Fitness Measures and
Health Outcomes in Youth

Committee on Fitness Measures and Health Outcomes in Youth

Russell Pate, Maria Oria, and Laura Pillsbury, Editors

Food and Nutrition Board

INSTITUTE OF MEDICINE
         OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Committee on Fitness Measures and Health Outcomes in Youth Russell Pate, Maria Oria, and Laura Pillsbury, Editors Food and Nutrition Board

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Grant No. 61747 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommenda- tions expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-26284-2 International Standard Book Number-10: 0-309-26284-4 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http:// www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover credit: Image designed by Casey Weeks. Suggested citation: IOM (Institute of Medicine). 2012. Fitness measures and health outcomes in youth. Washington, DC: The National Academies Press.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH RUSSELL R. PATE (Chair), Professor, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia CAMERON BLIMKIE, Professor, Department of Kinesiology, McMaster University, Hamilton, Ontario DARLA CASTELLI, Associate Professor, Department of Kinesiology and Health Education, University of Texas, Austin CHARLES B. CORBIN, Professor Emeritus, Department of Exercise and Wellness, Arizona State University, Phoenix STEPHEN R. DANIELS, Professor and Chair, Department of Pediatrics, University of Colorado School of Medicine, and Pediatrician-in-Chief, Children's Hospital Colorado, Aurora HAROLD W. KOHL III, Professor, School of Public Health and Michael & Susan Dell Center for Healthy Living, University of Texas Health Science Center-Houston, and Department of Kinesiology and Health Education, University of Texas, Austin ROBERT M. MALINA, Professor Emeritus, Department of Kinesiology and Health Education, University of Texas, Austin and Research Professor, Department of Kinesiology, Tarleton State University, Stephenville, Texas JENNIFER SACHECK, Associate Professor, John Hancock Research Center on Physical Activity, Nutrition, and Obesity Prevention, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts DAVID STODDEN, Associate Professor, Department of Health, Exercise, and Sport Sciences, Texas Tech University, Lubbock MELICIA WHITT-GLOVER, President and CEO, Gramercy Research Group, LLC, Winston-Salem, North Carolina WEIMO ZHU, Professor, Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign Study Staff MARIA ORIA, Study Director LAURA PILLSBURY, Program Officer ALLISON BERGER, Senior Program Assistant ALICE VOROSMARTI, Research Associate ANTON L. BANDY, Financial Officer v

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GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board Consultants MICHAEL W. BEETS, University of South Carolina, Columbia RONA BRIERE, Briere Associates, Inc., Arlington, Virginia WILLIAM H. DIETZ, Centers for Disease Control and Prevention, Atlanta, Georgia (retired) JOAN M. DORN, Centers for Disease Control and Prevention, Atlanta, Georgia JANET E. FULTON, Centers for Disease Control and Prevention, Atlanta, Georgia SARAH M. LEE, Centers for Disease Control and Prevention, Atlanta, Georgia MELINDA MILLARD-STAFFORD, Georgia Institute of Technology, Atlanta JANE WARGO, President's Council on Fitness, Sports, and Nutrition, Rockville, Maryland vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Virginia Rall Chomitz, Department of Public Health and Commu- nity Medicine, Tufts University School of Medicine, Boston, Massachusetts Wm. Cameron Chumlea, Lifespan Health Research Center, Boonshoft School of Medicine, Wright State University, Dayton, Ohio Angela Diaz, Department of Pediatrics and Department of Preventative Medicine, Mount Sinai School of Medicine, New York, New York Avery Faigenbaum, Department of Health and Exercise Science, The College of New Jersey, Ewing B. Don Franks, Department of Kinesiology, School of Public health, University of Maryland, College Park Maxine Hayes, State of Washington Department of Health, Tumwater vii

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viiiREVIEWERS Steven Heymsfield, Pennington Biomedical Research Center, Baton Rouge, Louisiana Duane Knudson, Department of Health & Human Performance, Texas State University, San Marcos Matthew Mahar, Department of Kinesiology, The College of Health & Human Performance, East Carolina University, Greenville, North Carolina J. Michael McGinnis, Institute of Medicine, Washington, DC Thomas McKenzie, School of Exercise and Nutritional Sciences, San Diego State University, California Mark Tremblay, Department of Pediatrics, University of Ottawa, Canada Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the report's conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Diane Birt, Professor, Department of Food Science and Human Nutrition, Iowa State University, and Elena O. Nightingale, Scholar-in-Residence, Institute of Medicine. Appointed by the Institute of Medicine, both were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface T his report, initiated at the request of the Robert Wood Johnson Foundation, belongs to a series that is part of a broad effort of the Institute of Medicine (IOM) on preventing childhood obesity. Past reports in the series have focused on areas in which preventive interventions could make a difference in the struggle against obesity. This report is the first to look directly at the role of youth physical fitness in health. The com- mittee that conducted this study was charged with recommending the best health-related measures of various components of fitness for inclusion in a national youth fitness survey and, secondarily, recommending test items for administration in educational settings. As an aid in accomplishing this task, the committee was provided with a scientific literature search conducted and managed by the Centers for Disease Control and Prevention. Physical fitness test batteries for youth have been designed and adminis- tered widely in the United States since the mid20th century. While the com- ponents of fitness measured and the specific test items included in protocols have varied considerably across test batteries and over time, youth fitness testing has become a well-established institution in school physical educa- tion programs. In addition, national surveys of youth fitness were conducted periodically between the late 1950s and the mid-1980s; the period from the mid-1980s to the present, however, has seen a hiatus in such surveys, perhaps as the result of an increased emphasis on surveys of physical activity behav- ior as distinct from fitness. With the increased prevalence of overweight and obesity in American youth and expanded knowledge of the impact of fitness on health outcomes, interest in the fitness status of contemporary children and adolescents has grown. Accordingly, this report is intended to provide ix

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xPREFACE guidance for the designers of a national survey of health-related fitness in American youth. Also, recognizing the importance of fitness testing in school physical education programs and in accordance with its statement of task, the committee recommends health-related fitness test items that are seen as both valid and feasible for administration in educational settings. An important and sometimes vexing aspect of health surveys is the establishment of criteria for interpreting the survey findings. Accordingly, this report also includes guidelines for setting standards for performance on the various fitness test items included in the recommended battery. In doing its work, moreover, the committee encountered many gaps in the relevant scientific evidence; thus an important element of the report is a set of recom- mendations for future research on fitness testing in youth. The committee comprised 11 experts with extensive knowledge in a range of areas related to fitness and physical activity, metabolic health, growth and maturation, body composition, and physical education, as well as the development of standards and validation of tests. In addition to its reviews of the literature and discussions in closed meetings, the commit- tee benefited from rich discussions with other experts in fitness and youth during an open session. On behalf of the committee, I sincerely thank the participants and speakers who contributed to this open session, providing information critical to the completion of this report. On behalf of the committee, I also would like to express my deep appre- ciation to the consultants who led the literature search, a main resource for the committee's recommendations. Michael W. Beets, William H. Dietz, Joan Dorn, Janet E. Fulton, Sarah M. Lee, Melinda L. Stafford-Millard, and Jane Wargo not only conducted the main literature search but also facilitated the committee's work by providing abstractions and summaries of the literature as requested. I would like to express my appreciation as well to Laura C. Leviton, senior adviser for evaluation at the Robert Wood Johnson Foundation, whose leadership has provided impetus for so many efforts on obesity prevention at the IOM, and to Tina J. Kauh, research and evaluation program officer at the Robert Wood Johnson Foundation. I would also like to gratefully acknowledge the effort and skill the com- mittee members brought to this study. Their backgrounds, experiences, and passion for the subject matter resulted in a report that will have a long life. Finally, I thank the project staff of the National Academies--Maria Oria, study director; Laura Pillsbury, program officer; and Allison Berger, senior pro- gram assistant--for their tireless dedication to the production of this report. Robert R. Pate, Chair Committee on Fitness Measures and Health Outcomes in Youth

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Contents SUMMARY1 1INTRODUCTION 15 Background, 16 Statement of Task, 18 Methods, 18 Organization of the Report, 21 References, 22 2 MEASURING FITNESS IN YOUTH 23 Early History of Physical Fitness Testing, 24 National Youth Fitness Testing: 1950 to 1980, 25 National Youth Fitness Testing: 1980 to 1990, 28 Youth Fitness Testing Since 1990, 31 Current Batteries of Youth Fitness Tests, 35 References, 43 3METHODOLOGY FOR SELECTION AND 49 INTERPRETATION OF HEALTH-RELATED FITNESS MEASURES IN YOUTH Conceptual Framework, 50 Selection of Appropriate Fitness Test Items, 52 Consideration of Modifying Factors, 58 Establishment of Cut-Points for Health-Related Youth Fitness Tests, 66 References, 72 xi

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xiiCONTENTS 4HEALTH-RELATED FITNESS MEASURES FOR YOUTH: 79 BODY COMPOSITION Measurement of Body Composition, 81 Literature Review Process, 83 Body Composition in Youth, 84 Body Composition, Fitness, and Health in Youth, 88 Validity and Reliability of Selected Body Composition Measures, 92 Administrative Feasibility, 95 Guidance for Interpretation of Test Results, 96 Conclusions, 99 Annex 4-1: Measurement of Body Composition Quality Control and Techniques, 101 References, 102 5HEALTH-RELATED FITNESS MEASURES FOR YOUTH: 111 CARDIORESPIRATORY ENDURANCE Definitions, 112 Cardiorespiratory Endurance Tests, 113 Cardiorespiratory Endurance and Health in Youth, 114 Validity and Reliability of Selected Test Items, 140 Administrative Feasibility, 142 Guidance for Interpretation of Test Results, 144 Conclusions, 145 References, 147 6HEALTH-RELATED FITNESS MEASURES FOR YOUTH: 153 MUSCULOSKELETAL FITNESS Definitions, 155 Musculoskeletal Fitness Tests, 157 Musculoskeletal Fitness and Health in Adults, 159 Musculoskeletal Fitness and Health in Youth, 160 Validity and Reliability of Selected Test Items, 176 Administrative Feasibility, 178 Guidance for Interpretation of Test Results, 179 Conclusions, 179 References, 181 7HEALTH-RELATED FITNESS MEASURES FOR YOUTH: 187 FLEXIBILITY Definitions, 189 Flexibility Fitness Tests, 190 Flexibility and Health, 192

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CONTENTS xiii Validity, Reliability, and Feasibility of Selected Flexibility Test Items, 199 Guidance for Interpretation of Test Results, 199 Conclusions, 200 References, 201 8 FITNESS MEASURES FOR A NATIONAL YOUTH SURVEY 207 Current Status of National Youth Fitness Testing, 208 Conclusions and Recommendations, 209 References, 213 9FITNESS MEASURES FOR SCHOOLS AND OTHER 215 EDUCATIONAL SETTINGS Factors Related to Selecting and Implementing Test Items, 218 Factors Related to Test Administration, 220 Factors Related to Interpretation of Test Results, 221 Factors Related to the Incorporation of Fitness Testing into a Curriculum or Program, 222 Appropriate and Inappropriate Practices, 223 Conclusions and Recommendations, 225 References, 229 10 FUTURE NEEDS 235 APPENDIXES A AGENDA 239 B GLOSSARY 243 C ACRONYMS 249 D BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS 253

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