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Methodology for Selection and Interpretation of Health-Related Fitness Measures in Youth

This chapter describes the methodology followed by the committee in reaching conclusions and making recommendations on the most appropriate health-related physical fitness test items for youth. Before reviewing the scientific literature, the committee developed a conceptual framework to illustrate its thinking on the theoretical associations among the various components of fitness, their modifiers, and relevant health markers. The chapter begins by describing this framework. It then describes the committee’s approach to the selection of test items for each of the four fitness components—body composition, cardiorespiratory endurance, musculoskeletal fitness, and flexibility. Included is a description of the literature review and the set of criteria that guided the selection process. The next section examines potential modifiers of fitness or of the associations between fitness and health, examples of which are included in the committee’s conceptual framework. Just as the extent of the evidence on the association of each fitness component and test item with health markers varies, so, too, does the evidence for the effect of potential modifying factors. In general, there is more evidence on the importance of gender and age, while less is known about the effect of developmental maturity, motor skill, and practice. Similarly, there is a dearth of information about the influence of some demographic factors, such as ethnicity and race or socioeconomic status, on performance on fitness tests and its interaction with health markers. The final section of the chapter presents the committee’s guidance for establishing cut-points (cutoff scores) for use in interpreting the results of youth fitness tests. Interpretation of test results is one of the



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3 Methodology for Selection and Interpretation of Health-Related Fitness Measures in Youth T his chapter describes the methodology followed by the commit- tee in reaching conclusions and making recommendations on the most appropriate health-related physical fitness test items for youth. Before reviewing the scientific literature, the committee developed a con- ceptual framework to illustrate its thinking on the theoretical associations among the various components of fitness, their modifiers, and relevant health markers. The chapter begins by describing this framework. It then describes the committee's approach to the selection of test items for each of the four fitness components--body composition, cardiorespiratory endur- ance, musculoskeletal fitness, and flexibility. Included is a description of the literature review and the set of criteria that guided the selection process. The next section examines potential modifiers of fitness or of the associa- tions between fitness and health, examples of which are included in the committee's conceptual framework. Just as the extent of the evidence on the association of each fitness component and test item with health mark- ers varies, so, too, does the evidence for the effect of potential modifying factors. In general, there is more evidence on the importance of gender and age, while less is known about the effect of developmental maturity, motor skill, and practice. Similarly, there is a dearth of information about the influence of some demographic factors, such as ethnicity and race or socio- economic status, on performance on fitness tests and its interaction with health markers. The final section of the chapter presents the committee's guidance for establishing cut-points (cutoff scores) for use in interpreting the results of youth fitness tests. Interpretation of test results is one of the 49

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50 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH most crucial aspects of such testing because it serves as a way of communi- cating with participants, health and school officials, and parents about their risk of negative health outcomes based on test performances. CONCEPTUAL FRAMEWORK To illustrate the overall challenge of its task and create a model for physical fitness measures that are most clearly associated with health out- comes in youth, the committee developed a conceptual framework (Figure 3-1). This framework guided the committee's analysis of research find- ings. Figure 3-1 depicts the potential relationships between physical fitness components--which can be measured by a variety of fitness test items rep- resented by the smaller embedded boxes--and markers of health. As illustrated in Figure 3-1, these relationships can be affected by both modifying factors and risk factors. As defined by the committee, modifying factors are those that can independently affect an individual's level of fit- ness. They include both factors that are measurable in the field (e.g., gender, race, ethnicity, maturity) and those that are not (e.g., heredity, practice level, skill level). Likewise, health outcomes are modified by certain risk factors that characterize an individual (e.g., low HDL cholesterol is a risk factor for cardiovascular disease). In the case of youth, health outcomes (i.e., diseases or conditions) are defined in terms of health markers or risk factors since youth are unlikely to experience a disease or condition (e.g., heart disease) as a result of their fitness level. The potential health outcomes that result from a specified level of performance on a fitness test are depicted within five categories: four categories of (positive or negative) markers of health- related outcomes (i.e., cardiovascular/respiratory health, metabolic health and obesity, mental and cognitive health, and musculoskeletal health) and a category that includes adverse events. Note that in this report, the terms health marker and health risk factor are used in a broad sense and inter- changeably to refer to indicators of health outcomes. The committee included body composition as a component of fitness, even though perspectives on this categorization vary. Body composition is also considered a modifier of performance on fitness tests and a health marker. Thus, it appears in all three categories of variables in the frame- work--fitness components, modifying factors, and health markers--and is highlighted in a different color from that of the other fitness components because of this unique nature. The next section describes the approach used by the committee to select the best youth fitness test items, considering (1) the strength of their association with health markers in youth, (2) their integrity (validity and reliability), and (3) the relative feasibility of their administration in the field.

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Physical Fitness Modifying Health Markers Components Factors Age Cardiovascular/Respiratory Health Body Composition Gender Race/Ethnicity Risk Factors Disease Outcomes Growth Status o Weight-for-Height o Body Composition Metabolic Health and Obesity Cardiorespiratory o Maturation Endurance Diet Risk Factors Disease Outcomes Genetics Culture Physical Activity Mental and Cognitive Health Motor Skill Risk Factors Disease Outcomes Musculoskeletal Fitness Musculoskeletal Health Risk Factors Disease Outcomes Flexibility Adverse Events Risk Factors Disease Outcomes FIGURE 3-1 Physical fitness measures and health outcomes: Conceptual framework. NOTE: The variety of fitness tests that can measure a particular fitness component is represented by the embedded boxes under each component. 51 Figure 3-1 Broadside

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52 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH SELECTION OF APPROPRIATE FITNESS TEST ITEMS Review of the Literature The committee used various resources to collect scientific data to in form its selection of fitness test items. A main source of information for the committee was a systematic review of the literature conducted by the Centers for Disease Control and Prevention (CDC). The CDC search crite- ria and vocabulary are described in Box 3-1. The committee supplemented this systematic search with selected publications based on the members' knowledge of the scientific literature. For the purposes of its review, the CDC defined health as a "human condition with physical, social, and psychological dimensions, each char- acterized as a continuum with positive (i.e., the absence of disease, along with a capacity to enjoy life and withstand its challenges) and negative (i.e., illness and premature death) aspects." The CDC defined health- related fitness as the fitness components that have an association with health-related outcomes and are typically identified as aerobic fitness (i.e., cardiorespiratory endurance), muscular strength, muscular endur- ance, body composition, flexibility, and balance. Only the literature on cardiorespiratory endurance, muscle strength, and muscle endurance was examined systematically, further selected based on the inclusion/ exclusion criteria presented in Box 3-1, and abstracted (only experimental and lon- gitudinal studies were abstracted). The CDC considered that the relation- ship between body composition and health outcomes is well established and therefore conducted a systematic review of it only as a health out- come. Although the CDC performed a systematic search for flexibility, the articles on this component were not abstracted because of limited time and resources. When studies addressing cardiorespiratory endurance or musculoskeletal strength or endurance also included flexibility as a fitness component, however, the CDC abstracted such information. A breakdown of the total number of studies that satisfied the CDC search criteria in Box 3-1 and were abstracted is as follows: Cardiorespiratory endurance: 47 experimental, 29 quasi-experimental, 35 experimental (no control), 24 longitudinal Musculoskeletal strength: 23 experimental, 12 quasi-experimental, 22 experimental (no control), 6 longitudinal Musculoskeletal endurance: 12 experimental, 6 quasi-experimental, 15 experimental (no control), 5 longitudinal Flexibility: 7 experimental, 5 quasi-experimental, 9 experimental (no control), 4 longitudinal

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METHODOLOGY FOR SELECTION AND INTERPRETATION 53 Identification and Selection of Test Items The committee followed the criteria listed in Box 3-2 in a stepwise fash- ion to select test items for the various components of fitness. Although the search for studies on tests measuring musculoskeletal strength and endurance was conducted separately by the CDC, the committee discusses those tests in Chapter 6 since they all measure dimensions of the same component, muscu- loskeletal fitness. As Box 3-2 shows, the committee applied five broad criteria in filtering and selecting the best test items for each fitness component: (1) the test item has been described and is currently being utilized; (2) the qual- ity of the research of individual studies showing the relationship between a test item and a health marker is high; (3) based on all the evidence, there is an association between performance on the test item and one or more health markers; (4) the test item has adequate integrity (validity and reliability); and (5) administering the test item in the field is feasible. The selection of high-quality studies for cardiovascular endurance, mus- culoskeletal fitness, and flexibility test items was based on the following cri- teria: (1) study design (e.g., randomized controlled trials versus longitudinal studies), (2) representativeness of the population (e.g., age range), (3) freedom from bias, (4) sample size, (5) validity of health markers, (6) adequacy of description of the intervention, (7) relationship between performance on the test item and one or more health markers, (8) statistical rigor, and (9) adjust- ment for confounders. Limitations of the scientific literature with regard to these criteria are described in the chapters on the fitness components that were assessed for their relationship to health in youth (Chapters 5, 6, and 7). Attempting to find associations between performance on fitness tests and health in youth entails important limitations that can help in under- standing the committee's approach to reviewing the evidence. In addition to challenges inherent in using field-based (as opposed to laboratory-based) fit- ness tests, two important challenges arise in analyzing associations between fitness performance and health in youth. First, health constructs in youth are not as well defined as they are in adults; for example, there are questions about whether elevated blood pressure in youth is directly associated with a poor health outcome. Second, diseases that typically are related to low levels of fitness in adults are found with low frequency in youth; therefore, finding an association between performance on fitness tests and health in youth is not highly probable, particularly in studies with small sample sizes. Consequently, studies that investigate the association between performance on a fitness test and health in youth often use health markers rather than health outcomes as health variables. Finding health markers with good ability to predict a future negative health outcome is in itself difficult. Although biological significance and strength of association are typical

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54 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH BOX 3-1 CDC Literature Search: Criteria and Vocabulary Literature Databases Searched CINAHL Sport Discus Embase Medline PsychINFO Pubmed Web of Knowledge Web of Science ProQuest PsyInfo Inclusion/Exclusion Criteria Peer-reviewed original research At least one fitness measure and at least one health measure No minimum sample size All study designs English language Population aged 5-18, healthy, obese and nonobese, sedentary and athletic Publication date: January 2000-December 2010 Exclusions: congenital diseases, disabilities (e.g., cerebral palsy, cys- tic fibrosis, heart abnormalities, motor deficits) Search Vocabulary for Fitness Measures Aerobic capacity: aerobic capacity, cardiorespiratory fitness, cardiovas- cular health, exercise tolerance, endurance capacity, maximum oxygen uptake, oxygen consumption, endurance training, aerobic exercise Flexibility: range of motion (articular), joint flexibility, range of motion, joint range of motion, motor skills, motor fitness, sit-and-reach, fitnessgram, fitness gram, muscle stretching exercises, hamstring flexibility, low-back flexibility criteria applied in reviewing scientific evidence, the above challenges led the committee to consider as evidence any significant positive association reported in a high-quality study. The strength of the association between

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METHODOLOGY FOR SELECTION AND INTERPRETATION 55 Muscular endurance: exercise test, fitnessgram, fitness gram, bicep curl, curl-up, pull-up, sit-up, muscle endurance, muscular endurance, physical exertion Muscular strength: climb, stairs, fitness centers, strength training, resis- tance training, weight lifting, gymnastics, tree climbing, rope climbing, rock climbing, calisthenics, muscle strength Search Vocabulary for Health Outcomes Body composition/obesity/diabetes: obesity, overweight, adiposity, body weight, body mass index, abdominal fat, adipose tissue, glucose metabo- lism disorders Cancer: neoplasms Cardiovascular/pulmonary: cardiovascular diseases, cardiovascular sys tem, cerebrovascular disorders, cardiac function, respiratory tract diseases, chronic obstructive pulmonary disease, lung diseases (obstruc- tive), respiratory function tests, lung function, asthma, cardiovascular risk, bronchoconstriction Cognitive/neurological: mental health, anxiety, depression, sleep dis- orders, cognition, memory, attention, dementia, stress (psychological), anger, self concept, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, attention deficit disorder with hyperactivity, pain, gait, gait disorders (neurologic) Skeletal/muscular/connective: osteoporosis, calcification (physiologic), muscular atrophy, fat-free mass, arthritis, bone and bones, bone density, bone mineral density, scoliosis, rhabdomyolysis Miscellaneous: risk, injury risk, functional health a test item and a health marker was categorized as sufficient when most high-quality studies showed a significant association between the test results and a specific health outcome or marker.

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56 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH BOX 3-2 Stepwise Application of Criteria for Selection of Fitness Test Items Phase 1: Identification of fitness test items for consideration S tep 1. Review fitness test batteries currently used (those listed in Table 2-6 in Chapter 2 and other sources). Step 2. Identify appropriate test items for each fitness component. Step 3. If appropriate and feasible, add test items identified through sources other than the CDC literature search. Phase 2: Summary of relationship of fitness components to health outcomes S tep 1. Review and summarize the literature that establishes a link between each fitness component and health outcomes. Phase 3: Evaluation of relationship of fitness test items to health markers in youth S tep 1. Review technical reports from currently used fitness tests and consider literature referenced in those reports, especially as it relates to health markers and the integrity of the fitness test items. Step 2. Review the CDC literature (and additional sources). Step 3. Evaluate the quality of the research of each study; select publications based on the quality of the research. Step 4. Based on all the evidence, identify health-related test items that qualify for further review in Phases 4 and 5. Phase 4: Evaluation of integrity of test items (i.e., validity and reliability) Step 1. Review the relevant literature on validity and reliability. Step 2. Identify the best test items (based on their association with health markers as identified in Phase 3 and on their integrity). The committee deliberated at length on the issue of considering stud- ies in adults to draw conclusions about the associations between fitness in youth and health outcomes. The committee also discussed the inclusion of studies exploring the relationship between meeting a level of fitness early in life and specific health outcomes as an adult. The committee concluded

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METHODOLOGY FOR SELECTION AND INTERPRETATION 57 Phase 5. Evaluation of administrative feasibility of test items Step 1. Review the relevant literature. Step 2. Complete a scorecard for the test items resulting from Phase 4 using the following list of questions: Can the item be conducted in a timely and efficient manner? Does the item impose an acceptable preparation burden on participants? Does the item impose an acceptable preparation burden on administrators? Is the item relatively free of motivational or self-esteem influence? Is the test item free of interpretation misuse? Can it be administered with acceptable privacy? Can it be administered with minimal equipment and space? Is (interpretation of) performance on the item independent of read- ing comprehension by the participant, socioeconomic status, and age bias? Is performance on the item independent of familiarity with the item? Is performance on the item relatively independent of prior practice? S tep 3. Assess the test items using the scorecard, considering whether they will be implemented in a national survey or in schools or other educational settings. Phase 6. Formulation of conclusions and recommendations on appropriate fitness test items for youth. that the assumptions entailed in extrapolating studies in adults to youth are sometimes uncertain, and therefore decided not to include such studies as the main or sole evidence of an association of a test item with health in youth but only as supportive evidence. In addition, because the literature search was limited to health in youth and prospective studies did not cover

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58 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH the length of time until youth reach adulthood, studies of the long-term consequences of fitness (i.e., whether reaching a specific fitness level as a youth would result in health consequences as an adult) were consid- ered only as secondary evidence in identifying fitness test items that are associated with health in youth. However, the committee understands the importance of assessing how well a health marker tracks into adulthood and identifying appropriate health markers in youth and makes recom- mendations to this effect. The approach used to select appropriate test items for body composi- tion differed. As noted earlier, the relationships between body composition, particularly percent body fat, and health outcomes are well established in both youth and adults. For this reason, the CDC did not provide the com- mittee with a systematic review of literature demonstrating the relationship between test items for body composition and health outcomes. Therefore, to identify appropriate test items for body composition, the committee selected field-based items that were valid, reliable, and feasible for either a national survey or an educational setting. CONSIDERATION OF MODIFYING FACTORS Gender and age often are analyzed as confounders or effect modifiers in research studies, and gender- and age-specific cut-points have been set for fitness test items. There are, however, other factors that may modify performance on fitness test items or the association between an item and health but are not routinely included in surveys of youth fitness or in study designs. For some modifiers (e.g., gender, age, race/ethnicity, body composition, maturation status, motor skill), evidence for their influence on specific fit- ness test items varies in quality (see, for example, Chapter 4 on the influence of body composition on fitness tests). In the studies reviewed, insufficient data were available with which to assess the influence of several potential modifiers--gender, age, race/ethnicity, body composition, maturation sta- tus, motor skill--on performance on cardiorespiratory endurance, muscu- loskeletal fitness, and flexibility tests. When these modifiers were considered in the designs of the studies reviewed, the committee comments on the results in the respective chapters (Chapters 5-7). The committee recommends including measures of some of these factors in surveys and study designs to gain a better understanding of their influ- ence. As more research is undertaken and survey data are collected, it may be appropriate to establish cut-points based on selected modifiers, but at this time the committee recommends that only age- and gender-based cut-points be established (see Chapter 8). Age- and gender-based cut-points, however,

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METHODOLOGY FOR SELECTION AND INTERPRETATION 59 need to be interpreted in the context of other potential modifiers (e.g., body composition, demographic characteristics). For that reason, the committee highlights the importance of training those who will be interpreting and communicating results (see Chapters 8 and 9). An important aspect of this training is learning to be cognizant of the influence of modifying factors. The following is a summary of what is known about the potential effects of maturation status, motor skill, and demographic factors (race/ ethnicity, socioeconomic factors) on fitness performance. Although body composition is also categorized as a modifying factor in the committee's framework, a summary of what is known about the influence of selected elements of body composition on fitness performance is included in Chapter 4 and is not repeated here. The committee's recommendations for including some of these factors in national surveys and research study designs can be found in Chapters 8 and 10, respectively. Maturation Status The literature review revealed extensive documentation of changes in fitness with age per se (Branta et al., 1984; Carron and Bailey, 1974; Ellis et al., 1975; Espenschade, 1960; Froberg and Lammert, 1996; Haubenstricker and Seefeldt, 1986; Keogh, 1965; Malina and Roche, 1983; Malina et al., 2004; Mizuno et al., 1973; Ostyn et al., 1980; Simons et al., 1990) and with individual differences in maturity status within a given age group (Espenschade, 1940; Jones, 1949; Little et al., 1997; Malina et al., 2004). This effect may be due in part to differentials in the timing of maturation. There are two indicators of this timing: age at menarche and age at peak height velocity (a measure of the maximum rate of growth in stature during a growth spurt) (Malina et al., 2004). Several measures of physical fitness have their own spurts, which have been documented more in boys than in girls (Beunen and Malina, 1988; Beunen et al., 1988; Carron and Bailey, 1974; Heras Yague and de la Fuente, 1998; Kemper and Verschuur, 1985; Mirwald and Bailey, 1986). Variation in fitness among youth has been clas- sified as late, on time (average), or early in skeletal age, age at menarche, and timing of peak height velocity (Jones, 1949; Lefevre et al., 1990; Little et al., 1997; Malina et al., 2004). Differences in maturity are more marked for boys than for girls, although relevant data are not as extensive for girls (Malina et al., 2004). While evidence suggests a relationship between maturity stages per se and performance on fitness tests, some questions remain to be answered--in contrast to the influence of body size and/or body composition on fitness, which is affected independently by individual differences in maturation (Malina et al., 2004). The following four methods can be used to measure maturity.

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68 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH Criterion-Referenced Setting of Cut-Points and Evaluation of Fitness Most of the limitations listed above are overcome with a criterion- referenced evaluation approach, whereby a test taker's performance is compared with an absolute criterion related to whether a child meets a minimal necessary physical fitness level. In contrast with the norm- referenced approach, because the criterion is defined independently, it is not impacted by changes in a population that occur over time or in the level of fitness of a specific population. Limitations related to genetic differences or the potential for discouraging unfit participants also can be minimized with this approach. Many methods have been developed for setting performance standards (Cizek, 2001; Livingston and Zieky, 1982), but for criterion-referenced evaluation of health-related fitness, the health outcomecentered method (Zhu et al., 2011) has predominated. Basically, this method involves linking health-related fitness performance with a particular (set of) health outcome measure(s). Specifically, this approach identifies a level of test performance that discriminates, with acceptable specificity and sensitivity, between par- ticipants who have and do not have a defined health characteristic. An example is identifying a level of performance on a measure of cardiorespi- ratory endurance that discriminates between groups of youth who have or do not have an at-risk score for metabolic syndrome. Steps completed before developing cut-points for the health-outcome centered method include determining the components of health-related fitness (e.g., cardiorespiratory endurance) and selecting valid, reliable cri- terion measures and field tests and health outcomes or markers. Field tests are selected because even though criterion measures (criterion-referenced standards) are the most accurate measure of a construct, they often are more expensive and time-consuming and require sophisticated equipment. Field tests are more practical, less costly, and less time-consuming for mass testing. It is important, however, to determine the validity and reliability of field tests by deriving the predictive relationship and determining its consistency with the selected criterion measure. The selection of health outcomes can be based on the expected rela- tionship between field tests and health markers or outcomes. Health is a construct, so there are many possible health outcome measures, such as mortality, a single risk factor (e.g., blood pressure), or a group of risk fac- tors (e.g., metabolic syndrome). Because no specific measure is considered superior, it is advisable to use multiple outcome measures to validate the test results when possible. Those selecting cut-points also need to identify health outcome measures using existing standards (e.g., a systolic blood pressure level of 103 mmHg for a 5-year-old child 104 cm in height) and make adjustments for specific populations if needed.

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METHODOLOGY FOR SELECTION AND INTERPRETATION 69 Guidance for Establishing Cut-Points for Youth Fitness Tests As mentioned above, setting cut-points for evaluating results of health- related fitness tests entails a number of challenges, one of which is the lack of appropriate data. Ideally, cut-points are established from data on performance on a specific fitness test and health outcomes in a broad- based youth population. More often, however, these data are not available; instead, there may be enough data on an association with health in the adult population but only growing evidence from studies in small samples of the youth population. In yet a different scenario, only growing evidence for an association between a specific test and health exists, with no data coming from broad populations. Until data in broad youth populations are gener- ated so cut-points can be derived, cut-points should be referred to as interim criterion-referenced cut-points (or interim cut-points). Various approaches can be used to select these interim criterion-referenced cut-points, depend- ing on the available data. The committee's guidance on these approaches is presented in this section. Often a number of field tests are used simultane- ously to measure the same fitness component. The reader is referred to Zhu et al. (2010) and Jackson (1989) for information on setting cut-points for multiple tests of a single component. Several considerations apply in interpreting the results of fitness tests. For health-related fitness testing in youth, the key interest is not only whether a test taker is "fit enough" to be free of potential health risks but also whether the test taker is "fit enough for the future." In addition, because the key outcome of interest of the criterion-referenced approach to evaluating test results is classification (e.g., being at risk of a health outcome versus not being at risk), the accuracy of the classification is key. Further, regardless of how well the related cut-point is established, it will be pos- sible to misclassify individuals. There are two kinds of misclassification: (1) when a fit test taker is misclassified as unfit and (2) when an unfit test taker is misclassified as fit. The committee considered the first of these to be more problematic because it would result in a greater likelihood of rec- ommending an exercise intervention to youth who do not need it, thereby depleting already limited resources that should be used for youth who need them the most. To minimize the effects of misclassification, cut-points need to be validated or cross-validated using additional measures and samples. Finally, whether cut-points should be established differently for various subpopulations must be examined and determined empirically. As discussed earlier, while age and gender often have been taken into consideration in setting cut-points, many other factors, such as race/ethnicity, maturation status, and disability, have not been considered. Once cut-points have been established for a specific test and age/gender group, they should be used in interpreting test results and communicating

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70 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH with participants, families, school and health officials, and the general public. Doing so will minimize the confusion that might arise from com- municating in terms of the percentiles used to derive the cut-points. For example, the CDC has used the 95th percentile from a previous decade to derive cut-points for obesity in children, yet more than 15 percent of youth currently exceed that 95th percentile. These are challenging issues to com- municate. In cases where percentiles may allow for a clearer presentation of the results than cut-points, as with BMI, the year of data collection should be reported with the percentile. In this connection, researchers developing percentile data with which to derive cut-points should also report the time of data collection. Establishing Cut-Points When the Relationship Between the Test of Interest and a Health Marker in Youth Is Known In the ideal situation, when there is a concurrent relationship between a health outcome and a fitness test, the cut-points for the test are deter- mined using a data mining procedure2 to establish statistical evidence for the relationship. While not common, this kind of concurrent relationship does exist and has been used for setting cut-points. For example, based on the concurrent relationship between body composition and a set of health outcome measures (total cholesterol, serum lipoprotein ratio, and blood pressure) (Williams et al., 1992), a set of cut-points was derived for evaluat- ing body composition (Going et al., 2008). Similar applications have been reported for setting cut-points for cardiorespiratory endurance (Lobelo et al., 2009) and waist circumference in Chinese school-aged children (Liu et al., 2010) and for body composition and cardiorespiratory endurance tests (Going et al., 2011; Welk et al., 2011). Establishing Cut-Points When a Concurrent Relationship Has Not Been Confirmed in Youth Even if a concurrent relationship between a health outcome measure and a putative health-related fitness test has been well established in adults and cut-points exist for that population, such a relationship often has not been confirmed in youth. Because a negative health outcome (e.g., low-back pain, cardiovascular diseases) may take years to develop, children's health 2Data mining involves varying cut-points, computing agreement-related statistics with the classification of health outcome measures each time, and determining the cut-points accord- ing to optimal statistical results (e.g., highest P- and kappa-coefficients, specificity index and relative risk statistics, findings and illustration of receiver operating characteristic [ROC] curve analysis). If the cut-points are set across a large range of groups, the data from these groups usually are smoothed before the data mining procedure is applied.

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METHODOLOGY FOR SELECTION AND INTERPRETATION 71 outcome measures may be in a normal range even if they are not fit. Meth- ods of setting cut-points based on evidence in adults assume that a fit child will likely become a fit adult. While there is some evidence to support this assumption for certain fitness components (see, e.g., Beunen et al., 1992; Campbell et al., 2001; Malina, 1996, 2001), more research, especially lon- gitudinal studies, is needed to confirm this assumption. When a relationship can be confirmed only in adults, there are two methods for estimating the cut-points for health-related fitness tests in youth--the relative position and the panel-driven methods. With the rela- tive position method, the percentile of adults considered to be at risk based on their performance on a fitness test is taken as the fitness standard in youth. For example, the lowest 20th percentile for performance on a cardiorespiratory endurance test item could be selected based on the dem- onstration by Blair and colleagues (1989) that morbidity and mortality are disproportionately elevated in the lowest quintile for performance on a maximal treadmill test in adults. In the panel-driven method, a panel of experts uses the cut-points from adults and all available information (e.g., growth curves and performance characteristics for different ages and gen- ders) to derive the cut-points for youth. For example, the criterion maximal oxygen uptake (VO2max) value in youth could be determined in various ways, ranging from expert opinion to extrapolation from associations between VO2max and health outcomes in adults. The panel-driven method was used to set the Fitnessgram standards for cardiorespiratory endurance test items (Cureton, 1994; Cureton and Warren, 1990). Establishing Cut-Points When the Relationship Between a Fitness Test and Health Outcomes Is Not Confirmed in Youth or Adults While the importance of some fitness components to health has been suggested, the relationship between specific fitness test items and health outcomes may not be confirmed. For example, while the validity and reliability of commonly used tests have generally been well established, evidence for the importance of muscular strength for health in adults is still growing and may be equivocal for some tests, and for youth remains largely unconfirmed. Until these relationships are confirmed, an alternative approach for setting cut-points is to use the comparatively relative position method, in which a percentile established for another measure is borrowed. If the percentile from another test is borrowed, the two tests should be as comparable as possible in their nature (e.g., both require movement of the body) and in the dimension they measure (e.g., upper-body strength). For example, if the cut-points for tests of the cardiorespiratory endurance com- ponent derived through a criterion-referenced evaluation procedure were set at about the 20th percentile, the cut-points for tests of the musculo

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