENIDOS [CONTENTS]
Proyectos de Investigación [Research Projects].……………………………………………. 8 Becas y Financiación [Grants and Funding].………………………………………..…….… 9 Lista de publicaciones [List of Publications].…………………………………………….…. 10 Resumen [Summary]……………………………………………………..………….………. 11 Abreviaturas [Abbreviations]...……………………………………………………….……... 19 Introducción [Introduction].…………………………………………………………….…… 23 Bibliografía [References]....…………………………………………………………………. 27 Objetivos [Aims]…………………………………………………………………………...... 33 Material y Métodos [Material and Methods].………………………….………………..…... 35 Resultados y Discusión [Results and Discussion].…….……………………………………. 41 1.
Aspectos metodológicos en la evaluación de la condición física [Methodological issues of fitness assessment] 1.1 Validez [Criterion-related validity] (Artículos I y II)..………………………..…. 43 1.2 Fiabilidad [Reliability] (Artículos III y IV)...…………………………..……..... 119
2.
Condición física y salud [Physical fitness and health] 2.1 Factores de riesgo cardiovascular [Cardiovascular disease risk factors] (Artículo V)….………………………………………………………………..... 177 2.2 Composición corporal [Body composition] (Artículo VI)……………………… 199 2.3 Determinantes tempranos de la condición física [Early determinants of physical fitness] (Artículo VII).………………………………………………... 215
Conclusiones [Conclusions]..………………………………………………...…………….. 245 Anexo [Annex]……………………………………………………………………………... 247 Curriculum Vitae abreviado [Short CV].…………………………………………..………. 253 Agradecimientos [Acknowledgements].…………………………………………………… 257
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PROYECTOS DE INVESTIGACIÓN [RESEARCH PROJECTS]
El trabajo desarrollado y los artículos que componen la presente memoria de Tesis Doctoral están basados en los siguientes proyectos de investigación: •
Estudio AVENA (Alimentación y Valoración del Estado Nutricional de los Adolescentes Españoles). Proyecto Nacional multicéntrico financiado por el Instituto de Salud Carlos III con Fondos de Investigación Sanitaria, Ministerio de Sanidad y Consumo (nº 00/0015), y por varias empresas privadas: Panrico S.A., Madaus S.A., y Procter and Gamble S.A. Página web: www.estudioavena.com
•
Estudio HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence). Proyecto financiado por la Unión Europea: European Union Sixth RTD Framework Programme (Contract FOOD-CT-2005-007034). Página web: www.helenastudy.com
•
Estudio ALPHA (Assessing Levels of Physical Activity and Fitness). Proyecto financiado por la Unión Europea: Public Health Executive Agency, DG SANCO, Health Information Strand (Ref. 2006120). Página web: www.thealphaproject.eu
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European PhD Thesis
BECAS Y FINANCIACIÓN [GRANTS AND FUNDING]
La presente memoria de Tesis Doctoral ha sido posible también gracias a las siguientes subvenciones:
•
Beca de Iniciación a la Investigación. Vicerrectorado de Política Científica e Investigación, Universidad de Granada. Departamento de Fisiología, Facultad de Medicina.
•
Ayudas a Grupos de Investigación de la Junta de Andalucía. Grupo de Investigación en Evaluación Funcional y Fisiología del Ejercicio CTS 262. Universidad de Granada.
•
Beca de Formación de Profesorado Universitario (FPU) del Ministerio de Educación y Ciencia (AP2005-4358). Departamento de Fisiología, Facultad de Medicina, Universidad de Granada.
•
Ayudas para estancias breves del Programa Nacional de Formación de Profesorado Universitario: 9 Departamento de Salud Pública, Universidad de Gante, Bélgica (agosto diciembre 2008). 9 Departamento de Ciencias del Ejercicio, Centro de Investigación en Salud Pública, 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 está compuesta por los siguientes artículos científicos:
10
I.
Castro-Piñero J, Artero EG, España-Romero V, Ortega FB, Sjöström 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, España-Romero V, Castro-Piñero J, Ruiz JR, Jiménez-Pavón D, Aparicio VA, Gatto-Cardia MC, Baena PA, Vicente-Rodríguez G, Castillo MJ, Ortega FB. Criterion-related validity of field-based muscular fitness tests in youth. Submitted.
III.
Artero EG, España-Romero V, Castro-Piñero 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-Rodríguez G, Bergman P, Hagströmer M, Ottevaere C, Nagy E, Konsta O, Rey-López JP, Polito A, Dietrich S, Plada M, Beghin L, Manios Y, Sjöstrom 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.
García-Artero E, Ortega FB, Ruiz JR, Mesa JL, Delgado M, González-Gross M, García-Fuentes M, Vicente-Rodríguez G, Gutiérrez 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, España-Romero V, Ortega FB, Jiménez-Pavón D, Ruiz JR, VicenteRodríguez G, Bueno M, Marcos A, Gómez-Martínez S, Urzanqui A, GonzálezGross M, Moreno LA, Gutiérrez 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, España-Romero V, Labayen I, Huybrechts I, Papadaki A, Rodríguez G, Mauro B, Widhalm K, Kersting M, Manios Y, Molnar D, Moreno LA, Sjöström 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.
European PhD Thesis
RESUMEN
En personas adultas, el nivel de condición física se considera hoy día un importante predictor de morbilidad y mortalidad tanto general como cardiovascular. La evidencia científica más reciente indica además que el nivel de condición física puede ser considerado un potente indicador de salud también en la infancia y adolescencia. Sin embargo, no existe aún consenso sobre la metodología a emplear para su evaluación, lo cual dificulta la identificación de aquellos jóvenes que presentan un bajo nivel de condición física y, por tanto, un mayor riesgo de enfermedad. La presente memoria de Tesis Doctoral tiene como objetivo analizar aspectos metodológicos relacionados con la evaluación de la condición física en adolescentes, así como estudiar la relación entre el nivel de condición física (especialmente fuerza muscular y capacidad aeróbica) y diversos parámetros de salud en estas edades. Los trabajos que componen esta memoria de Tesis Doctoral están basados en datos procedentes de los proyectos AVENA, HELENA y ALPHA. Un total de 2474 adolescentes españoles de cinco ciudades diferentes, 2567 adolescentes de nueve países europeos, y una muestra adicional de 126 adolescentes de la provincia de Granada, han sido analizados en esta investigación. Los principales resultados de este trabajo indican que: a) el test de 20m de ida y vuelta, la fuerza de prensión manual, el salto en longitud con pies juntos, el índice de masa corporal, el perímetro de cintura y los pliegues cutáneos son los test más válidos y fiables para evaluar la capacidad aeróbica, la fuerza muscular y la composición corporal en niños y adolescentes. b) Tanto la capacidad aeróbica como la fuerza muscular se asocian de manera independiente con factores de riesgo cardiovascular en adolescentes. c) No sólo el sobrepeso y la obesidad sino también un bajo peso corporal afectan al nivel de condición física de los adolescentes. d) Un período de lactancia materna de mayor duración podría estar asociado con una mayor capacidad muscular del tren inferior durante la adolescencia. La presente memoria de Tesis Doctoral propone una batería de test válida y fiable para evaluar la condición física en niños y adolescentes. Además, aporta nuevas perspectivas sobre la relación entre el nivel de condición física y diversos parámetros de salud durante la adolescencia.
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¿Qué se sabe en este ámbito?
¿Qué añade esta Tesis Doctoral?
Existen diversas baterías de test para evaluar la Una propuesta de batería de condición física condición física en niños y adolescentes. Validez
y
fiabilidad
son
dos
válida y fiable, compuesta por los siguientes
aspectos test:
fundamentales en cualquier instrumento de Test de 20m ida y vuelta para la capacidad medida. La validez de un test se define por la aeróbica; fuerza de prensión manual y salto en capacidad del mismo para evaluar aquello para longitud con pies juntos para la fuerza lo que ha sido diseñado. Sin embargo, el test muscular; e índice de masa corporal, perímetro no será apropiado si no es además lo de cintura y pliegues cutáneos para la suficientemente fiable.
composición corporal.
La actividad física, la capacidad aeróbica y la La capacidad aeróbica y la fuerza muscular se fuerza muscular se han asociado con factores asocian de manera independiente con factores de
riesgo
cardiovascular
durante
la de riesgo cardiovascular, mientras que la
adolescencia. Sin embargo, en pocas ocasiones actividad
física
evaluada
mediante
se ha analizado de manera conjunta la cuestionario podría no estar asociada con influencia independiente de esos parámetros.
dichos factores.
La condición física de los adolescentes con Aquellos adolescentes con un bajo peso sobrepeso ha sido objeto de estudio en corporal presentan menos masa libre de grasa numerosas ocasiones. Sin embargo, se ha y menos fuerza de prensión manual. prestado una menor atención a aquellos
En adolescentes con sobrepeso y obesidad, el
adolescentes con bajo peso corporal y se exceso de masa grasa supone un menor desconoce el efecto particular de la masa grasa rendimiento en aquellos test que requieren y la masa libre de grasa. transportar o mantener la masa corporal. Se ha sugerido que la lactancia materna no Una lactancia materna de mayor duración influye sobre la capacidad aeróbica que el podría asociarse con un incremento en la recién nacido pueda tener años más tarde. Sin fuerza muscular del tren inferior durante la embargo, se desconoce la posible influencia adolescencia. sobre otros componentes de la condición física.
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European PhD Thesis
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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European PhD Thesis
What is already known on this topic?
What does this PhD Thesis add?
Numerous test batteries have been developed A valid and reliable health-related fitness test to assess fitness in children and adolescents.
battery is proposed:
Validity and reliability are two characteristics 20m
shuttle
run
test
to
measure
that need to be considered in any measurement cardiorespiratory fitness; handgrip strength tool. Criterion-related validity refers to the and standing broad jump for muscular fitness; extent to which a field test correlates with the and body mass index, waist circumference and criterion measure. However the test will never skinfold be appropriate if it is not adequately reliable.
thickness
to
estimate
body
composition.
Physical activity, cardiorespiratory fitness and Cardiorespiratory and muscular fitness are muscular fitness have been associated with independently associated with cardiovascular cardiovascular disease risk factors during disease adolescence.
However,
the
risk
factors,
while
self-reported
independent physical activity could not be associated.
influence of each parameter has been rarely analyzed. The fitness levels of overweight and obese Underweight adolescents present lower fatadolescents
have
been
widely
analyzed. free mass and handgrip strength.
However, underweight youths have received less attention and the influence of fat mass and fat-free mass remains unclear.
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 Longer
breastfeeding
duration
may
be
duration and later cardiorespiratory fitness has associated with an increased lower body been suggested, but there is no evidence muscular fitness during adolescence. regarding other fitness components.
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European PhD Thesis
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
Alimentación y Valoración 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
Desviación típica
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 lipoproteína de alta densidad]
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García Artero E, 2010
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
Índice 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 lipoproteína de baja densidad]
MET
Metabolic equivalents
MSE
Mean squared error
NFTP-PRC
National Fitness Test Program in the Popular Republic China. China´s 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
President´s Challenge: Health Fitness. American Association for Health, Physical Education, and Recreation
PCPF
President´s 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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European PhD Thesis
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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European PhD Thesis
INTRODUCCIÓN [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 individual’s 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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García Artero E, 2010
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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European PhD Thesis
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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García Artero E, 2010
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 person’s 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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BIBLIOGRAFÍA [REFERENCES]
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Caspersen C.J., Powell K.E., and Christenson G.M. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985; 100(2): 126-31.
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Castillo M.J., Ruiz J.R., Ortega F.B., and Gutierrez A. Anti-aging therapy through fitness enhancement. Clin Interv Aging 2006; 1(3): 213-20.
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Bouchard C. and Sheppard R.J. Physical activity, fitness, and health: the model and key concepts, in Physical activity, fitness, and health, C. Bouchard, R.J. Shephard, and T. Stephens, Editors. 1994, Human Kinetics Books: Champaign, IL. p. 77-88.
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Cureton K.J., Sloniger M.A., O'bannon J.P., Black D.M., and Mccormack W.P. A generalized equation for prediction of VO2peak from 1-mile run/walk performance. Med Sci Sports Exerc 1995; 27(3): 445-51.
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Buono M.J., Robi J.J., Micale F.G., Sallis J.F., and Shepard W.E. Validity and reliability of predicting maximum oxygen uptake via field tests in children and adolescents. Pediatr Exer Sci 1991; 3: 250-5.
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De Ste Croix M., Deighan M., and Armstrong N. Assessment and interpretation of isokinetic muscle strength during growth and maturation. Sports Med 2003; 33(10): 727-43.
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Milliken L.A., Faigenbaum A.D., Loud R.L., and Westcott W.L. Correlates of upper and lower body muscular strength in children. J Strength Cond Res 2008; 22(4): 133946.
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Council of Europe Committee for the Development of Sport. Eurofit. Handbook for the EUROFIT tests of physical fitness. 1988, Edigraf editoriale grafica: Rome (Italy). p. 19-37.
9.
Cooper Institute for Aerobics Research. The Prudential Fitnessgram: Test administration manual. 3rd ed. 2004, Champaign, IL: Human Kinetics.
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Russell D.G., Isaac A., and Wilson P.G. New Zealand Fitness Test Handbook, ed. Department of Education. 1989, Wellington.
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Australian Council for Health Physical Education and Recreation (Achper). Handbook for the Australian Fitness Education Award Manual, ed. ACHPER. 1996, South Australia.
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China’s National Sports and Physical Education Committee. The national fitness testing methods, ed. National Sports and Physical Education Committee. 1990, Beijing, China.
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Currell K. and Jeukendrup A.E. Validity, reliability and sensitivity of measures of sporting performance. Sports Med 2008; 38(4): 297-316.
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Docherty D. Field tests and test batteries, in Measurement in pediatric exercise science, D. Docherty, Editor. 1996, Human Kinetics: Champain, Illinois, USA. p. 285334.
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Atkinson G. and Nevill A.M. Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine. Sports Med 1998; 26(4): 217-38.
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Hopkins W.G. Measures of reliability in sports medicine and science. Sports Med 2000; 30(1): 1-15.
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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 interventional proposal. I.Methodology]. Nutr Hosp 2003; 18(1): 15-28.
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 atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998; 338(23): 1650-6.
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Strong J.P., Malcom G.T., Mcmahan C.A., et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA 1999; 281(8): 727-35.
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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 Suppl 1: S62-7.
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 Sjöström 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.
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Wolfe R.R. The underappreciated role of muscle in health and disease. Am J Clin Nutr 2006; 84(3): 475-82.
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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.
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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.
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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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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.
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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.
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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.
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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.
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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.
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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): 616 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 metodológicos relacionados con la evaluación de la condición física en adolescentes, así como estudiar la relación entre el nivel de condición física (especialmente fuerza muscular y capacidad aeróbica) y diversos parámetros de salud en estas edades.
Específicos:
•
Analizar la validez y fiabilidad de los test de campo existentes para evaluar la condición física en niños y adolescentes (Artículos I a IV).
•
Estudiar de manera conjunta la influencia de la actividad física, la capacidad aeróbica y la fuerza muscular sobre factores de riesgo cardiovascular en adolescentes (Artículo V).
•
Analizar el nivel de condición física de los adolescentes en función de la categoría de peso corporal (Artículo VI).
•
Estudiar la relación entre la duración de la lactancia materna y el posterior nivel de condición física durante la adolescencia (Artículo 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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European PhD Thesis
MATERIAL Y MÉTODOS [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.
•
Alimentación y valoración del estado nutricional de los adolescentes españoles (Estudio AVENA). Evaluación de riesgos y propuesta de intervención. I. Descripción metodológica del proyecto [Feeding and assessment of nutritional status of Spanish adolescents (AVENA study). Evaluation of risks and interventional proposal. I. Methodology]. González-Gross M, Castillo MJ, Moreno L, Nova E, González-Lamuño D, Pérez-Llamas F, Gutiérrez A, Garaulet M, Joyanes M, Leiva A, Marcos A. Nutr Hosp 2003; 18(1): 1528. 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 Investigación 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 González-Gross, M Kersting, D Molnár, F Gottrand, L Barrios, M Sjöström, 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. Hagströmer, P Bergman, M. Sjöström. Selección 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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García Artero E, 2010
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,
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, backsaver sit and reach
ALPHA
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, LDLcholesterol, 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, fatfree 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: Alimentación y Valoración 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.
European PhD Thesis
RESULTADOS Y DISCUSIÓN [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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¿Qué se sabe en este ámbito?
¿Qué añaden estos estudios?
Existen diversas baterías de test para evaluar la El test de 20 m de ida y vuelta es un test condición física en niños y adolescentes. Como
consecuencia,
para
válido para evaluar la capacidad aeróbica.
algunos La fuerza de prensión manual y el salto en
componentes de la condición física existen más longitud con pies juntos son test válidos para de 10 posibles pruebas diferentes.
evaluar la fuerza muscular.
La validez de un test se define por la capacidad Los pliegues cutáneos (tríceps y subescapular) del mismo para evaluar aquello para lo que ha y el índice de masa corporal son estimadores sido diseñado.
válidos de la composición corporal, mientras que el perímetro de cintura es una medida válida para estimar la adiposidad central.
What is already known on this topic?
What do these studies add?
Numerous test batteries have been developed The 20m shuttle run is a valid test to measure to assess fitness in children and adolescents.
cardiorespiratory fitness.
As a consequence, there are more than 10 Handgrip strength and standing broad jump different tests available for some fitness are valid tests to measure muscular fitness. dimensions. Skinfold thickness (triceps and subscapular) Criterion-related validity refers to the extent to and body mass index are valid estimates of which a field test correlates with the criterion body composition, while waist circumference measure.
is a valid measure to estimate central body fat.
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I
CRITERION-RELATED VALIDITY OF FIELD-BASED FITNESS TESTS IN YOUTH: A SYSTEMATIC REVIEW
Castro-Piñero J, Artero EG, España-Romero V, Ortega FB, Sjöström M, Suni J, Ruiz JR
Br J Sports Med 2009 Apr 12 [Epub ahead of print]
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Review
Criterion-related validity of field-based fitness tests in youth: a systematic review J Castro-Pin˜ero,1 E G Artero,2 V Espan˜a-Romero,2,3 F B Ortega,2,3 M Sjo¨stro¨m,3 J Suni,4 J R Ruiz3 c Additional data (Supplementary information) are published online only at http:// bjsm.bmj.com/content/volXX/ issueX 1
Department of Physical Education, School of Education, University of Cadiz, Puerto Real, Spain; 2 Department of Physiology, School of Medicine, University of Granada, Granada, Spain; 3 Department of Biosciences and Nutrition at NOVUM, Unit for Preventive Nutrition, Karolinska Institutet, Huddinge, Sweden; 4 UKK Institute for Health Promotion Research, Tampere, Finland Correspondence to: J R Ruiz, Department of Biosciences and Nutrition, Unit for Preventive Nutrition, NOVUM, 14157, Huddinge, Sweden;
[email protected] Accepted 2 April 2009 Published Online First 12 April 2009
ABSTRACT The objective of this systematic review was to comprehensively study the criterion-related validity of the existing field-based fitness tests used in children and adolescents. The studies were scored according to the number of subjects, description of the study population and statistical analysis. Each study was classified as high, low and very low quality. Three levels of evidence were constructed: strong evidence, when consistent findings were observed in three or more high quality studies; moderate evidence, when consistent findings were observed in two high quality studies; and limited evidence when consistency of findings and/or the number of studies did not achieve the criteria for moderate. The results of 73 studies (50 of high quality) addressing the criterion-related validity of field-based fitness tests in children and adolescents indicate the following: that there is strong evidence indicating that the 20 m shuttle run test is a valid test to estimate cardiorespiratory fitness, that the hand-grip strength test is a valid measure of musculoskeletal fitness, that skin fold thickness and body mass index are good estimates of body composition, and that waist circumference is a valid measure to estimate central body fat. Moderate evidence was found that the 1-mile run/walk test is a valid test to estimate cardiorespiratory fitness. A large number of other field-based fitness tests presented limited evidence, mainly due to a limited number of studies (one for each test). The results of the present systematic review should be interpreted with caution due to the substantial lack of consistency in reporting and designing the existing validity studies.
Field-based fitness assessment depends on the prediction techniques, and thus is prone to error. In order for a test or a fitness test battery to be considered ‘‘good’’, it should measure what it is supposed to measure (ie, validity).7 Criterionrelated validity refers to the extent to which a field test of a fitness component correlates with the criterion measure (ie, the gold standard).8 In deciding whether or not to use a test, the user should be satisfied that the test has established validity. In the 1990s, Safrit9 summarised the criterion-related validity of several fitness tests; yet, despite the growing interest in this area, no other attempt has been made to summarise the criterion-related validity of the existing field-based fitness tests in youth. During the last two decades a great deal of attention has been devoted to the fitness of children and adolescents. As a result, numerous field-based fitness test batteries have been developed to assess fitness in this population (table 1). The objective of the present systematic review was to comprehensively study the validity of the existing field-based fitness tests used in children and adolescents. To better understand whether or not a field-based test has established validity will help physical educators, exercise scientists, health agencies and private organisations dealing with sport, fitness and health to decide which field test should be used to assess physical fitness.
METHODS Physical fitness refers to the full range of physical qualities (ie, cardiorespiratory fitness, muscular strength, agility, coordination and flexibility).1 It can be understood as an integrated measurement of all functions (skeletomuscular, cardiorespiratory, haematocirculatory, psychoneurological and endocrine/metabolic) and structures involved in the performance of physical activity and/or physical exercise.2 Physical fitness, especially cardiorespiratory fitness and muscular strength, is considered an important marker of health in adults,3 4 as well as in young people.5 6 Physical fitness can be objectively and accurately measured through laboratory tests. However, due to their high cost, necessity for sophisticated instruments and qualified technicians, and time constraints, their use is limited in school settings and in population-based studies. Field-based tests provide a reasonable alternative since they are time-efficient, low in cost and equipment requirements and can be easily administered to a large number of people simultaneously. Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
The present systematic review is produced as a part of the ALPHA (for ‘‘instruments for Assessing Levels of PHysical Activity and fitness’’) study.25 The ALPHA study aims to provide a set of instruments for assessing levels of physical activity as well as health-related physical fitness in a comparable way within the European Union.
Procedures The electronic databases MEDLINE, SCOPUS and SPORTS DISCUS were screened for criterionrelated validity studies in children and adolescents where one or more field-based fitness test were carried out. All the fitness tests from the most commonly used fitness test batteries in youth were included (table 1). The keywords used (in various combinations) were: criterion validity, validity, validation, crossvalidation, estimation, prediction, physical fitness, fitness, aerobic capacity, cardiorespiratory fitness, maximum oxygen consumption, strength, flexibility, motor, endurance, speed, agility, balance, body 1
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Review Table 1 Existing field-based physical fitness test batteries for children and adolescents Acronym 10
EUROFIT FITNESSGRAM11 PCHF12
PCPF13
AAUTB14 YMCAYFT15 NYPFP16 HRFT17 Physical Best18 IPFT19 CAHPER-FPT II20 CPAFLA21 NFTP-PRC22 NZFT23 AFEA24
Society/organisation
Country/region
Age, years
Council of Europe Committee for the Development of Sport The Cooper Institute President’s Challenge: Health Fitness. The President’s Council on Physical Fitness and Sports/American Association for Health, Physical Education, and Recreation (AAHPER) President’s Challenge: Physical Fitness. The President’s Council on Physical Fitness and Sports/American Association for Health, Physical Education, and Recreation (AAHPER) Amateur Athletic Union Test Battery. Chrysler Foundation/Amateur Athletic Union YMCA Youth Fitness Test National Youth Physical Program. The United States Marines Youth Foundation Health-Related Fitness Test, American Association for Health, Physical Education, and Recreation (AAHPER) American Association for Health, Physical Education, and Recreation (AAHPER) International Physical Fitness Test (United States Sports Academic/ General Organization of Youth and Sport of Bahrain) Fitness Performance Test II. Canadian Association for Health, Physical Education and Recreation (CAHPER) The Canadian Physical Activity, Fitness & Lifestyle Approach (Canadian Society for Exercise Physiology) National Fitness Test Program in the Popular Republic China (China’s National Sport and Physical Education Committee) New Zealand Fitness Test. Rusell/Department of Education Australian Fitness Education Award. The Australian Council for Health, Education and Recreation, ACHER
Europe USA USA
6–18 5–17 6–17
USA
6–17
USA
6–17
USA USA
6–17 5–17
USA
5–18
USA
5–18
USA
9–19
Canada
7–69
Canada
15–69
China
9–19+
New Zealand Australia
6–12 9–19
YMCA, Young Men’s Christian Association.
composition, anthropometry, Body Mass Index (BMI), skin folds and waist circumference. The specific names of the tests were also included. Tables 2 to 5 summarise the field-based fitness tests used to assess cardiorespiratory fitness, musculoskeletal fitness, motor fitness and body composition, respectively. The computer-based searches were limited to papers published from January 1990 to December 2008, full reports published in English or Spanish, in humans, and all children (0–18 years). An additional search using adolescents (13–18 years) was also performed. Additional studies were identified from reference lists. The results of the most recent reviews were summarised first, and then the studies potentially relevant for the selected topics were screened for retrieval. Finally, a snowball search was performed, in which reference lists of the selected articles were checked for titles including validity of physical fitness.
Quality assessment of the study The quality of the selected studies was scored using a quality assessment list. The list included three items based on number of study subjects, description of the study population and statistical methods; see table 6. The items were rated from 0 to 2, 2 being the best score. For all studies, a total quality score was calculated by counting up the number of positive items (a total score between 0 and 6). Studies were defined as high quality if they had a total score of 5 or higher. A total score of 3 or 4 was defined as low quality and a score lower than 3 was defined as very low quality. Two reviewers (JCP and JRR) evaluated the quality of the studies, separately. A consensus meeting was arranged to sort out differences between both reviewers. The articles were not blinded for authors because the reviewers who performed the quality assessment were familiar with the literature. 2
Levels of evidence Three 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 quality studies; (3) limited evidence: consistent findings in multiple low quality studies, inconsistent results found in multiple high quality studies, or results based on one single study. The degree of criterion-related validity of the field-based fitness test will be discussed for those tests on which we have found strong or moderate evidence that the test is (or not) valid.
Data extraction We extracted information on fitness quality, population characteristics, fitness test, gold standard, statistical methods, main outcome and conclusions from studies defined as high quality. We regarded results with a p(0.05 as statistically significant.
RESULTS Quality assessment The literature search identified 73 studies addressing the criterion-related validity of field-based fitness tests in children and adolescents (see supplementary material, table 1). Of these, 23 studies were of low quality and were not included in this manuscript. There were no studies with a score (2, that is, with a very low quality. A total of 31 high quality studies had the highest score (score = 6). The overall agreement between the two reviewers was 90% (k = 0.813). Disagreement was solved in a consensus meeting.
Levels of evidence Cardiorespiratory fitness The 20 m shuttle run test (20mSRT) was investigated in eight studies,26–33 and the 1-mile run/walk test was investigated in three studies.34–36 (see supplementary material, table 2). Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
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The Douglas bag method is considered the gold standard to assess maximal oxygen consumption (VO2max),37 yet there is agreement on that respiratory gas analyser is a valid method to assess oxygen uptake.37 All the studies measured VO2max or peak oxygen consumption (VO2peak) when performing a maximal treadmill test to measure, except Ruiz et al26 27 that measured VO2max when performing the 20mSRT.
N
N
N
N N N N
20mSRT Several studies26 28 30–32 attempted to develop an equation to estimate VO2max. McVeigh et al28 showed that the estimation of VO2peak from the 20mSRT might be improved by including skin fold thickness measurements in the regression model, particularly 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 for boys), which concurs with others.30 31 In contrast, Mahar et al32 showed that a model including sex, number of laps completed and body weight or BMI was not accurate to estimate VO2peak (R2 = 0.65, SEE: 6.35 ml/kg/min) in boys and girls aged 12–14 years. More recently, we have developed a new equation to estimate VO2max from 20mSRT performance (stage), sex, age, weight and height in adolescents aged 13–19 years using a more advance mathematical model, that is, artificial neural network modelling (R2 = 0.92, percentage error: 7.30%, SEE: 2.84 ml/kg/ min).26 Several studies have cross-validated the mentioned equations.26 27 29 33 Pitteti et al29 cross-validated the Leger and the Fernhall equations, and found significant but modest relationships between both regression equations and VO2peak (r = 0.57, p,0.01; r = 0.66, p,0.01, respectively). More recently, Ruiz et al27 assessed the validity of five different equations (ie, the Ruiz et al,26 Le´ger et al,38 Barnett et al (a),30 Barnett et al (b)30 and Matsuzaka et al31 equations) for estimating VO2max from the 20mSRT test in a relatively small sample of 48 Portuguese adolescents 13–19 years of age. They reported that equations to estimate VO2max from the 20mSRT should not be used at an individual level, and suggested that the equations reported by Barnett (b)30 and Ruiz26 seems to be the most accurate to estimate VO2max in adolescents.
PCHF (USA)
N N N N
N
N N
N
N N
Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
Organisational abbreviations given in table 1. EU, Europe; CAN, Canada; CHIN, China; NZ, New Zealand; AUS, Australia.
N N
N 5068 m shuttle run 4/3/2 min 25 m shuttle run Hoosier endurance shuttle run 1.5-mile run/walk test 1-mile run/walk test 1000 m run 1/2-mile run/walk test 1/4-mile run/walk test Cooper test 9-min running 1-min jump rope
20 m shuttle run
N
N
N
Distance run/walk tests
Aerobic capacity
FITNESSGRAM (USA)
Fitness test battery (country)
EUROFIT (EU) Fitness test Fitness quality
Table 2
Field-based fitness tests used to assess cardiorespiratory fitness
PCPF (USA)
N
AAUTB (USA)
N
YMCAYFT (USA)
N
NYPFP (USA)
N
HRFT (USA)
N N
Physical Best (USA)
N
IPFT (USA)
N N N N
CAHPER-FPT II (CAN)
CPAFLA (CAN)
N N
NFTP-PRC (CHIN)
N N
NZFT (NZ)
AFEA (AUS)
Review
The most commonly used equation to estimate VO2peak from the 1-mile run/walk test is the Cureton equation,34 which was selected for the FITNESSGRAM battery to estimate VO2peak.11 We have examined the criterion-related validity of Cureton equation in 66 endurance trained children and adolescents aged 8–17 years.35 We observed that there was a significant mean difference between measured and estimated VO2peak (10.01 ml/ kg/min, 95% confidence interval (CI) 9.2 to 11.8, p,0.001). The findings did not materially change when the analyses were performed by sex, age groups and weight status, which suggests that this equation is not accurate for estimating VO2peak in endurance trained children.35 Buono et al36 also developed an equation 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-mile run/walk test is not a friendly test, especially in young people. One of its major problems is the participant’s capacity to develop an appropriate pace. Participants may either start too fast so that they are not able to keep up the speed all through the test, or they may start too slow so that when they want to increase speed, the test is already finished. To ameliorate this problem, several versions were developed such us the 1-mile 3
4
Basketball throw Medicine ball throw Sand ball throw (0.25 kg) Shot put (1, 2, 3, 4 or 5 kg) Back throw (8 pounds) Standing broad jump N Vertical jump Sit and reach N V sit and reach Back saver sit and reach Shoulder stretch
N
N
N
N N
N
N
N
N
N N
PCHF (USA)
N N N
FITNESSGRAM (USA)
Organisational abbreviations given in table 1. EU, Europe; CAN, Canada; CHIN, China; NZ, New Zealand; AUS, Australia.
Flexibility
Lower body
Lower body Explosive strength: Upper body
Trunk
N
Trunk lift
Bent arm hang Pull-ups Modified pull-ups Parallel-bars dips Push-ups Modified push-ups Isometric push-ups Sit-ups Curl-ups Partial curl-ups Phantom chair
N
Hand-grip strength
Maximal isometric strength
Endurance strength: Upper body
N
Fitness test
Fitness quality
EUROFIT (EU)
Fitness test battery (country)
Table 3 Field-based fitness tests used to assess musculoskeletal fitness
N N
N N
N
N N
PCPF (USA)
N
N
N
N N N
N N
AAUTB (USA)
N
N
N
YMCAYFT (USA)
N
N
N N
N N N
NYPFP (USA)
N
N
HRFT (USA)
N
N
N
Physical Best (USA)
N
N
IPFT (USA)
N
N
CAHPERFPT II (CAN)
N N
N
N
N
N
CPAFLA (CAN)
N N
N
N N N N
NFTP-PRC (CHIN)
N
N
N
N N
N
NZFT (NZ)
N
N
N
N
AFEA (AUS)
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Shuttle run (1065 m) Shuttle run with sponges (1064 m) 10 sec 25 m shuttle run 100 m dash 50 m dash Plate tapping Flamingo balance
Speed and agility
N
N
N
Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321 N
PCHF (USA)
Height and N weight Waist circumference Hip circumference Waist-to-hip ratio Waist-to-height ratio Body mass index Skin fold N thickness
Anthropometric indices
PCPF (USA)
N
N
N N
PCHF (USA)
N
FITNESSGRAM (USA)
Organisational abbreviations given in table 1. EU, Europe; CAN, Canada; CHIN, China; NZ, New Zealand; AUS, Australia.
Fitness test
EUROFIT (EU)
Fitness test battery (country)
Field-based fitness tests used to assess body composition
Fitness quality
Table 5
Organisational abbreviations given in table 1. EU, Europe; CAN, Canada; CHIN, China; NZ, New Zealand; AUS, Australia.
Speed of limbs Balance
Speed
Fitness test
FITNESSGRAM EUROFIT (EU) (USA)
Fitness test battery (country)
Field-based fitness tests used to assess motor fitness
Fitness quality
Table 4
PCPF (USA)
N N
N
AAUTB (USA)
AAUTB (USA)
N
N
YMCAYFT (USA)
YMCAYFT (USA)
NYPFP (USA)
NYPFP (USA)
N
N
HRFT (USA)
HRFT (USA)
N N
Physical Best (USA)
Physical Best (USA)
N
N
N
N
IPFT (USA)
IPFT (USA)
N N
N
CAHPERFPT II (CAN)
CAHPER-FPT II (CAN)
N N
N
N
N
N
CPAFLA (CAN)
CPAFLA (CAN)
NFTP-PRC (CHIN)
N N
N
N
NFTP-PRC (CHIN)
N
N
NZFT (NZ)
NZFT (NZ)
N
AFEA (AUS)
AFEA (AUS)
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Review Table 6
Quality assessment criteria for criterion-related validity studies
Grading system parameter
Grade
Criterion
Number of study subjects
0 1 2 0
n(10 n = 11–50 n>51 Less items than required for grade 1
Description of the study population with respect to age, sex, health status, fitness levels, pubertal status, ethnicity, physical activity patterns, body composition, etc.
Maximal isometric strength 1
Statistical analysis included in the study
2 0 1 2
At least age, sex, health status and fitness levels More items than required for grade 1 Those not included in 1 Error indexes or regression analysis >3 items or Bland–Altman plot and/ or ANOVA for repeated measurements
Rating for total score: high quality = 5–6 low quality = 3–4 very low quality = 0–2
walk,39 the submaximal 1-mile track jog test (pacing test),40 and the 1/2-mile run/walk test (table 2).41 We assessed the criterionrelated validity of the 1/2-mile run/walk test in children aged 6– 17 years, and also examined the criterion-related validity of the Fernhall equation in a subgroup of children aged 10–17 years.41 We computed a regression equation that was assessed through several error measures and the Bland–Altman method. We found that the 1/2-mile run/walk time, sex and BMI were significantly associated with VO2peak. There was no systematic bias in the validation group nor in the cross-validation group (p.0.1), and the root mean squared error (RMSE) and the percentage error were 6.5 ml/kg/min and 13.9%, respectively. The newly developed equation had a lower RMSE and percentage error than the Fernhall equation in the subgroup of children aged 10–17 years (7.2 vs 17.7 ml/kg/min and 16.0% vs 50.4%, respectively, p,0.001). In conclusion, there is strong evidence indicating that the 20mSRT is a suitable test to estimate cardiorespiratory fitness. From the developed equations, it seems that the Barnett (b) and Ruiz equations yielded the most promising results to estimate VO2max. There is moderate evidence in the case of the 1-mile run/walk test, and limited evidence that the 1-mile walk test, the submaximal 1-mile track jog test (pacing test) and the 1/2run/walk test are valid tests to estimate VO2max (or VO2peak). The Cureton equation seems the best equation to predict VO2peak from the 1-mile run/walk test, but the fitness levels of the individuals may affect its validity.
Musculoskeletal fitness Two studies examined the criterion-related validity of the handgrip strength test (maximal isometric strength),42 43 one study examined the criterion-related validity of the bent arm hang, push-ups, pull-ups and modified pull-ups tests44 (upper body endurance strength) and one examined the criterion-related validity of the standing broad jump and vertical test.43 Two studies assessed the criterion-related validity of flexibility: one analysed the back saver sit and reach test,45 and the other one analysed the trunk lift test46 (see supplementary material, table 2). There is no established gold standard for most of the musculoskeletal fitness tests, which makes it difficult to determine the criterion-related validity of these tests. The specificity of the type of muscular work performed and the use of different energy systems are both major challenges for 6
establishing a gold standard method for maximal muscular strength and endurance strength tests.47 One repetition maximum (1RM) and repetitions to a certain percentage of 1RM (ie, 50% of 1RM or 70% of 1RM) have been used as gold standards.43 44 Concerning flexibility, radiography seems to be the best criterion measurement, but goniometry has also been used as a criterion measure.45 48–50
We have studied the criterion-related validity of the hand-grip strength test using Jamar, DynEx and TKK dynamometers in adolescents aged 12–16 years.42 We used known weights (ranging from 20 to 70 kg) as the criterion measure. We observed a negative systematic bias (underestimation) for the Jamar and DynEx dynamometers (21.92 and 21.43 kg, respectively, p,0.05), whereas a marginal positive overestimation was observed for the TKK dynamometer (0.49 kg, p,0.05). These results concur with those reported in studies performed in adults.51–59 We also examined whether the elbow position (extended or flexed at 90 degrees) affects the hand-grip strength in adolescents. We observed that performing the hand-grip strength test with the elbow extended seems the most appropriate protocol to evaluate maximal hand-grip strength in adolescents when using the TKK dynamometer. We have also conducted a series of studies in children60 and adolescents,61 to determine if there is an optimal grip span for determining the maximum hand-grip strength, and if the optimal grip span was related to hand size. We found that there was an optimal grip span to which the dynamometer should be adjusted when measuring hand-grip strength in children60 and adolescents.61 We provided sex and age specific equations to adjust the grip span of the dynamometer to the hand size of the individual in order to obtain the actual maximal hand-grip strength. Milliken et al43 analysed the association between hand-grip strength (using the TKK dynamometer) and 1RM chest press in children aged 7–12 years. They found that the hand-grip strength test is valid to assess upper body maximal strength.
Upper body endurance strength Woods et al44 studied the criterion-related validity of the bent arm hang, push-up, pull-ups and two modified pull-up tests using 1RM and repetitions at 50% of 1RM as criterion reference in children aged 9–11 years. They concluded that these tests are not valid to assess muscular endurance and that body fat percentage was the main determinant of performance. We observed that muscular strength is highly influenced by body weight in children aged 6–17 years,62 especially in relation to weight bearing tests. We showed that out of 2778, a total of 1037 (85%) of the girls and 889 (60%) of the boys were not able to perform a single repetition in the pull-up test. Likewise, a total of 478 (39%) of the girls and 409 (28%) of the boys were not able to perform for more than 0 s in the bent arm hang test. Collectively, these findings suggest that these tests are not appropriate to measure upper body endurance strength in children and adolescents.
Lower body explosive strength Milliken et al43 studied the criterion-related validity of the standing broad jump test and the vertical jump test using 1RM of leg press as criterion measure in children aged 7–12 years. They reported that the standing broad jump and vertical jump test, with BMI, accounted for 44.4% and for 40.8% of the variation in 1RM leg press, respectively. Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
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Review Flexibility Patterson et al studied the criterion-related validity of the back saver sit and reach test using goniometry (hamstring flexibility) and the MacRae and Wright method (low back flexibility) as gold standard in children and adolescents aged 11–15 years.45 The results suggested that this test has a moderate validity to assess hamstring flexibility (r = 0.51 to 0.72), and a low validity to assess the lower back flexibility (r = 0.10 to 0.25). Paterson et al46 reported that the correlations of trunk lift scores and the goniometry scores were moderate (r = 0.70 for boys and r = 0.68 for girls) in children of similar ranges of age. In conclusion, there is strong evidence that the hand-grip strength test with the elbow extended and with the grip span adapted to the individual’s hand size (using the TKK dynamometer) is a valid test to assess isometric muscular strength. Due to a limited number of studies, we found limited evidence that: (1) the bent arm hang, push-up, pull-ups and two modified pull-ups tests are not valid to assess muscular endurance and (2) the back saver sit and reach test and the trunk lift test have moderate validity to measure hamstring flexibility and lumbar flexibility.
Body composition A total of 22 studies investigated the criterion-related validity of BMI,63–84 18 investigated the validity of skin fold thickness,64–66 72–76 80 82 85–92 and 7 studied the validity of circumferences and/or ratios (ie, waist-to-hip ratio) (see supplementary material, table 2).63 65 66 82 83 92 93 Imaging methods (ie, axial CT and MRI),94 dual energy x ray aborptiometry (DXA),95 ultrasonography,96 and air displacement plethysmography97 98 are considered gold standards for assessing body composition in youth. Bioelectrical impedance analysis (BIA) has also been used a reference method for body fat determination,99 100 whereas hydrodensiometry is considered the gold standard in adults, but not in children due to the fact that they have difficulties with the breathing manoeuvre involved in determining underwater weight.85
Skin fold thickness The validity of different skin fold* equations to estimate percentage body fat, mainly the Slaughter equation, have been extensively analysed by using the Bland–Altman method72 82 85 87–89 and/or ANOVA for repeated measures.82 86 Rodrı´guez et al88 reported that the Slaughter equations using either triceps and subscapular or triceps and calf skin folds had the best agreement in male and female adolescents. Likewise, Buison et al89 found that the Brook equation is a valid alternative to measure percentage body fat in children aged 7–10 years (mean difference = 21.4% for percentage body fat; with limits of agreement of ¡12.2%). Treuth et al87 reported that the Slaughter equation appears to be valid to estimate percentage body fat in prepubertal multiethnic girls (R2 = 0.69). Gutin et al85 reported a strong correlation between the Slaughter equation and the criterion measure (BIA and DXA), yet the limits of agreement were high (DXA vs skin fold thickness 23.65 to 9.50 and BIA vs skin fold thickness 210.81 to 9.89). Likewise, Campanozzi et al91 reported similar results in obese children and adolescents when they compared the Brook equation, BIA and DXA. It is noteworthy that discrepancies between methods seem to increase with the degree of obesity, which indicates the presence of heteroscedascity. Ihmels et al90 showed a good overall agreement between estimates from BIA and sum of triceps and subscapular skin fold Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
(classification agreement values: 82.8–92.6%). Guida et al64 reported, with BIA vector distribution, that triceps skin fold had moderate validity to assess percentage body fat (r = 0.79, p,0.001), and that it was not affected by body size. Goran et al65 developed several equations to estimate intra-abdominal adipose tissue and subcutaneous abdominal adipose tissue. They concluded that intra-abdominal adipose tissue was best predicted by abdominal skin fold, ethnicity and subscapular skin fold (R2 = 0.82, SEE: 9.8 cm2), whereas subcutaneous abdominal adipose tissue was best predicted by waist circumference, subscapular skin fold, height and abdominal skin fold (R2 = 0.92, SEE: 28.8 cm2). However, in obese children and adolescents, using ultrasound as a gold standard method, triceps and subscapular skin fold did not show a good validity (r = 0.13 to 0.34, r = 0.02 to 0.37, respectively).66 Differences in criterion methods, statistical methods and techniques to measure skin fold thickness make comparison among studies difficult.
BMI Correlations between BMI and body fat measured by more advanced methods generally exceed 0.50 and are frequently much higher.67 68 This finding supports, a priori, the validity of BMI, yet several studies highlight that BMI should be used with caution when comparing groups with different demographic characteristics and using DXA as criterion measure.68–70 77 78 81 Ellis et al69 reported in children aged 3–10 years that the correlations between percentage body fat and BMI were significant for girls (R2 = 0.70, p,0.001) and boys (R2 = 0.34, p,0.001); however, when a linear model was used, the ability of BMI to accurately estimate percentage body fat was poor (SEE: 4.7% for girls and SEE: 7.3% for boys). Daniels et al70 studied whether BMI was a representative equivalent measure of body fat independent of age, race, gender, sexual maturation and distribution of fat in children and adolescents aged 7–17 years. They showed that BMI, gender, race, sexual maturation and distribution of fat were all significant independent correlates of the percentage body fat (R2 = 0.77). In order to detect possible changes in body composition, Guida et al64 analysed the association between BIA vector distribution and BMI in children aged 8 years. They showed a relationship between fat mass using BIA and BMI (r = 0.92, p,0.001) and fat free mass using BIA and BMI (r = 0.58, p,0.001). However, they showed that BMI was not able to differentiate whether the weight change was due to a variation in body fat or in fat free mass, which concurs with other studies.66 70 Moreno et al71 tried to improve the International Obesity Task Force BMI cut-off values, in terms of prediction of percentage body fat in adolescents aged 13–17 years. They concluded that BMI cut-off points seem to be useful as an approximate classification of obesity status, but cannot accurately predict a specific individual’s percentage body fat. Therefore, they suggested that BMI could be used as a screening test, but that in clinical setting the percentage body fat should be measured by using a more accurate method such as DXA. Several studies have compared the accuracy of BMI and skin fold thickness to estimate body fat.72–76 Steinberger et al72 reported that the Slaughter equation and BMI were highly correlated with DXA children and adolescents aged 11–17 years. Similarly, Sarria et al73 developed several equations to estimate body density from underwater weighing in boys aged 7–16 years. They found that the correlations between body density and logS4 skin folds (r = 20.781 to 0.820) were higher than those with BMI (r = 20.586 to 20.798) at all ages. The best estimators of body density were logS4 skin folds or a 7
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73.
74. 75.
76. 77.
78.
79. 80.
81.
82. 83.
84. 85.
86. 87. 88.
89.
90. 91. 92. 93.
94. 95.
96.
97. 98. 99. 100.
Sarria A, Garcia-Llop LA, Moreno LA, et al. Skinfold thickness measurements are better predictors of body fat percentage than body mass index in male Spanish children and adolescents. Eur J Clin Nutr 1998;52:573–6. Freedman DS, Wang J, Ogden CL, et al. The prediction of body fatness by BMI and skinfold thicknesses among children and adolescents. Ann Hum Biol 2007;34:183–94. Eliakim A, Ish-Shalom S, Giladi A, et al. Assessment of body composition in ballett dancers: correlation among anthropometric measurements, bio-electrical impedance analysis, and dual-energy x-ray absorptiometry. Int J Sports Med 2000;21:598–601. Cassady SL, Nielsen DH, Janz KF, et al. Validity of near infrared body composition analysis in children and adolescents. Med Sci Sports Exerc 1993;25:1185–91. Lindsay RS, Hanson RL, Roumain J, et al. Body mass index as a measure of adiposity in children and adolescents: relationship to adiposity by dual energy x-ray absorptiometry and to cardiovascular risk factors. J Clin Endocrinol Metab 2001;86:4061–7. Mei Z, Grummer-Strawn LM, Pietrobelli A, et al. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr 2002;75:978–85. Deurenberg P, Weststrate JA, Seidell JC. Body mass index as a measure of body fatness: age- and sex-specific prediction formulas. Br J Nutr 1991;65:105–14. Bray GA, DeLany JP, Harsha DW, et al. Evaluation of body fat in fatter and leaner 10-y-old African American and white children: the Baton Rouge Children’s Study. Am J Clin Nutr 2001;73:687–702. Taylor RW, Jones IE, Williams SM, et al. Body fat percentages measured by dualenergy x-ray absorptiometry corresponding to recently recommended body mass index cutoffs for overweight and obesity in children and adolescents aged 3–18 y. Am J Clin Nutr 2002;76:1416–21. Eisenmann JC, Heelan KA, Welk GJ. Assessing body composition among 3- to 8year-old children: anthropometry, BIA, and DXA. Obes Res 2004;12:1633–40. Brambilla P, Bedogni G, Moreno LA, et al. Crossvalidation of anthropometry against magnetic resonance imaging for the assessment of visceral and subcutaneous adipose tissue in children. Int J Obes (Lond) 2006;30:23–30. Freedman DS, Wang J, Maynard LM, et al. Relation of BMI to fat and fat-free mass among children and adolescents. Int J Obes (Lond) 2005;29:1–8. Gutin B, Litaker M, Islam S, et al. Body-composition measurement in 9–11-yr-old children by dual-energy x-ray absorptiometry, skinfold-thickness measurements, and bioimpedance analysis. Am J Clin Nutr 1996;63:287–92. Janz KF, Nielsen DH, Cassady SL, et al. Cross-validation of the Slaughter skinfold equations for children and adolescents. Med Sci Sports Exerc 1993;25:1070–6. Treuth MS, Butte NF, Wong WW, et al. Body composition in prepubertal girls: comparison of six methods. Int J Obes Relat Metab Disord 2001;25:1352–9. Rodriguez G, Moreno LA, Blay MG, et al. Body fat measurement in adolescents: comparison of skinfold thickness equations with dual-energy x-ray absorptiometry. Eur J Clin Nutr 2005;59:1158–66. Buison AM, Ittenbach RF, Stallings VA, et al. Methodological agreement between two-compartment body-composition methods in children. Am J Hum Biol 2006;18:470–80. Ihmels M, Welk GJ, McClain JJ, et al. The reliability and convergent validity of field tests of body composition in young adolescents. JPAH 2006;3:S67–77. Campanozzi A, Dabbas M, Ruiz JC, et al. Evaluation of lean body mass in obese children. Eur J Pediatr 2008;167:533–40. Paineau D, Chiheb S, Banu I, et al. Comparison of field methods to estimate fat mass in children. Ann Hum Biol 2008;35:185–97. Taylor RW, Jones IE, Williams SM, et al. Evaluation of waist circumference, waistto-hip ratio, and the conicity index as screening tools for high trunk fat mass, as measured by dual-energy x-ray absorptiometry, in children aged 3–19 y. Am J Clin Nutr 2000;72:490–5. Pietrobelli A, Tato L. Body composition measurements: from the past to the future. Acta Paediatr Suppl 2005;94:8–13. Sopher AB, Thornton JC, Wang J, et al. Measurement of percentage of body fat in 411 children and adolescents: a comparison of dual-energy x-ray absorptiometry with a four-compartment model. Pediatrics 2004;113:1285–90. Ferrozzi F, Zuccoli G, Tognini G, et al. An assessment of abdominal fatty tissue distribution in obese children. A comparison between echography and computed tomography [in Spanish]. Radiol Med (Torino) 1999;98:490–4. Fields DA, Hull HR, Cheline AJ, et al. Child-specific thoracic gas volume prediction equations for air-displacement plethysmography. Obes Res 2004;12:1797–804. Urlando A, Dempster P, Aitkens S. A new air displacement plethysmograph for the measurement of body composition in infants. Pediatr Res 2003;53:486–92. Pietrobelli A, Andreoli A, Cervelli V, et al. Predicting fat-free mass in children using bioimpedance analysis. Acta Diabetol 2003;40(Suppl 1):S212–15. Pietrobelli A, Rubiano F, St-Onge MP, et al. New bioimpedance analysis system: improved phenotyping with whole-body analysis. Eur J Clin Nutr 2004;58:1479–84.
Br J Sports Med 2009;000:0–10. doi:10.1136/bjsm.2009.058321
Supplementary Material
Table 1. Quality assessment of fitness criterion-related validity studies. Study
Fitness Component
Description of the study population
Cardiorespiratory fitness
1
1
1
3
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
2
2
0
4
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
1
2
1
4
Cardiorespiratory fitness
2
2
0
4
Cardiorespiratory fitness
2
2
1
5
Cardiorespiratory fitness
1
2
2
5
Cardiorespiratory fitness
1
2
2
5
Cardiorespiratory fitness
2
2
1
5
Cardiorespiratory fitness
1
2
2
5
Cardiorespiratory fitness
2
2
2
6
Cardiorespiratory fitness
2
2
2
6
Cardiorespiratory fitness
2
2
2
6
Matsuzaka et al.
Cardiorespiratory fitness
2
2
2
6
19
Cardiorespiratory fitness
2
2
2
6
Cardiorespiratory fitness
2
2
2
6
Cardiorespiratory fitness
2
2
2
6
Cardiorespiratory fitness
2
2
2
6
Naughton et al. Boreham et al. Anderson
2
3
4
Liu et al.
5
Mahoney
6
Rowland et al. 7
Huse et al.
8
Drinkard et al. 9
Li et al.
10
Buono et al.
11
McVeigh et al.
12
McSwegin et al. 13
Pitetti et al. Ruiz et al.
14 15
Barnett et al.
16
Cureton et al. 17
Hunt et al.
18
Suminski et al. 20
Mahar et al. Ruiz et al.
21 22
Castro-Piñero et al.
Statistical analysis
Total score
Downloaded from bjsm.bmj.com on 8 June 2009
Number of study subjects
1
1
Supplementary Material
Castro-Piñero et al.23 24
Ikeda et al.
25
Pate et al.
26
Cornbleet & Woolsey Fjørtoft
27 28
Hartman & Looney 29
Hannibal et al.
2
6
Musculoskeletal fitness
1
2
0
3
Musculoskeletal fitness
2
2
0
4
Musculoskeletal fitness
2
1
1
4
Musculoskeletal fitness
2
2
0
4
Musculoskeletal fitness
2
2
0
4
Musculoskeletal fitness
2
2
0
4
Musculoskeletal fitness
2
2
0
4
31
Musculoskeletal fitness
2
2
1
5
32
Musculoskeletal fitness
2
2
1
5
Musculoskeletal fitness
2
2
1
5
Musculoskeletal fitness
2
2
1
5
Musculoskeletal fitness
2
1
2
6
Motor fitness
2
1
0
3
Motor fitness
2
2
0
4
Body composition
1
2
0
3
Body composition
2
1
0
4
Body composition
2
2
0
4
Body composition
2
2
0
4
Body composition
2
2
0
4
Body composition
1
2
1
4
Body composition
1
2
2
5
Body composition
1
2
2
5
Body composition
2
2
1
5
Patterson et al. 33
Woods et al.
34
Milliken et al.
España-Romero et al. VanWaelvelde et al.
35
36
27 37
De Ridder et al. 38
White et al.
39
Maynard et al.
40
Casanova-Roman et al. 41
Ittenbach et al. 42
Watts et al.
43
Cassady et al. 44
Gutin et al.
Daniels et al.
2
30
Patterson et al.
Fjørtoft
2
45
Downloaded from bjsm.bmj.com on 8 June 2009
Kanbur et al.
Cardiorespiratory fitness
2
Supplementary Material
Lindsay et al.46
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
1
5
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Eliakim et al.
Body composition
2
2
2
6
61
Taylor et al.
Body composition
2
2
2
6
62
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Eisenmann et al.
Body composition
2
2
2
6
66
Body composition
2
2
2
6
67
Body composition
2
2
2
6
Steinberger et al.
Body composition
2
2
2
6
69
Body composition
2
2
2
6
Mei et al.
48
Moreno et al.
Freedman et al.
49
50
Semiz et al.
51
Rodríguez et al. 52
Guida et al.
53
Deurenberg et al. 54
Janz et al.
Goulding et al.
55
56
Goran et al.
57
Pietrobelli et al. 58
Sarria et al.
59
Ellis et al.
60
Bray et al.
63
Treuth et al.
Taylor et al.64 65
Freedman et al.
Rodriguez et al.
68
Brambilla et al.
Downloaded from bjsm.bmj.com on 8 June 2009
Body composition
47
3
Supplementary Material
Buison et al.70 71
Ihmels et al.
72
Campanozzi et al. 73
Paineau et al.
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Body composition
2
2
2
6
Downloaded from bjsm.bmj.com on 8 June 2009
4
Supplementary Material
Table 2. Overview of fitness criterion-related validity studies (high quality) in children and adolescents. Author
Subjects
Age (y)
Test
Gold standard
10 - 18
1-mile run, step test, cycle ergometer test
Gas analyzer in maximal treadmill test
Statistical methods
Main outcome
Conclusion
r=-0.73 between 1-mile and VO2max
Time distance run is superior predictor of cardiorespiratory fitness than step test and cycle ergometer test
Cardiorespiratory fitness Buono et al.10
Correlation coefficient (r), multiple regression analysis, SEE, %
r=0.48 between step test and VO2max r=0.49 between cycle ergometer test and VO2max Prediction equation r=0.84, SEE=4.3 ml/kg/min or 9% for 1mile
McVeigh et al.11
boys = 15 girls = 18
13 - 14
20mSRT
Gas analyzer in maximal treadmill test
Correlation coefficient (r), multivariate regression, SEE, SE
R2=0.85; SEE=2.4 ml/kg/min in girls; and R2=0.68; SEE=3.23 ml/kg/min in boys
20mSRT is a valid test to estimated VO2peak
McSwegin et al.12
boys =20 girls = 24
14 - 18
1-mile walk
Gas analyzer in maximal treadmill test (modified Balke Protocol)
Correlation coefficient (r), SEE, E, %error, paired t test
r=0.84. SEE=4.50 ml/kg/min, E=7.16 ml/kg /min, %error=38.6 for the Dolgener’s equation
1-mile walk is an acceptable test to estimate cardiorespiratory fitness if VO2max is estimated from Rockport Fitness Walking test
Gas analyzer in maximal treadmill test
Correlation coefficient (r), analysis of variance, SEE
r=0.78 between Fernhall’s and Leger’s equation
Pitetti et al.13
boys = 13 girls = 38
8 - 15
20mSRT
r=0.80. SEE=4.99 ml/kg/min, E=5.17 ml/kg/min, %error=65.9 for the Kline’s equation
R=0.671, SEE=5.8 ml/kg/min in
a) VO2peak was moderately related to both regression equations, b) correlation between the two regression equations was significantly high, and
5
Downloaded from bjsm.bmj.com on 8 June 2009
boys = 45 girls = 45
Supplementary Material
Fernhall´s equation R=0.613, SEE=6.1 ml/kg/min in Leger´s equation Ruiz et al.14
boys = 26 girls = 22
13 - 19
20mSRT
Portable gas analyzer during 20mSRT
Ruiz’s equation: r=0.758, SEE=5.3 ml/kg/min, mean difference=3.7 ml/kg/min
Barnet (b) and Ruiz’s equation seem to be the best ones to estimate VO2max in the present sample of adolescents
Leger’s equation: r=0.587, SEE=6.5 ml/kg/min, mean difference=5.5 ml/kg/min Barnett’s (a): r=0.757, SEE=5.3 ml/kg/min, mean difference=2.9 ml/kg/min Barnett’s (b): r=0.725, SEE=5.6 ml/kg/min, mean difference=1.3 ml/kg/min Matsuzaka’s equation: r=0.736, SEE=5.5 ml/kg/min, mean difference=3.2 ml/kg/min
Barnett et al.15
boys = 27 girls = 28
12 - 17
20mSRT
Gas analyzer in maximal treadmill test
Correlation coefficient (r), multiple regression, SEE, RMSE
r=0.72 between VO2peak and Leger´s Equation
20mSRT is a good predictor of VO2peak
r=0.74; SEE=4.6 ml/kg/min between maximal shuttle run speed and VO2peak New equation: r=0.82; SEE=4.0 ml/kg/min
Cureton et al.16
boys = 495 girls = 258
8 - 25
1-mile run/walk
Gas analyzer in maximal treadmill test
Correlation coefficient (r), multiple regression,
Prediction equation r=0.71, SEE=4.8 ml/kg/min Cross validation r=0.72, SEE=4.8 ml/kg/min
Generalized equation provides validity to estimates of VO2peak in youth and young adults
6
Downloaded from bjsm.bmj.com on 8 June 2009
Regression, ANOVA for repeated measures, Bland-Altman method, SSE, SEE, MSE, RMSE, %error, 95% CI
c) both regression equations had similar validity
Supplementary Material
SEE, TE Hunt et al.17
boys =42 girls = 41
13 - 17
1-mile jogging test (pacing)
Gas analyzer in maximal treadmill test
Correlation coefficient (r), ANOVA, SEE, total error, predicted residual sum of squares
Prediction equation r=0.88, SEE=3.26 ml/kg/min
Equation has sufficient accuracy to estimate VO2max
Cross-validation r=0.88, SEE=3.34 ml/kg/min, total error=4.39 ml/kg/min
boys = 62 girls = 70
8 - 17
20mSRT
Gas analyzer in maximal treadmill test
Correlation coefficient (r), stepwise regression, Bland-Altman, SEE
R2=0.81; SEE=3.3 ml/kg/min; r from 0.77 to 0.87 between predicted and measured VO2peak
The 20mSRT seems to be valid test
Suminski et al.19
boys = 58 girls = 67
10 - 12
20mSRT
Gas analyzer in maximal treadmill test
Correlation coefficient (r), Bland-Altman method, paired t test, SEE, E
r=0.62 (P0.05). The magnitudes of difference between test and retest scores were always three seconds or less. Tiltboard balance: inter-raters reliabilities were high, and in the majority of cases the two examiners’ ratings were exactly the same. No significant differences among raters were found (P>0.05). The test-retest correlations and the magnitude of differences for the tiltboard balance test were poor. No significant differences between test and retest scores were found for the tiltboard test in the eyes-open condition (P>0.05). However, in the eyes-closed condition, children were able to achieve an average of 29.6 degrees more tilt in the retest situation (P=0.007). In conclusion, these tests were found to have low to moderate reliability.
Body composition Stoddard et al. 2008
Mueller and Kaplowitz 1994
n = 70
n = 19
5 - 12
8-9
Height, weight
Height, weight, BMI,
interobserver (?)
intraobserver interobserver
Dichotomous variable representing agreement (± 0.5 centimeters for height and ± 0.5 kilograms for weight), absolute value of interrater difference
For weight, % agreement by age was 97% for the younger students and 100% for the older students. The mean and greatest interrater absoulte differences were 0.06 and 0.8 kg, respectively. For height, % agreement by age was 80% for the younger students and 85% for the older students. The mean and greatest interrater absoulte differences were 0.34 and 1.7 cm, respectively.
Paired t-test, measurement
Intra- and inter-observer precisions were highest for weight, height, BMI and six body circumferences (0.95-0.99), and were lower and
Overall, the nurses provided screening with very good reliability for weight measures compared to trained staff. Height, however, requieres more careful attention, especially among younger chidren, because of the importance of proper positioning in order to obtain an accurate measurement.
Artero et al., revised version submitted to J Sports Sci circumferences, skinfold thickness and indices of fat distribution
(?)
error variance, precision coefficient (an intraclass correlation)
more variable for five skinfold thicknesses (0.80-0.99). The measurement precision of ratio indices derived from the circumferences (waist/hip and waist/thigh) and the skinfolds (subscapular/thigh and triceps/subscapular) were lower and more variable than precisions of the single variables. Circumference ratio precisions varied from 0.81 to 0.96 and skinfold ratios varied from 0.28 to 0.94. Interobserver precisions tended to be significantly lower than intraobserver precisions for skinfold thicknesses and all composite indices, whereas height, weight, BMI and circumferences are less affected by this factor. The lower precision of ratio indices, compared to the measurement accuracy of the variables which make them up, needs to be considered in epidemiological studies of body fat distribution.
WHO Study Group 2006
n different for each measurement
0 - 5.9
Weight, recumbent length, height, head and arm circumferences, triceps and subscapular skinfolds
intraobserver interobserver (0 d ?)
TEM, coefficient of reliability (R), average bias (average difference between measurements taken by an expert and those taken by an observer)
TEM estimates for teams compared well with the expert. Average bias was within acceptable limits of deviation from the expert, with head circumference having both lowest bias and lowest TEM. Observer tended to underestimate length, height and arm circumference, and to overestimate skinfold measurements. This was likely due to difficulties associated with keeping children fully stretched out and still for length/height measurements and in manipulating soft tissues for the other measurements. Intra- and inter-observer TEMs were comparable, and newborns, infants and older children were measured with equal reliability. The coefficient of reliability was above 95% for all measurements except skinfolds whose R coefficient was 75-93%.
Artero et al., revised version submitted to J Sports Sci Nagy et al. 2008
boys = 10 girls = 10
14
Skinfold thickness, body circumferences
intraobserver interobserver (?)
TEM, coefficient of reliability, correlation (r)
Intraobserver TEMs were smaller than 1 mm (skinfold thickness) and 1 cm (circumferences). In most cases, intraobserver reliability was greater than 95% for skinfold thickness and greater than 97% for circumferences. Interobserver TEMs ranged from 1 to 2 mm for skinfold thicknesses and from 1 to 2 cm for circumferences. Interobserver reliabilities for skinfold thickness and circumference were always greater than 90%. Significant correlations observed between the means and standard deviations of skinfold thickness and circumferences indicate that the variability of measurements is greater when the measures taken are also greater. Anthropometric measurement error cannot be avoided but should be minimized as much as possible by paying close attention to every aspect of the data-collection process. At the end of the standardization process (workshop), the intra- and interobserver TEMs and coefficients of reliability for skinfold thicknesses and circumferences were better than the required levels, assuring the comparability of the data obtained in different cities.
Voss et al. 1990
n = 10
4 - 11
Height
intraobserver interobserver (0 d)
Paired statistics, mean difference, SD
The estimated SD for a single height measurement ranged from 0.17 to 0.58 cm. One of the stadiometer was significantly less reproducible than the other four. Significant interobserver differences were found in three of the five stadiometers. Mean interobserver difference ranged from 0.05 to 0.33 cm. Analysis of the components of variance showed that the participants' contribution to the total variance ranged from 100% to 88%, observers and instruments accounting for the remainder.
Artero et al., revised version submitted to J Sports Sci
Vegelin et al. 2003
boys = 11 girls = 7
2-7
Height, triceps skinfold thickness
intraobserver interobserver (0 d)
TEM, average bias (AB), Spearman Rank correlation coefficients, multiple linear regression, Bland-Altman method, F-test
The median TEM for height and skinfold thickness (0.36 cm and 0.57 mm, respectively) were about twice the expert value (0.21 cm and 0.37 mm, respectively). The best educated and most experienced observers scored the best precision and accuracy. Precision and accuracy in measuring height and triceps skinfold thickness are mainly predicted by knowledge of the measurement protocol (p
