Associations of Cardiorespiratory and
Musculoskeletal Fitness with Body Mass Index
and Waist Circumference:
Fitness versus Fatness in a Population-based
Sample of Chilean 8th Graders
March 21, 2014
Michael Garber, MPH, Emory University
[email protected]
Marcelo Sajuria, MD, Chile Institute of Sport
[email protected]
Felipe Lobelo, MD PhD, Centers for Disease Control and Prevention
[email protected]
Disclosure
Michael Garber, MPH
No relevant financial relationship exists.
Marcelo Sajuria, MD
No relevant financial relationship exists.
Felipe Lobelo, MD PhD
No relevant financial relationship exists.
Garber et al. Fitness vs. Fatness Chile 8th Graders 2
Outline
Background
Objectives
Methods
Results
Conclusions
Garber et al. Fitness vs. Fatness Chile 8th Graders 3
Background: Fitness, Fatness, and Risk of Cardio-Metabolic
Disease and Mortality
Cardiorespiratory fitness
• Adults: Cardiorespiratory fitness > BMI in
determining mortality risk1
• Adolescents: Within high fatness group, low fit at
four times cardiovascular risk than high fit.2
Musculoskeletal Fitness:
Independent of cardiorespiratory fitness and body
composition, low musculoskeletal fitness is
associated with higher cardio-metabolic risk and
mortality in adults and adolescents.3,4
Garber et al. Fitness vs. Fatness Chile 8th Graders 4
Background: Associations between Fitness and Fatness in
Adolescents
Cardiorespiratory fitness and fatness
Strength of association:
Imaging (e.g. CT) > waist circumference > BMI 5,6
Musculoskeletal fitness and fatness
Higher musculoskeletal fitness—assessed through
weight-bearing tests such as the standing long
jump—associated with lower fatness.5
Garber et al. Fitness vs. Fatness Chile 8th Graders 5
Background: Needs
• Association of musculoskeletal fitness with
fatness has been explored less than
cardiorespiratory fitness with fatness
• Fitness versus fatness relationship in adolescents
has not been studied in a population-based,
representative sample in Latin America.
Garber et al. Fitness vs. Fatness Chile 8th Graders 6
Objectives
In Chilean 8th grade students:
1. To investigate the association between
cardiorespiratory fitness and musculoskeletal
fitness with body mass index and waist
circumference, after adjusting for potential
confounders.
2. To examine the prevalence of students with
healthy fitness but unhealthy body
composition, and vice versa - healthy body
composition, but unhealthy fitness.
Garber et al. Fitness vs. Fatness Chile 8th Graders 7
Methods: Study Design and Population
Design: Cross-sectional
Study Population:
• 2011 National Physical Education Survey
(SIMCE)7
• N=19,904 8th grade students from all regions
of Chile (~9% of 8th grade pop.)
• Median age=14 y
Responsible Agencies:
• Chile Ministry of Education
• Chile Agency for the Quality of Education
• Chile Ministry of Sport
Source:
http://upload.wikimedia.org/wikipedia/co
mmons/6/61/ChileRegions.png
Garber et al. Fitness vs. Fatness Chile 8th Graders 8
Methods: Health-related Fitness Tests and Classification
Table 1. Selected health-related,8 validated,9 and reliable10 tests
recommended11,12 for adolescent fitness assessment.
Fitness Indicator
Field Test
Criterion-referenced
classification
Cardiorespiratory
20 m shuttle run
FITNESSGRAM®
Fitness
201113
Musculoskeletal
Standing long jump
Less than 20th
Fitness
percentile European
adolescents14
Body Mass Index
Weight/Height2
FITNESSGRAM®
201115
Waist Circumference Midway between the 1999-2004 NHANES16
lowest rib margin
and the iliac crest
Garber et al. Fitness vs. Fatness Chile 8th Graders 9
Methods: Statistical analysis
1. Gender-stratified multivariable logistic regression models
1. Cardiorespiratory Fitness Model: Dependent variables = Age (continuous),
categories of socioeconomic status, gender, region, body mass index, waist
circumference, and musculoskeletal fitness.
2. Musculoskeletal Fitness Model: Dependent variables = Age (continuous),
categories of socioeconomic status, gender, region, body mass index, waist
circumference, and cardiorespiratory fitness.
• Model-adjusted prevalence ratios were obtained as function of average
marginal predictions17
2. Unadjusted cross-tabulations to obtain prevalence of discordant pairs:
• Healthy fitness & unhealthy body composition
• Healthy body composition & unhealthy body composition
• SUDAAN used to account for complex sampling design and sample weights.
Garber et al. Fitness vs. Fatness Chile 8th Graders 10
Results: Unhealthy Cardiorespiratory Fitness versus Fatness
Body Composition
Characteristic
Gender
Body Mass Index‡
Healthy (Referent)
M
Unhealthy
F
Waist Circumference‡
Healthy (Referent)
M
Unhealthy
F
Adjusted†
Prevalence Ratio
(95% CI)
1.88 (1.59, 2.23)
1.71 (1.55, 1.89)
1.77 (1.53, 2.06)
1.21 (1.10, 1.34)
*
0.5
1
2
4
Figure 1. Association of unhealthy cardiorespiratory fitness‡ with unhealthy body
mass index and waist circumference in a representative sample of Chilean 8th
graders (N=19,904)
†Adjusted for age (continuous) and categories of socioeconomic status, gender,
region, musculoskeletal fitness, body mass index, and waist circumference.
‡Classified according to health-related cut-points. 13-16
*Prevalence ratio significantly different in males versus females.
Garber et al. Fitness vs. Fatness Chile 8th Graders 11
Results: Unhealthy Musculoskeletal Fitness versus Fatness
Body Composition
Characteristic
Body Mass Index‡
Healthy (Referent)
Unhealthy
Waist Circumference‡
Healthy (Referent)
Unhealthy
Adjusted†
Prevalence Ratio
Gender
(95% CI)
M
F
1.64 (1.46, 1.84)
*
1.32 (1.18, 1.47)
M
F
1.11 (1.003, 1.22)
1.07 (0.96, 1.19)
0.5
1
2
4
Figure 2. Association of unhealthy musculoskeletal fitness‡ with unhealthy body
mass index and waist circumference in a representative sample of Chilean 8th
graders (N=19,904)
†Adjusted for age (continuous) and categories of socioeconomic status, gender,
region, cardiorespiratory fitness, body mass index, and waist circumference.
‡Classified according to health-related cut-points. 13-16
*Prevalence ratio significantly different in males versus females.
Garber et al. Fitness vs. Fatness Chile 8th Graders 12
Healthy
Cardiorespiratory Fitness‡
Results: Fat but fit (Cardiorespiratory)
60%
40%
20%
0%
46%
25%
52%
28%
Male
Female
Male
Female
Unhealthy
Body Mass Index‡
Unhealthy
Waist Circumference‡
Figure 3.1 Prevalence of healthy cardiorespiratory fitness among Chilean 8th graders with
unhealthy body mass index and waist circumference in a representative sample
(N=19,904). Error bars are 95% CI. ‡Classified according to health-related cut-points.13-16
Garber et al. Fitness vs. Fatness Chile 8th Graders 13
Healthy
Musculoskeletal Fitness‡
Results: Fat but fit (Musculoskeletal)
60%
40%
20%
0%
47%
51%
54%
54%
Male
Female
Male
Female
Unhealthy
Body Mass Index‡
Unhealthy
Waist Circumference‡
Figure 3.2 Prevalence of healthy musculoskeletal fitness among Chilean 8th graders with
unhealthy body mass index and waist circumference in a representative sample
(N=19,904). Error bars are 95% CI. ‡Classified according to health-related cut-points.13-16
Garber et al. Fitness vs. Fatness Chile 8th Graders 14
Results: Unfit but Healthy Body Mass Index
Healthy
Body Mass Index‡
60%
40%
20%
0%
35%
41%
43%
43%
Male
Female
Male
Female
Unhealthy
Cardiorespiratory Fitness‡
Unhealthy
Musculoskeletal Fitness‡
Figure 4.1 Prevalence of healthy body mass index among Chilean 8th graders with
unhealthy cardiorespiratory and musculoskeletal fitness in a representative sample
(N=19,904). Error bars are 95% CI. ‡Classified according to health-related cut-points.13-16
Garber et al. Fitness vs. Fatness Chile 8th Graders 15
Healthy
Waist Circumference‡
Results: Unfit but Healthy Waist Circumference
60%
40%
20%
0%
40%
56%
56%
59%
Male
Female
Male
Female
Unhealthy
Cardiorespiratory Fitness‡
Unhealthy
Musculoskeletal Fitness‡
Figure 4.2 Prevalence of healthy waist circumference among Chilean 8th graders with
unhealthy cardiorespiratory and musculoskeletal fitness in a representative sample
(N=19,904). Error bars are 95% CI. ‡Classified according to health-related cut-points.13-16
Garber et al. Fitness vs. Fatness Chile 8th Graders 16
Conclusions
1. Cardiorespiratory fitness and weight-bearing musculoskeletal
fitness were inversely associated with fatness in adolescents.
2. Fitness ≠ fatness
• The substantial prevalence of healthy fitness but
unhealthy body composition, and vice versa, underscores
the need to evaluate physical fitness in addition to body
composition for a complete picture of cardio-metabolic
risk.
• Assessment via BMI or waist circumference alone would
underestimate cardio-metabolic risk.
Garber et al. Fitness vs. Fatness Chile 8th Graders 17
References
1.
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3.
4.
5.
6.
7.
8.
Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. Fatness on AllCause Mortality: A Meta-Analysis. Progress in Cardiovascular Diseases 2014; 56: 38290.
Eisenmann JC, Welk GJ, Ihmels M, Dollman J. Fatness, fitness, and cardiovascular
disease risk factors in children and adolescents. Med Sci Sports Exerc 2007; 39: 1251.
Artero EG, Lee D, Lavie CJ, et al. Effects of muscular strength on cardiovascular risk
factors and prognosis. Journal of Cardiopulmonary Rehabilitation and Prevention 2012;
32: 351-58.
Grontved A, Ried-Larsen M, Moller NC, et al. Muscle strength in youth and
cardiovascular risk in young adulthood (the European Youth Heart Study). Br J Sports
Med 2013.
Moliner-Urdiales D, Ruiz JR, Vicente-Rodriguez G, et al. Associations of muscular and
cardiorespiratory fitness with total and central body fat in adolescents: the HELENA
study. Br J Sports Med 2011; 45: 101-08.
Lee SJ, Arslanian SA. Cardiorespiratory fitness and abdominal adiposity in youth. Eur J
Clin Nutr 2007; 61: 561-65.
Informe de resultados, educación física, SIMCE 2011, 8° Educación Básica [Report of
results, Physical Education, SIMCE 2011 8th grade]. Santiago: Ministerio de Educación,
Gobierno de Chile; 2012: 1-68.
Ruiz JR, Castro-Pinero J, Artero EG, et al. Predictive validity of health-related fitness in
youth: a systematic review. Br J Sports Med 2009; 43: 909-23.
Garber et al. Fitness vs. Fatness Chile 8th Graders 18
References (cont.)
9.
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Castro-Pinero J, Artero EG, Espana-Romero V, et al. Criterion-related validity of fieldbased fitness tests in youth: a systematic review. Br J Sports Med 2010; 44: 934-43.
Espana-Romero V, Artero EG, Jimenez-Pavon D, et al. Assessing health-related fitness
tests in the school setting: reliability, feasibility and safety; the ALPHA Study. Int J
Sports Med 2010; 31: 490-97.
Ruiz JR, Castro-Pinero J, Espana-Romero V, et al. Field-based fitness assessment in
young people: the ALPHA health-related fitness test battery for children and
adolescents. Br J Sports Med 2011; 45: 518-24.
Pate R, Maria O, Laura P. Fitness Measures and Health Outcomes in Youth.
Washington, DC: The National Academies Press; 2012: 1-230.
Welk GJ, Laurson KR, Eisenmann JC, Cureton KJ. Development of Youth AerobicCapacity Standards Using Receiver Operating Characteristic Curves. Am J Prev Med
2011; 41: S111-16.
Ortega FB, Artero EG, Ruiz JR, et al. Physical fitness levels among European
adolescents: the HELENA study. Br J Sports Med 2011; 45: 20-29.
Laurson KR, Eisenmann JC, Welk GJ. Body Mass Index Standards Based on Agreement
with Health-Related Body Fat. Am J Prev Med 2011; 41: S100-05.
Messiah SE, Arheart KL, Lipshultz SE, Miller TL. Body Mass Index, Waist Circumference,
and Cardiovascular Risk Factors in Adolescents. J Pediatr 2008; 153: 845-50.
Bieler GS, Brown GG, Williams RL, Brogan DJ. Estimating model-adjusted risks, risk
differences, and risk ratios from complex survey data. Am J Epidemiol 2010; 171: 61823.
Garber et al. Fitness vs. Fatness Chile 8th Graders 19
Acknowledgments
• Participating students, teachers, and schools
• Chile Ministry of Education
• Chile Agency for Education Quality
• Chile Ministry of Sport
Garber et al. Fitness vs. Fatness Chile 8th Graders 20
Questions
?
Garber et al. Fitness vs. Fatness Chile 8th Graders 21
Questions
?
Garber et al. Fitness vs. Fatness Chile 8th Graders 22
Appendix: Descriptive Fitness Table
Table 2. Health-related physical fitness in a representative sample (N = 19,904) of Chilean 8th
grade students: The 2011 National Physical Education Survey
†
Males
(n=10,309)
46•4
(0•001)
74•3%
(0•7%)
10•8%
(0•4%)
15•0%
(0•5%)
169•3
(0•007)
70•6%
(0•8%)
29•4%
(0•8%)
21•8
(0•001)
61•2%
(0•7%)
17•2%
(0•4%)
21•6%
(0•5%)
74•3
(0•002)
69•2%
(0•6%)
30•8%
(0•6%)
†
Females
(n=9,595)
39•2
(0•001)
(1•0%)
44•6%
24•8%
(0•6%)
30•6%
(0•9%)
131•1
(0•006)
65•3%
(1•0%)
34•7%
(1•0%)
(0•001)
22•7
55•7%
(0•6%)
15•8%
(0•4%)
28•6%
(0•6%)
71•9
(0•002)
69•2%
(0•7%)
30•8%
(0•7%)
P
Fitness Characteristic
value#
Cardiorespiratory fitness (mL/kg/min)b
<0•0001
Healthy
<0•0001
Needs Improvement
<0•0001
NI - Health Risk
<0•0001
Musculoskeletal fitness (cm)c
<0•0001
Healthy
<0•0001
Health risk
Body mass index (kg/m2)d
<0•0001
Healthy
<0•0001
Needs Improvement
0•009
NI - Health Risk
<0•0001
Waist circumference (cm)e
<0•0001
Healthy
0•99
Health risk
Combined fitness categories
NI - Health-risk CRF & Health-risk MSF
9•2%
(0•4%)
16•1%
(0•7%)
<0•0001
NI-Health-Risk CRF & (NI-Health-Risk
9•3%
(0•4%)
15•9%
(0•5%)
<0•0001
BMI or health-risk WC)
Health risk MSF & (NI-Health-Risk BMI or
15•1%
(0•5%)
16•9%
(0•6%)
0•004
health-risk WC)
Health risk according to all 4 fitness
5•0%
(0•3%)
6•5%
(0•3%)
0•0004
variables
Health risk according to at least 1 fitness
50•0%
(0•8%)
61•1%
(0•9%)
<0•0001
variable
†
Data are mean (standard error) or percent (standard error) of category within gender.
‡
NI, needs improvement; CRF, cardiorespiratory fitness; MSF, musculoskeletal fitness; BMI, body mass index; WC, waist
circumference
#
P-values reflect gender differences within strata.
a
Sample size varies for each fitness variable: n, CRF = 17,928; n, MSF = 19,777; n, BMI = 19,904; n, WC = 19,895
b
Cardiorespiratory fitness is classified according to FITNESGRAM 2011 maximal aerobic capacity cut-points.32
c
Health-risk musculoskeletal fitness is defined as a standing broad jump score <20th percentile of European adolescents.9
d
Body mass index is classified according to the FITNESSGRAM 2011 health-related standards.35
e
Waist circumference is classified according to health-related cut-points.39
‡
Garber et al. Fitness vs. Fatness Chile 8th Graders 23