Fitness Measures and Health Outcomes in Youth (2012)

9


Fitness Measures for Schools and Other Educational Settings

The preceding chapters highlight the importance of measuring and monitoring the prevalence of physical fitness during childhood and address questions relating to the core purpose of this report—identifying fitness tests that are related to health and are valid and reliable. Tests for a national youth fitness survey are recommended based on those criteria and on practical considerations related to the feasibility of their administration in a national survey. In addition to national surveys, fitness tests often are conducted in schools (and other educational settings) for a variety of reasons. Examples include uses associated with state or local

physical fitness testing mandates in schools and with physical education curricula and instruction.

Along with improving the fitness performance of individuals, fitness tests in educational settings can yield other benefits when appropriately conducted and interpreted. One benefit is that, when integrated into physical education programs in school settings, fitness testing can provide clear technical performance expectations and minimize the effect of practice on test performance in a national survey. Another benefit is that fitness testing in schools allows for group and individual tracking of physical fitness trends and disease risk. Fitness test results can also be used for assessing learning outcomes and physical education content standards. Given the connection between physical activity/fitness and cognitive performance (Castelli et al., 2007; Hillman et al., 2009; Kamijo et al., 2011; Welk et al., 2010), moreover, it becomes important for knowledge, attributes, and awareness of fitness to be promoted in educational settings as part of fostering healthy lifestyle choices across the life span. When the primary objectives of physical education or physical activity programming are achieved as intended, such programming can lead to the development of habitual healthy behaviors. The inclusion of fitness testing in physical education provides a forum for supporting and measuring the attainment of learning standards associated with physical fitness (Tremblay and Lloyd, 2010).

Accordingly, physical fitness is a focus of six national standards for physical education that reflect the skills, knowledge, and abilities resulting from participation in effective physical education and physical activity programming in schools (NASPE, 2004). As of June 2011, all 50 states had learning standards centered on health-related fitness (Centeio and Keating, 2011); 14 states mandated direct measurement of physical fitness (NASPE, 2010). Physical education and the implementation of models such as Coordinated School Health and Comprehensive School Physical Activity Programs have outcomes concentrated on both the achievement and maintenance of health-enhancing levels of fitness and regular engagement in physical activity, as these variables are independent risk factors associated with health (Plowman, 2005).

To administer fitness testing appropriately in schools, it is necessary to consider such factors as ensuring that the testing has clear ties to improved physical fitness and fostering increased engagement in physical activity among students (Keating, 2003). Although some have questioned how the inclusion of physical fitness testing may influence time for academic learning, there is evidence that fitness may have positive effects on both health and learning (CDC, 2010; Rasberry et al., 2011; Rosas et al., 2009), including evidence for a causal relationship between children’s fitness and cognitive performance (Kamijo et al., 2011).

The committee’s literature review included only studies that involved populations of healthy and obese youth and excluded studies of youth with congenital diseases or disabilities. The fitness testing recommendations in this report, therefore, are driven by the evidence for healthy study populations. Nonetheless, it is important for students with disabilities to be included in fitness testing whenever possible and for the interpretation of test results to be modified accordingly. Specifically, those students with personal fitness goals should be encouraged to participate in fitness testing as a means of tracking progress toward their goals. The Brockport Fitness Test is an example of how specific fitness tests can be modified for students with disabilities, and the Brockport Physical Fitness Technical Manual provides criterion-referenced cut-points (cutoff scores) for a variety of disabilities (Winnick and Short, 1999). While the relationship between health outcomes and physical activity in people with disabilities is not the focus of this report, other reviews, such as the Physical Activity Guidelines Advisory Committee Report (Physical Activity Guidelines Advisory Committee, 2008), specifically examine this issue.

Given the potential benefits of fitness testing, the committee recommends the use of some measures in schools (and other educational settings) even though the evidence for their relationship with health is only promising at this time. The committee recommends these additional measures with the expectation that future research will elucidate whether they are related to health in youth.

This chapter examines factors related to the following issues in school and other educational settings: the selection and implementation of test items, the administration of the test items, the interpretation of test results, and the incorporation of fitness testing into a curriculum or program. It then briefly reviews appropriate and inappropriate fitness testing practices in these settings. The final section presents the committee’s conclusions and recommendations for school-based fitness testing.

FACTORS RELATED TO SELECTING AND IMPLEMENTING TEST ITEMS

Children enrolled in regularly scheduled physical education classes participate in significantly more physical activity than those who attend physical education infrequently (Cawley et al., 2007; Gordon-Larsen et al., 2000; Pate et al., 2007). On the other hand, participation in physical education alone cannot facilitate high levels of fitness in every child (Dale and Corbin, 2000), given heredity effects on fitness (Bouchard and Shephard, 1994), a lack of instructional time dedicated to physical activity (NASPE, 2010; Pate et al., 2011), and low to moderate relationships between physical activity and fitness (Morrow and Freedson, 1994; Pate et al., 1990;

Payne and Morrow, 1993). Furthermore, the lack of national fitness surveys since the 1980s makes it difficult to establish relationships between physical activity and fitness measures over time (Corbin and Pangrazi, 1992; Flegal et al., 1998).

Physical activity leaders and teachers selecting fitness test items for schools need to consider contextual variables such as access to high-quality equipment, space, cost, privacy, and the availability of volunteers, as schools differ greatly on these variables (Martin et al., 2010). Box 3-2 in Chapter 3 includes a general list of criteria for evaluating administrative feasibility. The use of only high-quality equipment is critical to avoid measurement and interpretation errors. To ensure that performance on a fitness test is actually a reflection of physical fitness, it is also necessary to consider the reliability, validity, and feasibility of test items; the standardization of test protocols; and the confidentiality of test results. It is vital as well for administrators to ensure the safety of fitness test participants by being sensitive to such variables as participants’ pre-existing disease(s), body composition, and maturation stage. Age is a particularly critical consideration for ensuring the validity, reliability, and safety of selected test items, as performance on some items may improve with age and maturity. Cultural relevance and potential racial/ethnic bias also are related to test performance and therefore should be considered in the selection of test items (Miech et al., 2006).

The educational value of a test item and its corresponding health-related fitness component should carry weight in the selection process. Specifically, how does the identified test item align with the existing curriculum goals, and to what degree can fitness education be carried out as a valued part of instruction?¹ When such evaluations and corresponding instruction occur, there is a high likelihood that health-related fitness knowledge will increase (Kulinna, 2004; Stewart and Mitchell, 2003) and that youth’s misconceptions about fitness will be addressed (Keating et al., 2009). Further, studies have shown that conceptual physical education may lead to less sedentary behavior after students complete their schooling (Dale and Corbin, 2000; Dale et al., 1998). If educators and physical activity leaders avoid teaching to the test and instead allow the results of fitness tests to drive instruction and create educational opportunities, the potential exists for youth to change their behaviors through self-management and goal setting. It is, however, important for students to know how to perform fitness tests and be given the opportunity to practice the tests prior to the testing session (see Chapter 8). Finally, despite evidence that augmented knowledge about health-related fitness may increase engagement in physical activity (Kulinna and Silverman, 2000), it remains unclear whether enhanced knowledge

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¹Available at http://www.aahperd.org/naspe/publications/upload/Instructional-Frameworkfor-Fitness-Education-in-PE-2012-2.pdf (accessed August 17, 2012).

(Ennis, 2007; Placek et al., 2001) and such learning experiences linked to fitness testing (Cale and Harris, 2009) will directly change behavior to a degree that will reduce health risk, as this area is understudied.

FACTORS RELATED TO TEST ADMINISTRATION

In a society where childhood obesity is a growing concern (Ogden et al., 2010), teachers are being asked to fulfill multiple responsibilities related to physical fitness and activity as part of their job description.² Since physical education teachers have limited opportunities for professional development (Doutis and Ward, 1999; O’Sullivan and Deglau, 2006; Stroot et al., 1994), learning experiences for these teachers in administering fitness tests are most valuable when they are school based and applicable to the teachers’ daily routine (e.g., how to manage the class while administering the tests), collaborative in nature, and centered on how to achieve the desired student outcomes (i.e., enhancing student understanding and progress toward attaining physical fitness standards) (Armour and Yelling, 2007). Professional development aimed at preparing physical education teachers to administer a battery of fitness tests can include a combination of the following components:

• how to integrate fitness testing into the curriculum;
• protocols and use of proper equipment for fitness test items;
• how to familiarize participants with the test, together with specifications regarding the amount and type of practice;
• how to communicate consistently with the students in ways that create a positive and encouraging environment for learners of all ability levels;
• teacher burden;
• participant burden;
• the validity and reliability of test items;
• class management during test periods; and
• how to interpret and communicate test results.

An extensive body of literature expands on components of effective and sustainable professional development, a topic that is beyond the scope of this report. In general, however, professional development enables physical education teachers to administer physical fitness tests accurately and with minimal bias (Morrow et al., 2010) while providing physical activity oppor-

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²For example, see the National Association for Sport and Physical Education (NASPE) Director of Physical Activity Certification Program, available at http://www.aahperd.org/naspe/professionaldevelopment/dpa/index.cfm (accessed June 26, 2012).

tunities that enhance fitness (Kibbe et al., 2011). A recent meta-analysis suggests that in general, students are motivated to participate and to learn in physical education (Chen et al., 2012). Yet student motivation is influenced by the school climate, specifically the task or ego orientation of the activities offered during physical education (Parish and Treasure, 2003; Standage et al., 2003). Teachers who develop a positive and mastery-oriented climate are more likely to have students who perform better on assessments such as fitness testing. When introducing students to fitness testing, for example, the use of instructions that provide personal relevance and meaning for a student can lead to enhanced performance (Simons et al., 2003). Accordingly, it is important for teachers to be consistent in the delivery of content related to fitness testing, as well as to be equally supportive to learners of all ability levels, or the test may be biased. Teachers need professional development to apply these principles of fitness testing in schools (Corbin, 2010; Keating, 2003).

FACTORS RELATED TO INTERPRETATION OF TEST RESULTS

Perhaps the most important element of fitness testing, the interpretation and dissemination of results must be planned for if the goals of the testing are to be achieved. Identifying the level of health risk associated with the established cut-points for a particular age is a way to involve and educate parents as well as children by providing personalized feedback, including comparison of current and previous test results. Note that in communicating test results, it is essential to ensure confidentiality to avoid the reduced self-esteem that can occur if the results (low performance on fitness tests or high body composition numbers) are shared with others (Fox, 1988). In addition to information about health risks, positive feedback and recommendations, including information and resources related to health care, are valuable characteristics of fitness test reports. Fitness education thereby has the potential to build fitness competence, create a sense of the importance of fitness, and provide motivation and opportunities to support the achievement of fitness goals (Fox, 1988). Administrators and those communicating results of fitness tests in schools should be trained in these areas.

Test scores are estimations of health-related fitness at a point in time. To maintain or improve scores, continued participation in physical activity is necessary. The Fitnessgram^® program suggests that, when interpreting performance on fitness tests, the following characteristics are essential in educational settings:

• “The physical fitness experience should always be fun and enjoyable.
• Physical fitness testing should not become a competitive sport.

• The performance of one student should not be compared to that of another student.
• The primary reason for testing is to provide the [participant] with personal information that may be used in planning a personal fitness program.
• The performance level on fitness tests should not be used as a basis for grading.” (Meredith and Welk, 2010, p. 58)

Test administrators and those interpreting and communicating results should be fully familiar with the meaning of cut-points and the effects of modifiers (e.g., maturation status, race/ethnicity) for each test. Other variables, such as biology, the emotional investment of the participant, tester error, equipment, the amount of practice, and testing conditions, also affect performance on a fitness test. As part of test interpretation, the test administrator and those interpreting and communicating results must decide whether the scores are valid or their deviation from expected results is beyond these sources of error. For example, having some participants engage repeatedly in a shuttle run in an effort to understand the technical protocol and necessary adherence not only allows for more valid and reliable test administration, but also may enable these participants to achieve a higher level of cardiorespiratory fitness than those who have not had the opportunity to practice the test. It is important, then, that an educational component be integrated into the physical education program to provide clear technical performance expectations for fitness testing and minimize practice effects. When physical education teachers and physical activity leaders adhere to these principles, fitness tests can help identify risk for developing chronic disease while helping participants better understand the concepts of fitness through comprehensive fitness education (Freedson et al., 2000).

FACTORS RELATED TO THE INCORPORATION OF FITNESS TESTING INTO A CURRICULUM OR PROGRAM

When fitness testing is integrated into educational programs or curricula, it provides a mechanism for longitudinally tracking and monitoring physical fitness trends and risk for disease among individuals and groups. In an educational setting, individual tracking is most relevant as school is one of the few places where feedback can be provided to both participants and their parents. However, group tracking over time also can be useful for physical education teachers, enabling them to utilize trends to inform instruction by identifying the needs of the current student body.

It has been suggested that, regardless of developmental stage, the benefits of being able to monitor progress, set goals, provide feedback, give

incentives, and design a personalized physical activity plan outweigh the risks of participation in physical fitness testing (Safrit, 1995). Clearly communicating to participants the meaning of each test item and discussing the training principle of specificity (i.e., the activity’s association with an identified joint or muscle group) is important. Participants then can set personalized goals and create an individualized plan for achieving those goals that purposefully links modes of physical activity to health-related fitness components. Learning experiences that apply knowledge to authentic situations increase the likelihood that conceptual learning will lead to enhanced participation in physical activity.

The use of fitness awards in schools has been the subject of ongoing controversy. Although fitness awards were created to motivate youth to be fit, questions have been raised about their motivational value. For example, reports have suggested that the Presidential Physical Fitness Awards may be awarded to youth who are already athletically successful (Corbin et al., 1990), that they are not motivating to youth with low fitness (Corbin et al., 1988), and that they may reduce rather than enhance intrinsic motivation (Whitehead and Corbin, 1991). To date, evidence has not been presented to support the use of fitness awards. While it is beyond the scope of this report to make suggestions about fitness awards, the committee believes a comprehensive study of such awards, similar to this study of fitness test items, should be conducted to determine whether there is sufficient scientific evidence to warrant their use.

APPROPRIATE AND INAPPROPRIATE PRACTICES

If physical fitness tests are to be used effectively in schools and other educational settings, appropriate practices must be employed in their administration. Appropriate practice varies by maturation stage; thus what may be suitable for elementary school students may be inappropriate for adolescents. Numerous authors have outlined appropriate practices (Corbin, 2009; Corbin and Pangrazi, 2008; Ernst et al., 2006), and regardless of stage of maturation, some basic tenets apply, as summarized and supported by national organizations (Table 9-1). These include the following:

• Health-related fitness activities are integrated into an existing curriculum.
• Fitness test results are used to set individual goals and develop fitness plans.
• Fitness assessments are part of the ongoing process of helping students understand, enjoy, improve, and maintain their physical fitness and well-being.
• Youth are physically prepared to participate in fitness testing.

TABLE 9-1 Appropriate and Inappropriate Practices Related to Fitness Testing in Schools and Other Educational Settings

SOURCES: Adapted from NASPE, 2009a,b,c.

Two specific unacceptable practices warrant further discussion: the use of fitness test scores for academic grading and for high-stakes accountability. Both of these practices are considered improper applications of fitness test results (NASPE, 2009a,b,c). It is inappropriate to include fitness test scores in academic grades or grade point averages (NASPE, 2009a,b,c). Although physical fitness can be increased through engagement in specific types of physical activity, factors other than physical activity affect a student’s fitness that are beyond the control of the student and physical education teacher. Examples include heredity, caloric consumption, access to opportunities to be physically active both within and beyond the school day, and possibly socioeconomic status. For similar reasons, physical fitness testing for the purpose of teacher and school accountability is also inappropriate. Even though physical fitness may be a primary goal of a given program, confounding, uncontrollable variables remain (e.g., heredity [Bouchard and Shephard, 1994], socioeconomic status, and other school contextual variables [Mitchell et al., 2003]); therefore, this practice is a misstep in the interpretation and utilization of fitness testing (Harris and Cale, 2007).

CONCLUSIONS AND RECOMMENDATIONS

In general, active children display healthier physical fitness profiles—including higher cardiorespiratory and musculoskeletal fitness and bone mass and lower body fat—than their inactive peers (Boreham and Riddoch, 2001). Because these trends often track to adulthood (Baranowski et al., 2000; Boreham et al., 2002; Hasselstrom et al., 2002; Janz et al., 2002; Lefevre et al., 2002; Twisk et al., 2002), the committee has highlighted the importance of measuring and monitoring the prevalence and specificity of physical fitness during youth in the preceding chapters. Using many of the factors outlined above, the committee considered the strengths and weaknesses of the test items recommended for a national survey (Chapter 8) with regard to their practicality in schools and other educational settings. The sections below detail the committee’s adaptations for fitness tests when the testing is to be conducted in such settings. Note that, regardless of the setting, it is important to develop and use standardized test protocols so comparisons can be made among surveys and studies.

Body Composition

Since body composition is an important health outcome, the committee recommends that it be measured to track health risk and long-term health relationships in youth (see Chapter 8). As a health marker, moreover, body composition—specifically being overweight or obese—is negatively related to academic achievement (Averett and Stifel, 2007; Bagully, 2006; Castelli et al., 2007) and inversely related to reaction time and accuracy of memory tasks (Kamijo et al., 2011).

The committee recommends that in educational settings, standing height and body weight be measured and transformed into body mass index (BMI) as a mediator of physical fitness and a measure of health risk. These data should remain private and be shared only with the child and parent(s). The already established Centers for Disease Control and Prevention (CDC) cut-points based on the 2000 CDC growth charts for children and adolescents should be applied when interpreting BMI data.

Although the committee recommends skinfold and waist circumference measurements for a national survey, their implementation in a school setting raises concerns. First, measuring skinfolds and waist circumference requires specific and intense training to avoid the introduction of errors (e.g., intra- and interobserver errors). Second, these two measurements are not free of potential motivational or self-esteem influence; self-esteem may be impacted by the interpretation of results for estimated body composition. Third, it is difficult to ensure the privacy of the measurement process given that measurement of skinfolds and waist circumference is more inva-

sive than measurements for BMI because it requires exposure of the trunk to allow the test administrator to access the subscapular and waist regions. As a result, conducting these tests likely requires the presence of two test administrators, thus increasing the administrative burden. By contrast, less effort is required for measurement of height and weight (see Chapter 4).

Cardiorespiratory Endurance

A large body of evidence suggests that cardiorespiratory endurance is related to health outcomes such as adiposity and cardiometabolic risk factors (e.g., blood pressure, blood lipids and glucose, insulin sensitivity) during childhood and adulthood (see Chapter 5). Cardiorespiratory endurance is believed to be lower in sedentary and overweight female youth. Approximately one-third of U.S. youth (males and females) aged 12 to 19 fail to meet the standards for cardiorespiratory endurance (Pate et al., 2006). As indicated earlier in this chapter, emerging evidence also identifies a link between cardiorespiratory endurance and academic achievement (Donnelly and Lambourne, 2011; Hillman et al., 2009), as well as working memory and attention—essential antecedents of learning (Kamijo et al., 2011).

Among the valid and reliable tests for which strong evidence indicates a relationship to health, the shuttle run has the feasibility required for implementation in a school setting, requiring no expensive equipment. An alternative to the shuttle run is any of the distance runs that, as noted in Chapter 5, have been used to measure cardiorespiratory endurance in fitness test batteries since the advent of large-scale fitness testing in the post-World War II era. Numerous studies have assessed the validity of distance run tests by examining the correlation between a criterion measure—directly measured maximal oxygen uptake (VO₂max) (ml/kg/min)—and time or distance on the run, and have concluded that distance runs of 1 mile or greater demonstrate acceptable validity (Freedson et al., 2000; Safrit, 1990). Also, distance runs have been found to be reliable based on test-retest correlations (Artero et al., 2011; Freedson et al., 2000).

Musculoskeletal Fitness

Musculoskeletal fitness, including muscle strength, muscle endurance, and muscle power, has been positively associated with quality of life and inversely linked to risk for cardiovascular disease in adults (see Chapter 6). In children, the link between musculoskeletal fitness and health is less clear given developmental and maturational influences and the paucity of recent normative data. However, the committee concluded that musculoskeletal fitness during childhood is likely linked to health during adulthood; thus,

musculoskeletal fitness tests should be used in schools as a tool for educating about their potential health benefits.

In Chapter 8, the handgrip strength and standing long jump tests are recommended for a national youth fitness survey as measures of musculoskeletal fitness because of this component’s suggestive relationship to health (particularly in adults), sufficient validity and reliability of both tests in youth, and feasibility (e.g., equipment cost, equipment calibration, administrator training). For schools, in addition to these two tests, the committee considered the value of other musculoskeletal fitness tests that are valid and that may have adequate reliability because of their wide use and familiarity to students and test administrators.

For example, the modified pull-up, which is currently used in school-based fitness test batteries in the United States, has moderate reliability and sound logical construct validity as a measure of upper-body strength (Engelman and Morrow, 1991; Erbaugh, 1990; Kollath et al., 1991; Pate et al., 1995; Saint Romain and Mahar, 2001). While there is scant evidence of this test’s relationship to health in youth, it does provide a valid assessment of an individual’s or group’s musculoskeletal fitness status (see Chapter 6) and is feasible for use in schools and other educational settings. Also used frequently in schools, the curl-up and push-up may have value as fitness educational tools. Both have been shown to have reasonable reliability and validity when administered in a large school-based survey; however, these values are lower than for cardiorespiratory endurance and body composition tests (Morrow et al., 2010; Plowman, 2008). Because the curl-up test measures a different construct of musculoskeletal fitness from the handgrip strength and standing long jump tests (i.e., core strength and endurance), it should not be considered as an alternative to those tests. It is important to stress that none of the musculoskeletal fitness tests should be interpreted in a health context until such relationships are more firmly established in the future.

Flexibility

As described in Chapter 7, information is lacking about the association between flexibility and health outcomes in youth and is inconsistent in adults. For this reason, the committee does not recommend flexibility testing as a foundational item in school-based fitness testing for youth. Although the evidence is not yet clear, however, flexibility may be linked to various health outcomes in youth, such as prevention of back pain, injury, and posture-related problems. Schools may therefore wish to include flexibility testing to help educate youth and their parents about flexibility as a component of overall musculoskeletal health, function, and performance.

Administrators can select flexibility tests to be implemented in schools and physical education settings based on their validity, reliability, and feasibility, for which evidence has been reported (see, e.g., Castro-Piñero et al., 2010; España-Romero et al., 2010; Freedson et al., 2000; Plowman, 2008; Safrit, 1990). Although the degree to which the sit-and-reach test is an indicator of overall systemic flexibility is unclear, only that test, including its alternatives (e.g., backsaver sit-and-reach), among the measures commonly used to assess flexibility in youth has been used widely, and it also has been the most frequently studied. The sit-and-reach test has reasonable validity and reliability when used in school settings.

Recommended Fitness Tests for Schools

The committee found strong evidence linking cardiorespiratory endurance and body composition to health in youth and evidence in adults to support a link between musculoskeletal fitness and health. Given the connections to health and the benefits of promoting a physically active lifestyle through physical fitness education, the committee selected measures of body composition, cardiorespiratory endurance, and musculoskeletal fitness that should be included in a fitness test battery for use in schools and other educational settings. As with national surveys, test administrators should distribute the equipment needed to conduct the recommended test items such that the students have the opportunity to receive sufficient training in the measurement protocols and to practice the tests. Likewise, both those administering the tests and those interpreting and communicating the test results should receive the appropriate training to prevent adverse events, minimize measurement and classification errors, create an encouraging environment for students, and ensure the confidentiality of the results.

RECOMMENDATION 9-1. Developers and administrators of fitness test batteries in schools and other educational settings should consider including the following test items:

• standing height (measure of linear growth status) and weight (measure of body mass) to calculate BMI as an indicator of body composition;
• a progressive shuttle run, such as the 20-meter shuttle run, to measure cardiorespiratory endurance; and
• handgrip strength and standing long jump tests to measure upper- and lower-body musculoskeletal strength and power, respectively.

Additional tests that have not yet been shown to be related to health but that are valid, reliable, and feasible may also be considered as supplemental educational tools. For cardiorespiratory endurance, alternatives to the shuttle run include distance and/or timed runs, such as the 9-minute or 1-mile run, while the modified pull-up and push-up are possible alternatives for measuring upper-body musculoskeletal strength. The curl-up may be considered in addition to the suggested musculoskeletal fitness tests for measuring core strength and endurance. Although the committee does not recommend a flexibility measure as a core component of a fitness test battery, administrators in schools and other educational settings may wish to include the sit-and-reach test or its alternatives (e.g., backsaver sit-and-reach) to measure flexibility. Experts who establish cut-points for interpreting performance on these fitness test items should follow the guidance provided in Chapter 3.

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