Condición Física, Salud Positiva Psicosocial, Conductas de

Transcription

PORTADA:
fusionada con el agua…..ese momento……tras el esfuerzo…..
antes de salir a la superficie…….suave…….en equilibrio…. como una
burbuja……respirar …….sin apenas romper el agua.
(Virginia Aparicio)
DEPARTAMENTO DE DIDÁCTICA DE LA EDUCACIÓN FÍSICA, PLÁSTICA
Y MUSICAL
FACULTAD DE CIENCIAS DE LA EDUCACIÓN
UNIVERSIDAD DE CÁDIZ
Condición Física, Salud Positiva Psicosocial,
Conductas de Riesgo y Alteraciones Psicosomáticas
en Niños de 6 a 17 años
Physical Fitness, Psychosocial Positive Health, Health Risk
Behaviors and Health Complaints in Children Aged 6 to 17 years
CARMEN PADILLA MOLEDO
17 DE DICIEMBRE 2010
A mis padres Antonio y Victoria
A mis sobrinos Pablo, Jorge y Jimena
DEPARTAMENTO DE DIDÁCTICA DE LA
EDUCACIÓN FÍSICA, PLÁSTICA Y MUSICAL
FACULTAD DE CIENCIAS DE LA EDUCACIÓN
Condición Física, Salud Positiva Psicosocial,
Conductas de Riesgo y Alteraciones Psicosomáticas
en Niños de 6 a 17 años
Physical Fitness, Psychosocial Positive Health, Health Risk
Behaviors and Health Complaints in Children Aged 6 to 17 years
CARMEN PADILLA MOLEDO
DIRECTORES DE TESIS
Dr. José Castro Piñero
Profesor Titular de Universidad
Universidad de Cádiz
PhD
Dr. Jonatan Ruiz Ruiz
Investigador Post-Doctoral
Instituto Karolinska
PhD
Dr. Jesús Mora Vicente
Catedrático de Esc. Universitaria
PhD
Dra. Palma Chillón Garzón
Profesora Ayudante Doctor
Universidad de Granada
PhD
Dr. Julio Conde Caveda
Profesor Titular de Esc. Universitaria
PhD
Dra. Rute Marina Santos
Associate Professor
University of Porto
PhD
Dra. Mª José Girela Rejón
Profesora Asociada
Universidad de Granada
PhD
Dr. Diego Moliner Urdiales
Profesor Ayudante Doctor
Universidad Jaume I
PhD
MIEMBROS DEL TRIBUNAL
Cádiz, 17 de diciembre 2010
European PhD Thesis
CONTENIDOS
Becas y Financiación [Grants and Funding] …………………………………………………..15
Lista de publicaciones [List of Publications] ……………………………………………….....16
Resumen ………………………………………………………………..………………….......17
Summary ………………………………………………………………..………………..........18
Abreviaturas [Abbreviations] ……………………………………………..…………………..19
Introducción [Introduction] ……………………………………………..………………..........21
Objetivos ………………………………………………………………..………………......... 29
Aims …………………………………………………………………………..……………… 30
Referencias [References] …………………………………………………...………………....31
Material y Métodos [Material and Methods] ………………………………..……………..… 37
Resultados y Discusión [Results and Discussion] …………………………...……….........….39
I.
Health complaints and health risk behaviors are associated with cardiorespiratory
fitness and fatness in youth. (Artículo I) ……………………………………………....41
II. Psychological positive health, cardiorespiratory fitness and fatness in children and
adolescents. (Artículo II)…………………………………………………………….....65
III. Associations of psychological positive health, health complaints and health risk
behaviors with muscular fitness in Spanish children and adolescents. (Artículo III).....93
IV. Television viewing, psychological positive health, health complaints and health risk
behaviors in Spanish children and adolescents. (Artículo IV) ……………………....115
Conclusiones ………………………………………………………………..………………..141
Conclusions …………………………………………………………..……………………....143
Agradecimientos [Acknowledgements] ……………..………………………………..……...145
13
European Phd Thesis
BECAS Y FINACIACIÓN [GRANTS AND FUNDING]
El presente trabajo de investigación ha sido posible gracias a la subvención obtenida en el
siguiente proyecto de investigación:
•
Estudio “Batería de tests para la valoración de la condición física en los diferentes
grupos de población. BATESTAN. Propuesta unificadora”. Proyecto financiado por el
Centro Andaluz de Medicina del Deporte de la Junta Andalucía (Ref: JA-CTD2005-01,
BOJA num. 247, 21/12/2005).
15
Padilla-Moledo C, 2010
LISTA DE PUBLICACIONES [LIST OF PUBLICATIONS]
La presente memoria de tesis está compuesta por los siguientes artículos científicos:
I.
Castro-Piñero J, Padilla-Moledo C, Ortega FB, Moliner-Urdiales D, Xiaofen DK, Mora
J, Ruiz JR. Health complaints and health risk behaviors are associated with
cardiorespiratory fitness and fatness in youth. Submitted.
II.
Padilla-Moledo C, Castro-Piñero J, Ortega FB, Mora J, Marquez S, Sjöström M, Ruiz
JR. Psychological positive health, cardiorespiratory fitness and fatness in children and
adolescents. Submitted.
III.
Padilla-Moledo C, Ruiz JR, Ortega FB, Mora J, Castro-Piñero J. Associations of
psychological positive health, health complaints and health risk behaviors with
muscular fitness in Spanish children and adolescents. Submitted.
IV.
Padilla-Moledo C, Castro-Piñero J, Ortega FB, Pulido M, Sjöström M, Ruiz JR.
Television viewing, psychological positive health, health complaints and health risk
behaviors in Spanish children and adolescents. Submitted.
16
European Phd Thesis
RESUMEN
El objetivo general de la presente Memoria de Tesis Doctoral es estudiar la asociación entre
indicadores de salud positiva psicológica, las alteraciones psicosomáticas y las conductas de
riesgo con la condición física y las conductas sedentarias en niños y adolescentes.
Un total de 691 jóvenes españoles de la provincia de Cádiz de 6 a 17 años conforman la
población que ha participado en este estudio.
Los principales resultados fueron: a) Indicadores de salud positiva psicológica están
positivamente asociados con la capacidad aeróbica y la fuerza muscular; e inversamente
asociados con el grado de sobrepeso-obesidad; b) Las alteraciones psicosomáticas están
inversamente asociadas con la capacidad aeróbica; y positivamente asociadas con el grado de
sobrepeso-obesidad; c) Las conductas de riesgo tales como consumir alcohol y fumar están
inversamente asociadas con la capacidad aeróbica y la fuerza muscular; d) El hábito de ver la
televisión (durante más de 2 horas al día) está inversamente asociado con indicadores de salud
positiva psicológica; y positivamente asociado con las alteraciones psicosomáticas.
Los resultados de la presente memoria de Tesis indican la relación existente entre la
salud positiva psicológica, las alteraciones psicosomáticas y las conductas de riesgo con la
condición física y las conductas sedentarias en niños y adolescentes. Estos resultados subrayan
la importancia de monitorizar y promover estrategias para mejorar la salud positiva psicológica
así como para prevenir las alteraciones psicosomáticas y las conductas de riesgo en niños y
adolescentes.
17
SUMMARY
The overall objective of this Thesis was to examine the association of psychological positive
health indicators, health complaints and health risk behaviors with physical fitness and
sedentary behaviors in children and adolescents.
A total of 691 Spanish (from Cádiz, south of Spain) children and adolescents aged 6-17
years were involved in the present work.
The main outcomes were: a) Psychological positive health indicators are positively
associated with cardiorespiratory fitness and muscular fitness; and inversely associated with
fatness; b) Health complaints are inversely associated with cardiorespiratory fitness and
positively associated with fatness; c) Health risk behaviors such as drinking alcohol and
tobacco are inversely associated with cardiorespiratory fitness and muscular fitness; d)
Television viewing is inversely associated with psychological positive health indicators and
positively associated with health complaints.
These results show a clear link between psychological positive health, health complaints,
and health risk behaviors with physical fitness and sedentary behaviors in children and
adolescents. The present Thesis highlights the importance of monitoring and promoting a better
psychological positive health as well as the prevention of health complaints and health risk
behaviors already from childhood and adolescence.
18
European Phd Thesis
ABREVIATURAS [ABBREVATIONS]
AVENA
Análisis y Valoración del Estado Nutricional de los
Adolescentes Españoles
BOJA
Boletín Oficial de la Junta de Andalucía
BMI
Body mass index
CD
Compact disk
CI
Confidence interval
HBSC
Health Behavior in school-aged children
FITNESGRAM
Fitness proGRAM
IMC
Índice de masa corporal
PASW
Predictive Analystics SoftWare
OR
Odds ratio
SD
Standard deviation
s.d.
Standard deviation
SEM
Standard error of the measure
TV
Televisión
20mSRT
20 meters shuttle run test
19
European PhD Thesis
INTRODUCCIÓN [INTRODUCTION]
La infancia y la adolescencia son etapas decisivas en el desarrollo humano por los múltiples
cambios fisiológicos y psicológicos que en ellas concurren [1]. Unos y otros influyen sobre el
comportamiento y el estilo de vida de niños y adolescentes, no sólo a medio sino también a
largo plazo. Además, a lo largo de estas etapas el sujeto va a adquirir una serie de hábitos, tales
como, hacer actividad física, comer de manera saludable, fumar, consumir alcohol o ver la
televisión, que suelen persistir durante muchos años o incluso durante toda la vida, con el
consiguiente beneficio o riesgo para la salud. Por ello, es de vital importancia fomentar desde
estas edades, tanto la adquisición de hábitos saludables (salud positiva) como la prevención de
hábitos no saludables (conductas de riesgo), así como conocer y comprender todos los factores
asociados a ellos. El entorno familiar, social y escolar de niños y adolescentes va a jugar un
papel clave en este proceso.
Salud positiva psicológica, alteraciones psicosomáticas y conductas de riesgo
La salud positiva es un concepto multifactorial que describe un estado más allá de la mera
ausencia de enfermedad e incluye variables biológicas, funcionales y subjetivas de la persona
[2]. La combinación de estas variables constituye un potencial predictor de los futuros costes
de salud, de las alteraciones mentales, de los pronósticos médicos [2] y de la longevidad [2,3].
La dimensión biológica-funcional de la salud positiva ha sido la que mayor atención ha
recibido por parte de los investigadores, destacando entre otros, aquellos estudios relacionados
con las enfermedades cardiovasculares y la obesidad, como algunos de los problemas de salud
más acuciantes.
Por su parte, las variables subjetivas de la salud positiva (salud positiva psicológica)
hacen referencia al bienestar psicológico de la persona: emociones positivas, satisfacción con
21
la vida, autoconcepto, optimismo, sentirse saludable, sensación de bienestar [2]. Asímismo las
relaciones sociales positivas también son consideradas en el ámbito de la salud positiva
psicológica [4-7] por su contribución al bienestar de la persona [8,9]. Estudios realizados con
adultos sugieren que indicadores relacionados con la salud positiva psicológica, tales como el
optimismo, ejercen un efecto protector contra afecciones físicas y mentales como la gripe [10],
enfermedades cardiovasculares [11], accidentes cerebro vasculares [12] o depresión [13]. Hasta
fechas recientes, este grupo de variables había sido objeto de escasas investigaciones. Sin
embargo, durante los últimos años el interés por el estudio de las mismas y sus consecuencias
positivas para la salud ha ido en aumento.
El término alteración psicosomática (health complaint en inglés) hace referencia a un
conjunto heterogéneo de síntomas físicos y psíquicos que no corresponden a ninguna
enfermedad orgánica definida [14]. Las alteraciones psicosomáticas más frecuentes son: dolor
abdominal, dolor de cabeza, dolor de espalda, dolor de cuello, fatiga, nauseas, depresión,
ansiedad, pérdida de apetito y mareo [15]. Estas alteraciones se presentan con frecuencia en
niños y adolescentes [16], afectando a su vida personal y siendo en ocasiones motivo de
absentismo escolar [17]. Además, muchas de ellas tienden a hacerse crónicas [18].
Por último, las conductas de riesgo (health risk behaviors en inglés) hacen referencia a
la práctica de hábitos perjudiciales para la salud. Ejemplos de estas conductas de riesgo son:
fumar, beber alcohol, emborracharse, consumir drogas, tener malos hábitos alimenticios, y no
respetar las normas de seguridad vial. Concretamente, el consumo de alcohol y de tabaco son
considerados como dos de las principales causas de morbilidad y mortalidad [19,20].
Existen estudios que sugieren que la práctica regular de ejercicio físico y/o actividad
física está positivamente asociada con indicadores relacionados con la salud positiva
psicológica, tales como, autoimagen [21-23], satisfacción con la vida, felicidad, relaciones
22
European PhD Thesis
familiares, relaciones sociales y salud autopercibida [22,23]; e inversamente asociada con
alteraciones psicosomáticas y conductas de riesgo (consumo de tabaco) [22,23] .
Un factor íntimamente ligado al nivel de actividad física y/o ejercicio que se realiza es el
estado de condición física que tiene una persona. La condición física está parcialmente
determinada por la actividad física que realiza un individuo.
Condición física relacionada con la salud
El término condición física es la traducción del término inglés physical fitness y hace
referencia a la capacidad que tiene un sujeto para realizar un ejercicio o trabajo físico. Define
un estado dinámico del sujeto, producto de la combinación de la actividad física regular y de
estructuras y funciones anatómicas, fisiológicas, motoras y psicológicas. La condición física
puede ser considerada como uno de los marcadores de salud más importantes, y se ha
establecido como un potente predictor de morbilidad y mortalidad tanto por enfermedad
cardiovascular como por cualquier otra causa [1,24,25]. Los principales componentes de la
condición física relacionados con la salud son: la capacidad aeróbica, la fuerza muscular y la
composición corporal [24].
Capacidad Aeróbica
La capacidad aeróbica es una de las cualidades más importantes de la condición física
relacionada con la salud tanto en jóvenes como en adultos [1,26]. Es la capacidad que tiene un
individuo de soportar un esfuerzo prolongado, representando una medida directa del estado
general de salud y de manera específica del estado del sistema cardiovascular, respiratorio y
metabólico [27].
Existen numerosas investigaciones que abordan las asociaciones entre la capacidad
aeróbica y las variables biológicas de la salud positiva. Así diferentes estudios observaron que
23
los niños y adolescentes que poseen un nivel medio-alto de capacidad aeróbica tienen un
menor riesgo de desarrollar enfermedades cardiovasculares que aquellos jóvenes que tienen un
menor nivel [1,24,28]. Esta asociación parece ser independiente del sexo, edad, etnia y grado
de obesidad. Además, una baja capacidad aeróbica durante la infancia y la adolescencia está
inversamente asociada con diversos parámetros de salud tales como: perfil lipídico,
hipertensión, obesidad [1,24], síndrome metabólico [29,30] y rigidez de las arterias [31,32] en
la edad adulta. El conjunto de estos resultados sugiere que la capacidad aeróbica podría ejercer
un efecto protector sobre el sistema cardiovascular desde edades tempranas [1,24,28].
Capacidad aeróbica, salud positiva psicológica, alteraciones psicosomáticas y conductas de
riesgo
La asociación entre capacidad aeróbica con algunos indicadores relacionados con la salud
positiva psicológica (autoestima y rendimiento académico) y las alteraciones psicosomáticas
(ansiedad y depresión) en niños y adolescentes, ha sido abordada por escasos estudios,
mostrando resultados contradictorios. Crews et al. [33] observaron que la capacidad aeróbica
se asocia positivamente con la autoestima e inversamente con la depresión, mientras que no
hallaron asociación significativa entre capacidad aeróbica y ansiedad. Por su parte Bonhauser
et al. [34] mostraron que la capacidad aeróbica se asocia positivamente con la autoestima e
inversamente con la ansiedad, pero no observaron asociación significativa entre capacidad
aeróbica y depresión. Además, diversos estudios hallaron una asociación positiva entre la
capacidad aeróbica y el rendimiento académico [35-37], mientras que Ruiz et al. [38] no
encontraron asociación.
En cuanto a la asociación entre condición física y conductas de riesgo en jóvenes,
varias investigaciones observaron que la capacidad aeróbica se asocia inversamente con el
24
European PhD Thesis
consumo de tabaco [39-41], mientras que Montoye et al. [39] no hallaron asociación entre
capacidad aeróbica y conductas de riesgo tales como el consumo de alcohol.
Fuerza muscular
La fuerza muscular es la capacidad de realizar un trabajo en contra de una resistencia.
Actualmente la fuerza muscular es considerada como un referente de salud y bienestar tanto en
adultos [42] como en jóvenes [43-45]. Estando además inversamente relacionada con índices
de mortalidad y positivamente con la garantía de autonomía de una persona [42,46-48].
El reconocimiento del papel de la fuerza muscular en la prevención de enfermedades ha
aumentado considerablemente en los últimos años [42,49,50]. Un buen nivel de fuerza
muscular durante la infancia y la adolescencia va a estar asociado con un mejor perfil
cardiovascular [1]. Además, las mejoras en el nivel de fuerza muscular entre la infancia y la
adolescencia están negativamente asociadas con tensión arterial, perfil lipídico y cambios
evidentes en la adiposidad total y moderados en la adiposidad central. [24].
Fuerza muscular, salud positiva psicológica, alteraciones psicosomáticas y conductas de
riesgo
Los estudios que analizan la relación entre fuerza muscular, salud positiva psicológica,
alteraciones psicosomáticas y conductas de riesgo en niños y adolescentes son escasos. En el
ámbito de la salud positiva psicológica, Chomitz et al. [51] hallaron que la fuerza muscular se
asocia positivamente con el rendimiento académico, aunque otros estudios sugieren que esta
asociación es de carácter débil [35,52].
En una revisión sobre diferentes estudios, Reenen et al. [53] observaron que no existía
asociación entre fuerza muscular y la alteración psicosomática del dolor de espalda.
25
Obesidad
El sobrepeso y/o obesidad se definen como la acumulación excesiva de grasa, la cual
representa un riesgo para la salud [54]. Actualmente los niños invierten menos tiempo en la
práctica deportiva y en las actividades físicas [50], y más tiempo en ver la televisión y en jugar
con los vídeo juegos [5]. Estos cambios conductuales provocan disminuciones en el gasto
diario de energía, lo que podría explicar, al menos parcialmente, el creciente aumento en la
obesidad infantil [56].
Whitaker et al. [55] sugieren que los niños que fueron obesos durante su infancia
probablemente también lo sean en la edad adulta. Además se ha observado que los adultos que
fueron obesos de niños presentan un elevado perfil lipídico, hipertensión arterial, altos niveles
de insulina en ayunas, y un mayor riesgo de enfermedad cardiovascular comparados con
aquellos adultos que no lo fueron [24].
La condición física puede ser un factor de prevención contra la obesidad. Varios
estudios indican que los niños y adolescentes que tienen un nivel alto de capacidad aeróbica
poseen menos grasa corporal total [56-60] y abdominal [61,62]. Igualmente varios estudios han
mostrado una asociación inversa entre la fuerza muscular y la grasa corporal total y abdominal
[56,63-69]. Además, estudios prospectivos muestran una asociación inversa entre los valores
de capacidad aeróbica en adolescentes y la grasa corporal total [70,71], y abdominal [72-77] en
edades adultas. Durante la edad adulta, la fuerza muscular adquirida durante la adolescencia,
está inversamente asociada con la adiposidad total [78,79], aunque no tanto con los cambios en
la adiposidad central [74,75].
Obesidad, salud positiva psicológica, alteraciones psicosomáticas y conductas de riesgo
Estudios realizados con niños y adolescentes observaron una relación inversa entre el índice de
masa corporal (kg/m2) e indicadores relacionados con la salud positiva psicológica tales como
26
European PhD Thesis
satisfacción con la vida (felicidad) [80,81], rendimiento académico [82,83] y salud
autopercibida [81,84].
Por otro lado, diferentes investigaciones sugieren que el índice de masa corporal
(kg/m2) está positivamente asociado con alteraciones psicosomáticas como la depresión
[81,85-89]. Sin embargo, la asociación entre el sobrepeso y/o la obesidad con conductas de
riesgo (consumir alcohol y/o tabaco) no ha sido analizada en profundidad, mostrando además
resultados contradictorios [81,89,90].
Sedentarismo
Se definen como actividades sedentarias aquellas actividades que no suponen un gasto superior
al gasto energético del nivel de reposo, tales como ver la televisión, jugar con los video juegos
o trabajar con el ordenador [91].
Como ya indicábamos al comienzo de esta introducción, datos recientes sugieren que
las actividades sedentarias están aumentando de forma alarmante en niños y adolescentes
[92,93], siendo la televisión una de las actividades sedentarias con mayor prevalencia entre los
jóvenes [94]. Varios estudios en niños y adolescentes han mostrado una asociación entre ver la
televisión, y dolores músculo-esqueléticos [95-97], problemas de comportamiento [98], riesgos
cardiovasculares [99,100], baja condición física [101,102] y obesidad [98,103].
Sedentarismo, salud positiva psicológica, alteraciones psicosomáticas y conductas de riesgo
Varias investigaciones muestran una asociación inversa entre ver la televisión e indicadores
relacionados con la salud positiva psicológica (rendimiento académico) en niños y adolescentes
[104-106]. Sin embargo, otras investigaciones sugieren que los niños que ven programas
educativos obtienen mejores calificaciones escolares [107,108].
27
Por otro lado, diversos estudios realizados con niños y adolescentes hallaron que ver la
televisión estaba positivamente asociada con alteraciones psicosomáticas [22,23], consumo de
tabaco [23] y alcohol [22,23,109].
Justificación
Actualmente, la condición física se considera como uno de los marcadores de salud biológica
más importantes en la infancia y adolescencia, estableciéndose además como un potente
predictor de morbilidad y mortalidad tanto por enfermedad cardiovascular como por cualquier
otra causa en la edad adulta.
También, es necesario considerar el creciente aumento de actividades sedentarias entre
niños y adolescentes y sus negativas consecuencias para la salud.
Por otro lado, la salud positiva psicológica representa el bienestar psicológico y social
de la persona. Mientras que las alteraciones psicosomáticas y las conductas de riesgo tienen
efectos negativos sobre la salud.
Las investigaciones sobre la relación de la condición física y el sedentarismo con la
salud positiva psicológica, las alteraciones psicosomáticas y los comportamientos de riesgo en
niños y adolescentes son escasas, obteniendo en ocasiones resultados contradictorios. Es
necesaria una mayor investigación para poder determinar en qué medida la condición física y
las actividades sedentarias afectan a la salud positiva psicológica, a las alteraciones
psicosomáticas y a las conductas de riesgo y en niños y adolescentes.
Con la base de estos antecedentes, la presente memoria de Tesis fija los siguientes
objetivos:
28
European PhD Thesis
OBJETIVOS
General:
El objetivo general de la presente Tesis Doctoral es estudiar la asociación entre indicadores de
salud positiva psicológica, las conductas de riesgo y las alteraciones psicosomáticas con la
condición física y las conductas sedentarias en niños de 6 a 17 años.
Específicos:
I.
Estudiar la asociación entre alteraciones psicosomáticas y las conductas de riesgo
con la capacidad aeróbica y la obesidad en niños y adolescentes. (Artículo I).
II.
Estudiar la asociación entre indicadores de salud positiva psicológica con la
capacidad aeróbica y la obesidad en niños y adolescentes. (Artículo II).
III.
Estudiar la asociación entre indicadores de salud positiva psicológica, las
alteraciones psicosomáticas y las conductas de riesgo con la fuerza muscular en
niños y adolescentes. (Artículo III).
IV.
Estudiar la asociación entre los hábitos televisivos con indicadores de salud positiva
psicológica, las alteraciones psicosomáticas y las conductas de riesgo en niños y
adolescentes. (Artículo IV).
29
AIMS
Overall:
The overall objective of this Thesis is to examine the association of psychological positive
health indicators, health complaints and health risk behaviors with physical fitness and
sedentary behaviors in children and adolescents aged 6-17.
Specific:
I.
To examine the association of health complaints and health risk behaviors with
cardiorespiratory fitness and fatness in children and adolescents. (Paper I).
II.
To examine the associations of psychological positive health indicators with
cardiorespiratory fitness and fatness in children and adolescents. (Paper II).
III.
To examine the association of psychological positive health indicators, health
complaints and health risk behaviors with muscular fitness in Spanish children and
adolescents. (Paper III).
IV.
To examine the association of television viewing with psychological positive health
indicators, health complaints and health risk behaviors in children and adolescents.
(Paper IV).
30
European PhD Thesis
REFERENCIAS (REFERENCES)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Ortega FB, Ruiz JR, Castillo MJ, Sjostrom M. Physical fitness in childhood and
adolescence: a powerful marker of health. Int J Obes (Lond) 2008;32:1-11
Seligman MEP. Positive health. Applied Psychology: An International Review
2008;57:3-18
Ortega F, Lee D, Sui X, et al. Psychological well-being, cardiorespiratory fitness and
long-term survival. Am J Prev Med in press
Carr A. The science of happiness and human strengths. New York: Brunner-Rotledge;
2004
Ong AD, van Dulmen MHM. Oxford handbook of methods in positive psychology.
New York: Oxford University Press; 2007
Peterson C. A primer in positive psychology. New York: Oxford University Press;
2006
Snyder CR, Lopez SJ. Positive psychology: The scientific and practical explorations of
human strengths. Thousand Oaks, CA: Sage; 2007
Bloom BL, Asher SJ, White SW. Marital disruption as a stressor: A review and
analysis. Psychological Bulletin 1978;85:867-894
Proulx CM, Helms HM, Buehler C. Marital quality and personal well-being: A metaanalysis. Journal of Marriage and Family 2007;69:576-593
Cohen S, Alper CM, Doyle WJ, Treanor JJ, Turner RB. Positive emotional style
predicts resistance to illness after experimental exposure to rhinovirus or influenza a
virus. Psychosom Med 2006;68:809-815
Kubzansky LD, Thurston RC. Emotional vitality and incident coronary heart disease:
benefits of healthy psychological functioning. Arch Gen Psychiatry 2007;64:1393-1401
Ostir GV, Markides KS, Peek MK, Goodwin JS. The association between emotional
well-being and the incidence of stroke in older adults. Psychosom Med 2001;63:210215
Seligman MEP, Rashid T, Parks AC. Positive psychotherapy. American Psychologist
2006;61:774-788
Brown RJ. Introduction to the special issue on medically unexplained symptoms:
background and future directions. Clin Psychol Rev 2007;27:769-780
Eminson DM. Medically unexplained symptoms in children and adolescents. Clin
Psychol Rev 2007;27:855-871
Barkmann C, Braehler E, Schulte-Markwort M, Richterich A. Chronic somatic
complaints in adolescents: prevalence, predictive validity of the parent reports, and
associations with social class, health status, and psychosocial distress. Soc Psychiatry
Psychiatr Epidemiol 2010
Mikkelsson M, Salminen JJ, Kautiainen H. Non-specific musculoskeletal pain in
preadolescents. Prevalence and 1-year persistence. Pain 1997;73:29-35
Rocha EM, Prkachin KM, Beaumont SL, Hardy CL, Zumbo BD. Pain reactivity and
somatization in kindergarten-age children. J Pediatr Psychol 2003;28:47-57
Burke GL, Hunter SM, Croft JB, Cresanta JL, Berenson GS. The interaction of alcohol
and tobacco use in adolescents and young adults: Bogalusa Heart Study. Addict Behav
1988;13:387-393
Rehm J, Taylor B, Room R. Global burden of disease from alcohol, illicit drugs and
tobacco. Drug Alcohol Rev 2006;25:503-513
31
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
32
Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and
self-image and problem behaviour among adolescents. Soc Psychiatry Psychiatr
Epidemiol 2002;37:544-550
Iannotti RJ, Janssen I, Haug E, et al. Interrelationships of adolescent physical activity,
screen-based sedentary behaviour, and social and psychological health. Int J Public
Health 2009;54 Suppl 2:191-198
Iannotti RJ, Kogan MD, Janssen I, Boyce WF. Patterns of Adolescent Physical
Activity, Screen-Based Media Use, and Positive and Negative Health Indicators in the
U.S. and Canada. Journal of Adolescent Health 2009;44:493-499
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;43:909-923
Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. A
prospective study of healthy men and women. JAMA 1989;262:2395-2401
Castillo-Garzon MJ, Ruiz JR, Ortega FB, Gutierrez-Sainz A. A Mediterranean diet is
not enough for health: Physical fitness is an important additional contributor to health
for the adults of tomorrow. World Rev Nutr Diet 2007;97:114-138
Taylor HL, Buskirk E, Henschel A. Maximal oxygen intake as an objective measure of
cardio-respiratory performance. J Appl Physiol 1955;8:73-80
Mesa JL, Ruiz JR, Ortega FB, et al. Aerobic physical fitness in relation to blood lipids
and fasting glycaemia in adolescents: influence of weight status. Nutr Metab
Cardiovasc Dis 2006;16:285-293
Ferreira I, Henry RM, Twisk JW, et al. The metabolic syndrome, cardiopulmonary
fitness, and subcutaneous trunk fat as independent determinants of arterial stiffness: the
Amsterdam Growth and Health Longitudinal Study. Arch Intern Med 2005;165:875882
Carnethon MR, Gidding SS, Nehgme R, et al. Cardiorespiratory fitness in young
adulthood and the development of cardiovascular disease risk factors. JAMA
2003;290:3092-3100
Boreham CA, Ferreira I, Twisk JW, et al. Cardiorespiratory fitness, physical activity,
and arterial stiffness: the Northern Ireland Young Hearts Project. Hypertension
2004;44:721-726
Ferreira I, Twisk JW, Stehouwer CD, van Mechelen W, Kemper HC. Longitudinal
changes in VO2max: associations with carotid IMT and arterial stiffness. Med Sci
Sports Exerc 2003;35:1670-1678
Crews DJ, Lochbaum MR, Landers DM. Aerobic physical activity effects on
psychological well-being in low-income Hispanic children. Percept Mot Skills
2004;98:319-324
Bonhauser M, Fernandez G, Puschel K, et al. Improving physical fitness and emotional
well-being in adolescents of low socioeconomic status in Chile: results of a schoolbased controlled trial. Health Promot Int 2005;20:113-122
Castelli DM, Hillman CH, Buck SM, Erwin HE. Physical fitness and academic
achievement in third- and fifth-grade students. J Sport Exerc Psychol 2007;29:239-252
Grissom J. Physical fitness and academic achievement. California Department of
Education. Journal of Exercise Physiologyonline 2005;8:(http://asep.org/journals)
Kwak L, Kremers SP, Bergman P, et al. Associations between physical activity, fitness,
and academic achievement. J Pediatr 2009;155:914-918 e911
Ruiz JR, Ortega FB, Castillo R, et al. Physical Activity, Fitness, Weight Status, and
Cognitive Performance in Adolescents. J Pediatr 2010
Montoye HJ, Gayle R, Higgins M. Smoking habits, alcohol consumption and maximal
oxygen uptake. Med Sci Sports Exerc 1980;12:316-321
European PhD Thesis
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
Boreham C, Twisk J, van Mechelen W, et al. Relationships between the development
of biological risk factors for coronary heart disease and lifestyle parameters during
adolescence: The Northern Ireland Young Hearts Project. Public Health 1999;113:7-12
Bernaards CM, Twisk JW, Van Mechelen W, Snel J, Kemper HC. A longitudinal study
on smoking in relationship to fitness and heart rate response. Med Sci Sports Exerc
2003;35:793-800
Ruiz JR, Sui X, Lobelo F, et al. Association between muscular strength and mortality in
men: prospective cohort study. BMJ 2008;337:a439
Benson AC, Torode ME, Singh MA. Muscular strength and cardiorespiratory fitness is
associated with higher insulin sensitivity in children and adolescents. Int J Pediatr Obes
2006;1:222-231
Garcia-Artero E, Ortega FB, Ruiz JR, et al. [Lipid and metabolic profiles in adolescents
are affected more by physical fitness than physical activity (AVENA study)]. Rev Esp
Cardiol 2007;60:581-588
Ruiz JR, Ortega FB, Warnberg J, et al. Inflammatory proteins and muscle strength in
adolescents: the Avena study. Arch Pediatr Adolesc Med 2008;162:462-468
Gale CR, Martyn CN, Cooper C, Sayer AA. Grip strength, body composition, and
mortality. Int J Epidemiol 2007;36:228-235
Metter EJ, Talbot LA, Schrager M, Conwit R. Skeletal muscle strength as a predictor of
all-cause mortality in healthy men. J Gerontol A Biol Sci Med Sci 2002;57:B359-365
Seguin R, Nelson ME. The benefits of strength training for older adults. Am J Prev
Med 2003;25:141-149
Wolfe RR. The underappreciated role of muscle in health and disease. Am J Clin Nutr
2006;84:475-482
Jurca R, Lamonte MJ, Barlow CE, et al. Association of muscular strength with
incidence of metabolic syndrome in men. Med Sci Sports Exerc 2005;37:1849-1855
Chomitz VR, Slining MM, McGowan RJ, et al. Is there a relationship between physical
fitness and academic achievement? Positive results from public school children in the
northeastern United States. J Sch Health 2009;79:30-37
Dwyer T, Sallis JF, Blizzard L, Lazarus R, Dean K. Relation of Academic Performance
to Physical Activity and Fitness in Children. Pediatr Exerc Sci 2001;13:225-238
Hamberg-van Reenen HH, Ariens GA, Blatter BM, van Mechelen W, Bongers PM. A
systematic review of the relation between physical capacity and future low back and
neck/shoulder pain. Pain 2007;130:93-107
Organización mundial de la salud. http://www.who.int/topics/obesity/en. Accessed 16
july, 2010.
Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young
adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-873
Bovet P, Auguste R, Burdette H. Strong inverse association between physical fitness
and overweight in adolescents: a large school-based survey. Int J Behav Nutr Phys Act
2007;4:24
Ortega FB, Ruiz JR, Castillo MJ, et al. Cardiorespiratory Fitness is Associated with a
Favorable Lipid Profile Independent of Abdominal Fat in Male Adolescents: 10:30AM10:45AM: 611. Med Sci Sports Exerc 2006;38:S7-S8
Ara I, Moreno LA, Leiva MT, Gutin B, Casajus JA. Adiposity, physical activity, and
physical fitness among children from Aragon, Spain. Obesity (Silver Spring)
2007;15:1918-1924
Mota J, Guerra S, Leandro C, et al. Association of maturation, sex, and body fat in
cardiorespiratory fitness. Am J Hum Biol 2002;14:707-712
33
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
34
Fogelholm M, Stigman S, Huisman T, Metsamuuronen J. Physical fitness in
adolescents with normal weight and overweight. Scand J Med Sci Sports 2008;18:162170
Hussey J, Bell C, Bennett K, O'Dwyer J, Gormley J. Relationship between the intensity
of physical activity, inactivity, cardiorespiratory fitness and body composition in 7-10year-old Dublin children. Br J Sports Med 2007;41:311-316
Ortega FB, Tresaco B, Ruiz JR, et al. Cardiorespiratory fitness and sedentary activities
are associated with adiposity in adolescents. Obesity (Silver Spring) 2007;15:15891599
Aires L, Silva P, Santos R, et al. Association of physical fitness and body mass index in
youth. Minerva Pediatr 2008;60:397-405
Brunet M, Chaput JP, Tremblay A. The association between low physical fitness and
high body mass index or waist circumference is increasing with age in children: the
'Quebec en Forme' Project. Int J Obes (Lond) 2007;31:637-643
Ara I, Vicente-Rodriguez G, Jimenez-Ramirez J, et al. Regular participation in sports is
associated with enhanced physical fitness and lower fat mass in prepubertal boys. Int J
Obes Relat Metab Disord 2004;28:1585-1593
Casajus JA, Leiva MT, Villarroya A, Legaz A, Moreno LA. Physical performance and
school physical education in overweight Spanish children. Ann Nutr Metab
2007;51:288-296
Deforche B, Lefevre J, De Bourdeaudhuij I, et al. Physical fitness and physical activity
in obese and nonobese Flemish youth. Obes Res 2003;11:434-441
Malina RM, Beunen GP, Classens AL, et al. Fatness and physical fitness of girls 7 to
17 years. Obes Res 1995;3:221-231
Kim J, Must A, Fitzmaurice GM, et al. Relationship of physical fitness to prevalence
and incidence of overweight among schoolchildren. Obes Res 2005;13:1246-1254
Eisenmann JC, Wickel EE, Welk GJ, Blair SN. Relationship between adolescent fitness
and fatness and cardiovascular disease risk factors in adulthood: the Aerobics Center
Longitudinal Study (ACLS). Am Heart J 2005;149:46-53
Ara I, Vicente-Rodriguez G, Perez-Gomez J, et al. Influence of extracurricular sport
activities on body composition and physical fitness in boys: a 3-year longitudinal study.
Int J Obes (Lond) 2006;30:1062-1071
Andersen LB, Hasselstrom H, Gronfeldt V, Hansen SE, Karsten F. The relationship
between physical fitness and clustered risk, and tracking of clustered risk from
adolescence to young adulthood: eight years follow-up in the Danish Youth and Sport
Study. Int J Behav Nutr Phys Act 2004;1:6
Boreham C, Twisk J, Neville C, et al. Associations between physical fitness and
activity patterns during adolescence and cardiovascular risk factors in young adulthood:
the Northern Ireland Young Hearts Project. Int J Sports Med 2002;23 Suppl 1:S22-26
Hasselstrom H, Hansen SE, Froberg K, Andersen LB. Physical fitness and physical
activity during adolescence as predictors of cardiovascular disease risk in young
adulthood. Danish Youth and Sports Study. An eight-year follow-up study. Int J Sports
Med 2002;23 Suppl 1:S27-31
Janz KF, Dawson JD, Mahoney LT. Increases in physical fitness during childhood
improve cardiovascular health during adolescence: the Muscatine Study. Int J Sports
Med 2002;23 Suppl 1:S15-21
Twisk JW, Kemper HC, van Mechelen W. The relationship between physical fitness
and physical activity during adolescence and cardiovascular disease risk factors at adult
age. The Amsterdam Growth and Health Longitudinal Study. Int J Sports Med 2002;23
Suppl 1:S8-14
European PhD Thesis
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
Byrd-Williams CE, Shaibi GQ, Sun P, et al. Cardiorespiratory fitness predicts changes
in adiposity in overweight Hispanic boys. Obesity (Silver Spring) 2008;16:1072-1077
Janz KF, Dawson JD, Mahoney LT. Increases in physical fitness during childhood
improve cardiovascular health during adolescence: the Muscatine Study. International
Journal of Sports Medicine 2002;23 Suppl 1:S15-21
Twisk JW, Kemper HC, van Mechelen W. Tracking of activity and fitness and the
relationship with cardiovascular disease risk factors. Med Sci Sports Exerc
2000;32:1455-1461
Al Sabbah H, Vereecken C, Abdeen Z, Coats E, Maes L. Associations of overweight
and of weight dissatisfaction among Palestinian adolescents: findings from the national
study of Palestinian schoolchildren (HBSC-WBG2004). J Hum Nutr Diet 2009;22:4049
Fonseca H, Matos MG, Guerra A, Pedro JG. Are overweight and obese adolescents
different from their peers? Int J Pediatr Obes 2009;4:166-174
Mellin AE, Neumark-Sztainer D, Story M, Ireland M, Resnick MD. Unhealthy
behaviors and psychosocial difficulties among overweight adolescents: the potential
impact of familial factors. J Adolesc Health 2002;31:145-153
Roberts CK, Freed B, McCarthy WJ. Low aerobic fitness and obesity are associated
with lower standardized test scores in children. J Pediatr 2010;156:711-718, 718 e711
Swallen KC, Reither EN, Haas SA, Meier AM. Overweight, obesity, and health-related
quality of life among adolescents: the National Longitudinal Study of Adolescent
Health. Pediatrics 2005;115:340-347
Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents:
pathophysiology, consequences, prevention, and treatment. Circulation 2005;111:19992012
Goodman E, Whitaker RC. A prospective study of the role of depression in the
development and persistence of adolescent obesity. Pediatrics 2002;110:497-504
Crow S, Eisenberg ME, Story M, Neumark-Sztainer D. Psychosocial and behavioral
correlates of dieting among overweight and non-overweight adolescents. J Adolesc
Health 2006;38:569-574
Erermis S, Cetin N, Tamar M, et al. Is obesity a risk factor for psychopathology among
adolescents? Pediatr Int 2004;46:296-301
Pasch KE, Nelson MC, Lytle LA, Moe SG, Perry CL. Adoption of risk-related factors
through early adolescence: associations with weight status and implications for causal
mechanisms. J Adolesc Health 2008;43:387-393
Potter BK, Pederson LL, Chan SS, Aubut JA, Koval JJ. Does a relationship exist
between body weight, concerns about weight, and smoking among adolescents? An
integration of the literature with an emphasis on gender. Nicotine Tob Res 2004;6:397425
Pate RR, O’Neill JR, Lobelo F. The evolving definition of "sedentary". Exerc Sport Sci
Rev 2008;36:173-178
Eisenmann JC, Bartee RT, Wang MQ. Physical activity, TV viewing, and weight in
U.S. youth: 1999 Youth Risk Behavior Survey. Obes Res 2002;10:379-385
Gordon-Larsen P, Nelson MC, Popkin BM. Longitudinal physical activity and
sedentary behavior trends: adolescence to adulthood. Am J Prev Med 2004;27:277-283
Currie C, Nic Gabhainn S, Godeau E, et al. http://www.euro.who.int/en/what-wedo/health-topics/Life-stages/child-and-adolescenthealth/publications2/2011/inequalities-in-young-peoples-health. Accessed 23 june
2010.
35
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
36
Kristjansdottir G, Rhee H. Risk factors of back pain frequency in schoolchildren: a
search for explanations to a public health problem. Acta Paediatr 2002;91:849-854
Torsheim T, Eriksson L, Schnohr CW, et al. Screen-based activities and physical
complaints among adolescents from the Nordic countries. BMC Public Health
2010;10:324
Hakala PT, Rimpela AH, Saarni LA, Salminen JJ. Frequent computer-related activities
increase the risk of neck-shoulder and low back pain in adolescents. Eur J Public
Health 2006;16:536-541
Russ SA, Larson K, Franke TM, Halfon N. Associations between media use and health
in US children. Acad Pediatr 2009;9:300-306
Martinez-Gomez D, Rey-Lopez JP, Chillon P, et al. Excessive TV viewing and
cardiovascular disease risk factors in adolescents. The AVENA cross-sectional study.
BMC Public Health 2010;10:274
Ekelund U, Brage S, Froberg K, et al. TV viewing and physical activity are
independently associated with metabolic risk in children: the European Youth Heart
Study. PLoS Med 2006;3:e488
Mota J, Ribeiro JC, Carvalho J, Santos MP, Martins J. Television viewing and changes
in body mass index and cardiorespiratory fitness over a two-year period in
schoolchildren. Pediatr Exerc Sci 2010;22:245-253
Armstrong CA, Sallis JF, Alcaraz JE, et al. Children's television viewing, body fat, and
physical fitness. Am J Health Promot 1998;12:363-368
Vicente-Rodriguez G, Rey-Lopez JP, Martin-Matillas M, et al. Television watching,
videogames, and excess of body fat in Spanish adolescents: the AVENA study.
Nutrition 2008;24:654-662
Sharif I, Wills TA, Sargent JD. Effect of visual media use on school performance: a
prospective study. J Adolesc Health 2010;46:52-61
Pagani LS, Fitzpatrick C, Barnett TA, Dubow E. Prospective associations between
early childhood television exposure and academic, psychosocial, and physical wellbeing by middle childhood. Arch Pediatr Adolesc Med 2010;164:425-431
Hancox RJ, Milne BJ, Poulton R. Association of television viewing during childhood
with poor educational achievement. Arch Pediatr Adolesc Med 2005;159:614-618
Anderson DR, Huston AC, Schmitt KL, Linebarger DL, Wright JC. Early childhood
television viewing and adolescent behavior: the recontact study. Monogr Soc Res Child
Dev 2001;66:I-VIII, 1-147
Wright JC, Huston AC, Murphy KC, et al. The relations of early television viewing to
school readiness and vocabulary of children from low-income families: the early
window project. Child Dev 2001;72:1347-1366
Armstrong KE, Bush HM, Jones J. Television and video game viewing and its
association with substance use by Kentucky elementary school students, 2006. Public
Health Rep 2010;125:433-440
European PhD Thesis
MATERIAL Y MÉTODO [MATERIAL AND METHODS]
El material y métodos de la presente memoria de Tesis se muestran en una tabla resumen que
ilustra la información metodológica más relevante de los artículos que componen la presente
memoria de Tesis.
37
Tabla 1. Resumen de la metodología utilizada en los artículos que componen la presente memoria de Tesis
Artículo
Diseño
Participantes
Variables estudiadas
Metodología
I. Health complaints and health risk
behaviors are associated with
cardiorespiratory fitness and fatness in
youth. (Las alteraciones psicosomáticas y las
conductas de riesgo se asocian con la
capacidad aeróbica y la obesidad en jóvenes)
Transversal
♀: 368
♂: 323
Edad: 6-17.9
años
Índice de alteraciones psicosomáticas (dolor de cabeza, dolor de
estómago, dolor de espalda, sentirse deprimido, irritado, sentirse
nervioso, dificultades para dormir, sentirse mareado), conductas
de riesgo (consumo de alcohol, consumo de tabaco y
embriaguez), capacidad aeróbica, IMC y porcentaje de grasa
corporal.
Cuestionario HBSC,
20mSRT, talla y
peso, pliegues
cutáneos (tríceps y
pierna).
II. Psychological positive health,
cardiorespiratory fitness and fatness in
children and adolescents. (Salud positiva
psicológica, capacidad aeróbica y obesidad en
niños y adolescentes)
Transversal
♀: 365
♂: 319
Edad: 6-17.9
años
Indicadores relacionados con la salud positiva psicológica
(percepción de la salud, felicidad, relaciones sociales, relaciones
familiares y rendimiento académico), capacidad aeróbica, IMC
y porcentaje de grasa corporal.
Cuestionario HBSC,
20mSRT, talla y
peso, pliegues
cutáneos (tríceps y
pierna).
III. Associations of psychological positive
health, health complaints and health risk
behaviors with muscular fitness in Spanish
children and adolescents. (Asociación de la
salud positiva psicológica, las alteraciones
psicosomáticas y las conductas de riesgo con
la fuerza muscular en niños y adolescentes
españoles)
Transversal
♀: 368
♂: 322
Edad: 6-17.9
años
Indicadores relacionados con la salud positiva psicológica
(percepción de la salud, felicidad, relaciones sociales, relaciones
familiares y rendimiento académico), índice de alteraciones
psicosomáticas (dolor de cabeza, dolor de estómago, dolor de
espalda, sentirse deprimido, irritado, sentirse nervioso,
dificultades para dormir, sentirse mareado), conductas de riesgo
(consumo de alcohol, consumo de tabaco y embriaguez) y
fuerza muscular.
Cuestionario HBSC,
lanzamiento de
balón de baloncesto,
salto de longitud
con pies juntos.
IV. Television viewing, psychological
positive health, health complaints and
health risk behaviors in Spanish children
and adolescents. (Hábitos televisivos, salud
positiva psicológica, alteraciones
psicosomáticas y conductas de riesgo en
niños y adolescentes españoles)
Transversal
♀: 361
♂: 319
Edad: 6-17.9
años
Hábitos televisivos, (nº horas/día), indicadores relacionados con
la salud positiva psicológica (percepción de la salud, felicidad,
relaciones sociales, relaciones familiares y rendimiento
académico), índice de alteraciones psicosomáticas (dolor de
cabeza, dolor de estómago, dolor de espalda, sentirse deprimido,
irritado, sentirse nervioso, dificultades para dormir, sentirse
mareado) y conductas de riesgo (consumo de alcohol, consumo
de tabaco y embriaguez).
Cuestionario HBSC.
♀: niñas, ♂: niños, IMC: índice de masa corporal, 20mSRT: test de ida y vuelta de 20 metros, HBSC: Health Behavior in school-aged children
38
European PhD Thesis
RESULTADOS Y DISCUSIÓN [RESULTS AND
DISCUSSION]
Los resultados y discusión se presentan a continuación en la forma en que han sido
previamente sometidos en revistas científicas.
39
European PhD Thesis
I
HEALTH COMPLAINTS AND HEALTH RISK BEHAVIORS ARE
ASSOCIATED WITH CARDIORESPIRATORY FITNESS AND
FATNESS IN YOUTH
Castro-Piñero J, Padilla-Moledo C, Ortega FB, Moliner-Urdiales D,
Xiaofen DK, Mora J, Ruiz JR.
Submitted
41
European PhD Thesis
Health complaints and health risk behaviors are associated with cardiorespiratory fitness
and fatness in youth
José Castro-Piñero1,2, Carmen Padilla-Moledo1,2, Francisco B. Ortega2,3, Diego MolinerUrdiales4, Keating Den Xiaofen5, Jesús Mora1, Jonatan R. Ruiz2
1
Department of Physical Education, School of Education, University of Cádiz, Puerto Real,
Spain.
2
Unit for Preventive Nutrition Department of Biosciences and Nutrition at NOVUM,
Karolinska Institutet, Huddinge, Sweden.
3
Departmen of Physiology, School of Medicine, University of Granada, Spain.
4
Department of Education, University of Jaime I, Castellón, Spain.
5
Department of Curriculum and Instruction, University of Texas-Austin, USA.
Corresponding author: Jose Castro-Piñero. Department of Physical Education, School of
Education, University of Cadiz, Puerto Real 11519, Spain. Tel: +3495601622, Fax:
+34956016253. E-mail: [email protected]
Running head: Health complaints, health risk behaviors, fitness and fatness.
Type of manuscript: Original Articles
Key words: Health complaints, alcohol and tobacco, aerobic capacity, obesity, children and
adolescents.
Abstract word count: 205
Manuscript word count: 2651
43
Castro-Piñero et al., Submitted
Abstract
Objective: We examined the association of health complaints and health risk behaviors with
cardiorespiratory fitness and fatness in 691 (323 girls) Spanish children aged 6-17.9.
Methods: Health complaints and health risk behaviors were self-reported using items of the
Health Behavior in School-aged Children questionnaire. Weight and height were measured and
body mass index was computed. Body fat percentage was estimated from triceps and calf
skinfolds thickness. Cardiorespiratory fitness was measured by the 20m shuttle-run test, and
youth categorized as fit/unfit.
Results: Children and adolescents reporting health complaints sometime were more likely to
have lower fitness level (OR: 2.556, 95% CI: 1.299-5.031; and OR: 1.997, 95% CI: 1.1623.433, respectively) than their counterparts reporting health complaints never (v.s. sometime).
Likewise, children and adolescents reporting health complaints were more likely to being
overweight-obese or with high fat levels (OR: 1.732, 95% CI: 1.019-2.945; and OR: 1.983,
95% CI: 1.083-3.629, respectively). The analysis of the combined influence of fitness and
fatness revealed that fit youth had lower health complaints index than the fat-unfit and unfatunfit groups (all P<0.05).
Conclusions: Having health complaints increased the risk of having low fitness and being
overweight-obesity in youth, yet high levels of cardiorespiratory fitness might overcome
deleterious effects of overweight-obesity on health complaints.
44
European PhD Thesis
Introduction
Health complaints refer to somatic and psychological symptoms experienced by the individual
with or without a defined diagnosis such as abdominal pain, headache, backache, nervousness,
and sleeping difficulties. It constitutes a diverse set of symptoms where few are related to a
defined diagnosis or disease.1 Such symptoms constitute both everyday experiences and health
problems, and are common causes of disability and sickness certificates in adults.2 In youth,
previous studies showed weekly health complaints, which likely influences on wellbeing and
functional ability.3 Health complaints has also been considered as a negative outcome of the
developmental processes.3
Health risk behaviors, especially smoking and drinking, are one the major health
concerns among west countries. Both are associated with the leading causes of morbidity and
mortality, posing immediate risks to health during adolescence and increasing the likelihood of
excess preventable morbidity and death in adulthood.4, 5
Findings
from
cross-sectional
and
longitudinal
studies
showed
that
high
cardiorespiratory fitness is associated with a healthier cardiovascular profile in youth.6-8 Less is
known however whether health complaints and health risk behaviors are associated with
cardiorespiratory fitness in youth. Likewise, studies examining the association of health
complaints and health risk behaviors with fatness in youth are scarce and the results
contradictory.
The aim of the present study was to examine the association of health complaints and
health risk behaviors with cardiorespiratory fitness and fatness in Spanish youth.
45
Methods
Subjects
A sample of 691 (368 boys and 323 girls) healthy Caucasian children and adolescents (6 to 17
years age) participated in the study. Data collection took place from February to June 2006.
The sample was randomly selected using a two-phase, proportional cluster sampling using as a
reference the database of the census of the province of Cádiz (South Spain). In the first phase,
the school was selected from the stratum according to the geographical localization, by age and
sex. A total of 18 governmental schools agreed to participate in the study. In the second phase,
classes from schools were randomly selected and used as the smallest sampling units. All the
pupils of the selected classroom were invited to participate in the study. The participation was
higher than 95%.
A comprehensive verbal description of the nature and purpose of the study was given to
the children, adolescents, their parents and teachers. This information was also sent to parents
or youth’ supervisors by regular mail, and written consents from parents, children and
adolescents were requested. The study was approved by the Review Committee for Research
Involving Human Subjects at the University of Cádiz, Spain.
Measures
Health complaints and health risk behaviors (tobacco and alcohol use, and drunk) were
assessed by the Health Behavior in School-aged Children (HBSC) questionnaire.9,
10
Participants completed the questionnaire in school classroom with trained investigators. All the
questions used in the HBSC questionnaire showed a good reliability and validity in youth.11, 12
46
European PhD Thesis
Health complaints
Participants indicated how frequently (5-point scale: rarely or never (1), almost every month
(2), almost every week (3), more than once a week (4), and almost every day (5)) they had each
of the following symptoms: headache, stomach-ache, backache, feeling low, irritability or bad
temper, feeling nervous, difficulties getting to sleep, feeling dizzy. A mean of the responses
represented subjective health complaints index.13 The internal consistency of the items of the
health complaints index was acceptable (Cronbach’s alpha = 0.714).
Tobacco use
We used a single item to assess cigarette smoking: “How often do you smoke tobacco at
present?” Possible answers were: I do not smoke (1), less than once a week (2), at least once a
week but not every day (3), and every day (4).
Alcohol use
Participants indicated how frequently (converted to days/week: never (0), rarely (.1), every
month (.25), every week (1), and every day (7)) they drunk each of three beverages (beer,
wine, combined liquors). A mean of the responses represented alcohol use.13 The internal
consistency of the items of alcohol use was high (Cronbach’s alpha = 0.937).
Drunk
A single item asking “Have you ever got drunk any time?” (5-point scale: never (0), once (1),
2–3 times (2), 4–10 times (3), and more than 10 times (4)) indicated get drunk.
47
Cardiorespiratory fitness
Cardiorespiratory fitness was assessed by means of the 20m shuttle run test as described by
Léger et al.14 In brief, participants were required to run between two lines 20 m apart, while
keeping the pace with audio signals emitted from a pre-recorded compact disk (CD). The initial
speed was 8.5 km/h, which was increased by 0.5 km/h per minute (one minute equal one
stage). The CD used was calibrated over one minute of duration. Participants were instructed to
run in a straight line, to pivot on completing a shuttle, and to pace themselves in accordance
with the audio signals. The participants were encouraged to keep running as long as possible
throughout the course of the test. The test was finished when the participant failed to reach the
end lines concurrent with the audio signals on two consecutive occasions. Otherwise, the test
ended when the subject stopped because of fatigue. All measurements were carried out under
standardized conditions on an indoor rubber floored gymnasium. The last stage completed was
scored (precision of 0.5 steps).
Participants were classified in low and high cardiorespiratory fitness level according to
the FITNESSGRAM standards for Healthy Fitness Zone.15 All participants received a
comprehensive instruction of the test after which they also practiced it. They were instructed to
abstain from strenuous exercises 48 hours prior to the test.
Body fatness
Height and weight were measured with physical education clothing (shorts and t-shirt) and
with barefoot. Height was measured to the nearest 0.1 cm using stadiometer (Holtain LTd,
Crymmych, Pembs, United Kingdom). Weight was measured to the nearest 0.1 kg using a Seca
scale (Seca, Hamburg, Germany). Instruments were calibrated to ensure the acceptable
accuracy. Body mass index (BMI) was calculated as weight/height squared (kg/m2).
48
European PhD Thesis
Participants were categorized according to the BMI international cut-off values as nonoverweight and overweight plus obese.16
Body fat percentage was calculated by the equations reported by Slaughter et al. using
triceps and calf skinfolds.17 Skinfolds were measured to the nearest 0.1 with a skinfold caliper
(Slim guide Tom Kit Rosscraft1, Canada). Triceps skinfold was measured on the right side of
the body at the following site: a vertical fold halfway between the acromion process and the
superior head of the radius, in the posterior aspect of the arm. Calf skinfold was measured on
the inside of the right leg at the level of maximal calf girth. The right foot was placed flat on an
elevated surface with the knee flexed at a 90° angle. The vertical skinfold should be grasped
just above the level of maximal girth and the measurement made below the grasp.
Participants were categorized in low and high body fat percentage, according to the
FITNESSGRAM standards for Healthy Fitness Zone.15
Statistical analysis
Data are presented as mean and standard deviation, unless otherwise indicated. Analyses were
performed using the PASW (v. 18.0 for WINDOWS, Chicago), and the level of significance
was set to 0.05.
We compared health complaints index and health risk behaviors between children and
adolescents using the Mann-Whitney U test. The association of health complaints index and
health risk behaviors with fitness and fatness was examined using regression analysis. Further,
we performed binary logistic regression analysis to examine health complaints and health risk
behaviors with the combined association of low fitness and overweight-obesity. Since there
were no sex*health complaints index or sex*health risk behaviors interactions with
cardiorespiratory fitness and fatness, all the analyses were performed jointly for boys and girls
and the models adjusted for sex.
49
Finally, we examined the combined effects of cardiorespiratory fitness and fatness
(based on BMI cut-off points) on health complaints index using one-way analysis of
covariance after adjusting for age and sex. For this analysis, we created four fat-fit combination
categories: (i) fat and unfit (overweight+obese and low fitness); (ii) fat and fit
(overweight+obese and high fitness); (iii) unfat and unfit (non-overweight and low fitness);
and (iv) unfat and fit (non-overweight and high fitness). Pair group comparisons were
performed with Bonferroni test.
50
European PhD Thesis
Results
Adolescents had significantly higher values of health complaints index and health risk
behaviors than children (Table 1).
Health complaints index were inversely associated with cardiorespiratory fitness and
positively associated with BMI in children and adolescents (Table 2). In adolescents tobacco
use was inversely associated with cardiorespiratory fitness whereas alcohol use was positively
associated with BMI in children. Similar results were observed when body fatness was
expressed as body fat percentage.
Children and adolescents having health complaints and drinking alcohol sometime had
significantly higher odds ratio (OR) of having low cardiorespiratory fitness (Table 3).
Likewise, adolescents getting drunk sometime had significantly higher OR of having low
cardiorespiratory fitness. Children having health complaints sometime had higher OR of being
overweight-obese or having high body fat percentage.
The association between health complaints index and fat-fit categories is presented in
figure 1. Children and adolescents with lower health complaints index have higher fitness than
their group counterparts having higher heath complaints index independently of their weight
status. Furthermore, the multinomial logistic regression analysis indicated that youth reporting
health complaints sometime were more likely to be fat-unfit and unfat-unfit (OR: 2.593, 95%
CI: 1.458-4.610; and OR: 2.654, 95% CI: 1.586-4.458, respectively) compared with their
group counterparts reporting health complaints never (v.s. sometime). We repeated the
analyses using body fat groups according to the FITNESSGRAM standards instead of BMI
groups and results did not change (data not shown).
51
Discussion
The main finding of the present study is that health complaints are negatively associated with
cardiorespirartory fitness and positively associated with fatness in youth. Moreover, having
health complaints and health risk behaviors such as drinking alcohol sometime is associated
with higher OR of having low cardiorespiratory fitness. We also showed that youth with lower
values of health complaints index have higher fitness than their group counterparts having
higher values of heath complaints index regardless of their weight status.
Health complaints and cardiorespiratory fitness
Only two studies examined the relationship between health complaints and cardiorespiratory
fitness in youth, with contradictory results. Crews et al.18 observed that high levels of
cardiorespiratory fitness were associated with lower depression, whereas no association was
observed between fitness and anxiety. In contrast, Bonhauser et al.19 observed that
cardiorespiratory fitness was inversely associated with anxiety but not with depression. In our
study, we computed a health complaints index because subjective health complaints such as
headache, stomach-ache, backache, feeling low, irritability or bad temper, feeling nervous,
difficulties getting to sleep, and feeling dizzy tend to occur in cluster rather than as single
symptoms.20 We observed a negative association between health complaints index and
cardiorespiratory fitness in both children and adolescents. Additionally, our data showed that
youth reporting health complaints sometime had ~2.5 higher OR of having lower
cardiorespiratory fitness than their counterparts reporting health complaints never (v.s.
sometime).
52
European PhD Thesis
Health risk behaviors and cardiorespiratory fitness
We observed that smoking was inversely associated with cardiorespiratory fitness in
adolescents, which is in line with prior studies.21-23 On the other hand we did not observe an
association between alcohol use and cardiorespiratory fitness, which confirms the findings
reported by Montoye et al.21 They showed, in a 16-20 years old group, that non-drinkers and
the heaviest drinkers had the lowest cardiorespiratory fitness levels, whereas moderate drinkers
had the highest cardiorespiratory fitness levels. We found that youth reporting drinking
sometime had higher OR of having low cardiorespiratory fitness. Likewise, adolescents
reporting getting drunk sometimes had higher OR of being unfit. From a public health
perspective, this observation is particularly important given the negative consequences of
drinking. Despite many studies have been conducted on alcohol ingestion and physical
performance in adults, no consensus has been achieved.24
Health complaints and fatness
The association between psychological health symptoms (e.g. depression) and overweightobesity has been widely addressed in youth.25-30 In contrast, less is known regarding the
association between psychosomatic symptoms (e.g. health complaints) and overweight-obesity.
We observed that children reporting health complaints sometime had ~2 times higher OR of
being overweight-obese or having high body fat percentage than their peers reporting health
complaints never (v.s. sometimes). This finding is consistent with another study conducted in
Palestinian adolescents.31 However, we did not observe an association between health
complaints and overweight-obesity in adolescents. This findings might suggest that the
association between health complaints and overweight-obese in childhood does not track into
adolescence. Further longitudinal studies may also clarify these associations.
53
Health risk behaviors and fatness
The association between smoking and alcohol use with weight status remains unclear.
26, 30, 32
We observed that alcohol use was positively associated with overweight-obesity in children but
not in adolescents. Pasch et al.
30
found that joined alcohol, tobacco and other drug use in
seventh grade predicted BMI in eighth grade, but not separated. Recently, Farhat et al.33
showed that overweight and obesity was significantly associated with frequent smoking and
drinking in adolescent girls but not in adolescent boys. These findings are alarming as the
confluence of drinking alcohol and smoking and being overweight might have profound impact
on youth overall current and long-term health. Future studies are needed to clarify which role
of potential confounding factors, such as peer and family relationship, socioeconomic status
and parental education in the relationship of smoking and drinking with BMI.
Health complaints and fatness-fitness
We also analyzed the combined influence of fitness and fatness on health complaints. We
observed that youth with lower values of health complaints index had significantly higher level
of fitness than their group counterparts reporting higher health complaints index regardless of
the weight status (i.e. fat-unfit and unfat-unfit). This indicates that high levels of
cardiorespiratory fitness might overcome the deleterious effects of overweight-obesity. This
finding is consistent with other studies that examined the combined influence of fitness and
fatness on other health outcomes such as insulin resistance,34 blood pressure,35 and metabolic
risk.7, 36 This implies that interventions to prevent states of unfavorable health profiles should
focus not only on weight reduction but also on enhancing cardiorespiratory fitness.
54
European PhD Thesis
Limitations of the study
A limitation of this study is its cross-sectional nature, which does not permit inferences about
causality to any of the associated factors in the study. In addition, as health complaints index
and health risk behaviors are based on self-report, it is possible that some study participants
may have misreported either intentionally or inadvertently on any question asked. However,
intentional misreporting was probably minimized by the fact that study participants completed
the questionnaires anonymously, and the questions used in this study, belonging to HBSC
questionnaire, are reliable and valid.11, 12 It should also be recognized that the studied sample is
not representative of the Spanish children and adolescent population; yet, our data are fully
comparable with nationally representative data obtained from the AVENA study37, 38 and the
HBSC 2005/2006 survey.39 In addition, cardiorespiratory fitness and fatness were assessed by
objective measures.
55
Conclusions
The present study suggests that health complaints index are inversely associated with
cardiorespiratory fitness in youth. Having health complaints and drinking sometime increase
the risk of having a low cardiorespiratory fitness level. It also shows that health complaints are
positively associated with fatness, mainly in children. These findings suggest the need to
increase cardiorespiratory fitness and prevent body weight and fat gain early during
development. However, the deleterious consequences ascribed to overweight-obesity may be
attenuated with high levels of cardiorespiratory fitness.
56
European PhD Thesis
Funding source
The study was funded by Centro Andaluz de Medicina del Deporte, Junta de Andalucía, Orden
4/02/05, BOJA nº 37 (Ref. JA-CTD2005-01), the Swedish Council for Working Life and
Social Research (FAS) and the Spanish Ministry of Education (EX-2008-0641).
57
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
58
Garralda ME. A selective review of child psychiatric syndromes with a somatic
presentation. Br J Psychiatry 1992;161:759-73.
Tellnes G, Svendsen KO, Bruusgaard D, Bjerkedal T. Incidence of sickness
certification. Proposal for use as a health status indicator. Scand J Prim Health Care
1989;7:111-7.
Haugland S, Wold B, Stevenson J, Aaroe LE, Woynarowska B. Subjective health
complaints in adolescence. A cross-national comparison of prevalence and
dimensionality. Eur J Public Health 2001;11:4-10.
Rehm J, Taylor B, Room R. Global burden of disease from alcohol, illicit drugs and
tobacco. Drug Alcohol Rev 2006;25:503-13.
Burke GL, Hunter SM, Croft JB, Cresanta JL, Berenson GS. The interaction of alcohol
and tobacco use in adolescents and young adults: Bogalusa Heart Study. Addict Behav
1988;13:387-93.
adolescence: a powerful marker of health. Int J Obes (Lond) 2008;32:1-11.
Mesa JL, Ruiz JR, Ortega FB, Warnberg J, Gonzalez-Lamuno D, Moreno LA, et al.
Aerobic physical fitness in relation to blood lipids and fasting glycaemia in adolescents:
influence of weight status. Nutr Metab Cardiovasc Dis 2006;16:285-93.
Ruiz JR, Castro-Pinero J, Artero EG, Ortega FB, Sjostrom M, Suni J, et al. Predictive
validity of health-related fitness in youth: a systematic review. Br J Sports Med
2009;43:909-23.
Balaguer I. Estilos de vida de la adolescencia. Valencia: Promolibro, 2002.
Wold B. Health-behavior in schollchildren: a WHO cross-national survey. Resource
package questions 1993-94. Bergen: University of Berguen, 1995.
Roberts C, Freeman J, Samdal O, Schnohr CW, de Looze ME, Nic Gabhainn S, et al.
The Health Behaviour in School-aged Children (HBSC) study: methodological
developments and current tensions. Int J Public Health 2009;54 Suppl 2:140-50.
Booth ML, Okely AD, Chey T, Bauman A. The reliability and validity of the physical
activity questions in the WHO health behaviour in schoolchildren (HBSC) survey: a
population study. Br J Sports Med 2001;35:263-7.
Iannotti RJ, Janssen I, Haug E, Kololo H, Annaheim B, Borraccino A.
Interrelationships of adolescent physical activity, screen-based sedentary behaviour,
and social and psychological health. Int J Public Health 2009;54 Suppl 2:191-8.
Leger LA, Mercier D, Gadoury C, Lambert J. The multistage 20 metre shuttle run test
for aerobic fitness. J Sports Sci 1988;6:93-101.
Cooper Institute for Aerobics Research. The Prudential Fitnessgram: Test
administration manual. 3rd ed. Champaign, IL: Human Kinetics, 2004.
Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for
child overweight and obesity worldwide: international survey. BMJ 2000;320:1240-3.
Slaughter MH, Lohman TG, Boileau RA, Horswill CA, Stillman RJ, Van Loan MD, et
al. Skinfold equations for estimation of body fatness in children and youth. Hum Biol
1988;60:709-23.
2004;98:319-24.
Bonhauser M, Fernandez G, Puschel K, Yanez F, Montero J, Thompson B, et al.
Improving physical fitness and emotional well-being in adolescents of low
European PhD Thesis
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
socioeconomic status in Chile: results of a school-based controlled trial. Health Promot
Int 2005;20:113-22.
Garralda ME. Somatisation in children. J Child Psychol Psychiatry 1996;37:13-33.
Montoye HJ, Gayle R, Higgins M. Smoking habits, alcohol consumption and maximal
oxygen uptake. Med Sci Sports Exerc 1980;12:316-21.
Boreham C, Twisk J, van Mechelen W, Savage M, Strain J, Cran G. Relationships
between the development of biological risk factors for coronary heart disease and
lifestyle parameters during adolescence: The Northern Ireland Young Hearts Project.
Public Health 1999;113:7-12.
Bernaards CM, Twisk JW, Van Mechelen W, Snel J, Kemper HC. A longitudinal study
on smoking in relationship to fitness and heart rate response. Med Sci Sports Exerc
2003;35:793-800.
Ferreira SE, de Mello MT, Rossi MV, Souza-Formigoni ML. Does an energy drink
modify the effects of alcohol in a maximal effort test? Alcohol Clin Exp Res
2004;28:1408-12.
Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, et al.
Overweight in children and adolescents: pathophysiology, consequences, prevention,
and treatment. Circulation 2005;111:1999-2012.
different from their peers? Int J Pediatr Obes 2009;4:166-74.
Goodman E, Whitaker RC. A prospective study of the role of depression in the
development and persistence of adolescent obesity. Pediatrics 2002;110:497-504.
Crow S, Eisenberg ME, Story M, Neumark-Sztainer D. Psychosocial and behavioral
correlates of dieting among overweight and non-overweight adolescents. J Adolesc
Health 2006;38:569-74.
Erermis S, Cetin N, Tamar M, Bukusoglu N, Akdeniz F, Goksen D. Is obesity a risk
factor for psychopathology among adolescents? Pediatr Int 2004;46:296-301.
Pasch KE, Nelson MC, Lytle LA, Moe SG, Perry CL. Adoption of risk-related factors
through early adolescence: associations with weight status and implications for causal
mechanisms. J Adolesc Health 2008;43:387-93.
study of Palestinian schoolchildren (HBSC-WBG2004). J Hum Nutr Diet 2009;22:409.
Potter BK, Pederson LL, Chan SS, Aubut JA, Koval JJ. Does a relationship exist
between body weight, concerns about weight, and smoking among adolescents? An
integration of the literature with an emphasis on gender. Nicotine Tob Res 2004;6:397425.
Farhat T, Iannotti RJ, Simons-Morton BG. Overweight, obesity, youth, and health-risk
behaviors. Am J Prev Med 2010;38:258-67.
Ruiz JR, Rizzo NS, Ortega FB, Loit HM, Veidebaum T, Sjostrom M. Markers of
insulin resistance are associated with fatness and fitness in school-aged children: the
European Youth Heart Study. Diabetologia 2007;50:1401-8.
Ruiz JR, Ortega FB, Loit HM, Veidebaum T, Sjostrom M. Body fat is associated with
blood pressure in school-aged girls with low cardiorespiratory fitness: The European
Youth Heart Study. J Hypertens 2007;25:2027-34.
Eisenmann JC, Welk GJ, Ihmels M, Dollman J. Fatness, fitness, and cardiovascular
disease risk factors in children and adolescents. Med Sci Sports Exerc 2007;39:1251-6.
59
37.
38.
39.
60
Moreno LA, Mesana MI, Fleta J, Ruiz JR, Gonzalez-Gross M, Sarria A, et al.
Overweight, obesity and body fat composition in spanish adolescents. The AVENA
Study. Ann Nutr Metab 2005;49:71-6.
Ortega FB, Ruiz JR, Castillo MJ, Moreno LA, Gonzalez-Gross M, Warnberg J, et al.
[Low level of physical fitness in Spanish adolescents. Relevance for future
cardiovascular health (AVENA study)]. Rev Esp Cardiol 2005;58:898-909.
Moreno C, Muñoz-Tinoco V, Pérez P, Sánchez-Queija I, Granado MC, Ramos P, et al.
Desarrollo adolescente y salud. Resultados del Estudio HBSC-2006 con chicos y chicas
españoles de 11 a 17 años. Madird: Ministerio de Sanidad y Consumo, 2008.
European PhD Thesis
Table 1. Mean (M) and standard deviation (SD) for health complaints index and health risk
behaviors by age group.
Adolescents (12-17 y)
Children (6-11.9 y)
n
mean
s.d.
n
mean
s.d.
Health complaints index (1 to 5)
365
1.570 ± 0.588
300
1.761 ± 0.610
Tobacco use (1 to 4)
381
1.000 ± 0.051
306
1.242 ± 0.772
Alcohol use (days/week)
385
0.019 ± 0.359
303
0.080 ± 0.159
Drunk (0 to 4)
383
0.020 ± 0.250
306
0.480 ± 0.996
s.d. indicates standard deviation
All P<0.001 age group differences.
61
Table 2. Standardized regression coefficients (β) showing the association of health complaints
index and health risk behaviors (tobacco use, alcohol use and drunk) and cardiorespiratory
fitness (expressed as ml/kg/min), body mass index (kg/m2) and body fat percentage in children
and adolescents.
Children (6-11.9 y)
Adolescents (12-17 y)
N
β
P
N
β
P
Health complaints index
354
-0.149
0.005
285
-0.176
0.002
Tobacco use
370
-0.066
0.202
291
-0.108
0.048
Alcohol use
369
-0.037
0.469
288
-0.078
0.152
Drunk
372
0.039
0.449
291
-0.080
0.144
354
0.108
0.044
290
0.128
0.029
Tobacco use
369
-0.018
0.726
296
0.006
0.915
Alcohol use
369
0.118
0.024
293
0.073
0.202
Drunk
371
-0.014
0.794
296
0.068
0.234
353
0.113
0.033
288
0.054
0.501
Tobacco use
368
-0.031
0.555
294
0.021
0.715
Alcohol use
367
0.112
0.032
291
-0.049
0.388
Drunk
370
0.027
0.601
294
-0.088
0.119
Body mass index
Body fat percentage
All analyses were controlled for sex.
62
European PhD Thesis
Table 3. Odds Ratio (OR) and 95% confident intervals (CI) for having a low cardiorespiratory
fitness level (FITNESSGRAM standards for Healthy Fitness Zone), for being overweight and
obese, and for having a high body fat percentage (FITNESSGRAM standards for Healthy
Fitness Zone), according to health complaints index and health risk behaviors (tobacco use,
alcohol use and drunk) in children and adolescents.
N
Children (6-11.9 years)
OR
95%CI
Adolescents (12-17 years)
N
OR
95%CI
Never
Sometime
303
51
1 Referent
2.556 1.299-5.031
173
112
1 Referent
1.997 1.162-3.433
Tobacco use
Never
Sometime
318
52
1 Referent
- -
177
114
1 Referent
1.720 0.782-3.783
Alcohol use
Never
Sometime
318
51
1 Referent
5.142 1.214-21.783
175
113
1 Referent
2.413 1.484-3.923
Drunk
Never
Sometime
320
52
1 Referent
- -
177
114
1 Referent
1.952 1.137-3.351
Never
Sometime
250
104
1 Referent
1.732 1.019-2.945
218
72
1 Referent
1.218 0.664-2.236
Tobacco use
Never
Sometime
261
108
1 Referent
- -
223
73
1 Referent
0.661 0.240-1823
Alcohol use
Never
Sometime
262
107
1 Referent
3.247 0.857-12.370
220
73
1 Referent
1.409 0.821-2.418
Drunk
Never
Sometime
262
109
1 Referent
1.160 0.104-12.978
223
73
1 Referent
1.054 0.565-1.968
Never
Sometime
280
73
1 Referent
1.983 1.083-3.629
238
50
1 Referent
1.224 0.605-2.477
Tobacco use
Never
Sometime
290
78
1 Referent
- -
242
52
1 Referent
0.813 0.266-2.486
Alcohol use
Never
Sometime
290
77
1 Referent
1.725 0.405-7.348
240
51
1 Referent
0.692 0.372-1.287
Drunk
Never
Sometime
291
79
1 Referent
2.479 0.203-30.336
242
52
1 Referent
0.334 0.135-0.823
Overweight/Obese
Body fat percentage
63
Figure 1. Health complaints index by Fat-Fit categories. Values express mean and SEM.
64
European PhD Thesis
II
PSYCHOLOGICAL POSITIVE HEALTH, CARDIORESPIRATORY
FITNESS AND FATNESS IN CHILDREN AND ADOLESCENTS
Padilla-Moledo C, Castro-Piñero J, Ortega FB, Mora J, Marquez S,
Sjöström M, Ruiz JR.
Submitted
65
European PhD Thesis
Psychological positive health, cardiorespiratory fitness and fatness in children and
adolescents
Carmen Padilla-Moledo1,2, José Castro-Piñero1,2, Francisco B. Ortega2,3, Jesús Mora1, Sara
Márquez4, Michael Sjöström2, Jonatan R. Ruiz2
1
Spain.
2
3
4
Institute of Biomedicine and Department of Physical Education and Sports, University of
Leon, Spain.
Corresponding author: Carmen Padilla Moledo, Department of Physical Education, School
of Education, University of Cádiz, Puerto Real, Spain, telf: + 34 956016222, fax: +34
956016253, e-mail: [email protected]
67
Padilla-Moledo et al., Submitted
Abstract
Background: Psychological positive health is likely a buffer against physical and mental
illness. Psychological positive health may explain some of the health benefits associated with
increasing cardiorespiratory fitness and decreasing fatness in youth. We examined the
association of psychological positive health indicators with cardiorespiratory fitness and
fatness in 684 (365 boys and 319 girls) Spanish children aged 6 to 17.9 years.
Methods: Psychological positive health indicators were self-reported using items of the Health
Behavior in School-aged Children questionnaire. The study health indicators were: perceived
health status, life satisfaction, quality of family relationships, quality of peer relationships and
academic performance. Weight and height were measured and body mass index was computed.
We also measured triceps and calf skinfolds thickness and body fat percentage was estimated.
Cardiorespiratory fitness was measured by the 20m shuttle-run test.
Results: Life satisfaction was positively associated with cardiorespiratory fitness in children
and adolescents. Perceived health status was inversely associated with fatness in children and
adolescents, whereas life satisfaction, quality of family relationships and academic
performance were inversely associated with fatness only in children.
Conclusion: These findings suggest a link between psychological positive health indicators
and cardiorespiratory fitness and fatness, suggesting that improving psychological positive
health during childhood and adolescence could exert a favourable effect on both
cardiorespiratory fitness and fatness.
Key words: Cardiorespiratory fitness, obesity, psychological positive health, children and
adolescents.
68
European PhD Thesis
Introduction
Positive health is a multifactor construct (subjective, biological and functional variables) that
describes a state beyond the mere absence of disease. Subjective variables of positive health
(psychological positive health) refer to psychological and social well- being and it includes
positive emotion, perceived health status, self-concept, optimism, life satisfaction and positive
relationships.
depression,
2
1
Several studies suggested that psychological positive health alleviates
acts as preventive against of the common influenza,
cardiovascular events,
4
stroke
5
and is a predictor of mortality.
6
3
protects against
The use of psychological
positive health indicators as an additional outcome measure in medical research has increased
during past years. Assessment of psychological positive health is typically based on reports and
they can provide valid information about patient’s experience that complements clinical
measures.
Cardiorespiratory fitness is a direct indicator of individual’s physiological status and
reflects the overall capacity of the cardiovascular and respiratory system.
7
Findings from
cross-sectional studies showed that children and adolescents with high levels of
cardiorespiratory fitness have also a more favourable cardiovascular profile compared with
their unfit counterparts.
8
Likewise, low levels of cardiorespiratory fitness during childhood
and adolescence seems associated with later cardiovascular risk factors such as hyperlipidemia,
hypertension and obesity. 8, 9
Paediatric obesity is nowadays and important public health threat. Pediatric
overweight/obesity is strongly associated with adult overweight.
10
Adults who were
overweight in childhood have higher levels of blood lipids and lipoproteins (i.e. dyslipidemia),
blood pressure (i.e. hypertension), and fasting insulin levels (i.e. type 2 diabetes), and thus are
at increased risk for cardiovascular disease compared with adults who were thin as children. 9
69
Studies examining the relationship between psychological positive health and
cardiorespiratory fitness in children and adolescents are scarce and are mainly focused on selfesteem,
11, 12
and academic performance.
13-15
There are however more studies examining the
association between psychological positive health and obesity in children and adolescents, yet
the results are inconclusive.
16-19
More research is needed before a determination of whether,
and to what extent, psychological positive health may be responsible for some of the health
benefits associated with increasing cardiorespiratory fitness and decreasing fatness.
The aim of the present study was to examine the associations of psychological positive
health indicators with cardiorespiratory fitness and fatness in Spanish children and adolescents.
70
European PhD Thesis
Methods
Subjects
A sample of 684 (365 boys and 319 girls) healthy Caucasian children and adolescents (6 to
17.9 years age) participated in the study. The sample was randomly selected using a two
phases, proportional cluster sampling using as a reference the database of the census of the
province of Cádiz (Spain). In the first phase, the school was selected from the stratum. The
different strata were selected according to the geographical localization, by age and sex. A total
of 18 governmental schools agreed to participate in the study. In the second phase, classes from
schools were randomly selected and used as the smallest sampling units. All the children of the
selected classroom were invited to participate in the study. The participation rate was higher
than 95%.
or children supervisors by regular mail, and written consents from parents, children and
Measures
A number of psychological positive health indicators were assessed: perceived health status,
life satisfaction, quality of family relationships, quality of peer relationships and academic
performance from the Health Behavior in School-aged Children (HBSC) questionnaire
20, 21
.
Participants completed the questionnaire in school classroom with trained investigators. All the
questions used in the HBSC questionnaire have shown a good reliability and validity in
schoolchildren. 22, 23
71
Perceived health status
Children and adolescents reported how they perceived their health status (3-point scale:
excellent, good, and fair) at present.
Life satisfaction
Participants indicated how they felt (4-point scale: very happy, happy, not very happy and not
happy at all) about their life at present.
Quality of family relationships
Participants indicated how easy (5-point scale: very easy, easy, difficult, very difficult and I
don’t have) was to talk to family members about things that were bothering them. The internal
consistency of the items of quality of family relationships (father, mother, other adults, brother,
sister) was acceptable (Cronbach’s alpha = 0.734).
Quality of peer relationships
Participants indicated how easy (5-point scale: very easy, easy, difficult, very difficult and not
relationship) was to talk with friends about things that were bothering them. The internal
consistency of the items of quality of peer relationships (to talk with friends, to go out with
friends, to have good friends, to find new friends) was acceptable (Cronbach’s alpha = 0.84).
Academic performance
Participants indicated what they think (4-point scale: very good, good, average and under
average) about their academic performance compared with their classmates.
72
European PhD Thesis
Cardiorespiratory fitness was assessed by means of the 20m shuttle run test as described by
Léger et al.
24
In brief, participants were required to run between two lines 20 m apart, while
keeping the pace with audio signals emitted from a pre-recorded compact disk (CD). The initial
speed was 8.5 km/h, which was increased by 0.5 km/h per minute (one minute equal one
stage). The CD used was calibrated over one minute of duration. Participants were instructed to
run in a straight line, to pivot on completing a shuttle, and to pace themselves in accordance
with the audio signals. The participants were encouraged to keep running as long as possible
throughout the course of the test. The test was finished when the participant failed to reach the
end lines concurrent with the audio signals on two consecutive occasions. Otherwise, the test
ended when the subject stopped because of fatigue. All measurements were carried out under
standardized conditions on an indoor rubber floored gymnasium. The last stage completed was
scored (precision of 0.5 steps).
Participants were classified in low and high cardiorespiratory fitness level, according to
the FITNESSGRAM standards for Healthy Fitness Zone.
25
All participants received a
comprehensive instruction about the test after which they also practiced the test. They were
instructed to abstain from strenuous exercises 48 hours prior to the test.
Body mass index
Height and weight were measured with physical education clothing (short and t-shirt) and
barefoot. Height was measured to the nearest 0.1 cm using stadiometer (Holtain LTd,
Crymmych, Pembs, United Kingdom). Weight was measured to the nearest 0.1 kg using a Seca
scale (SECA, Hamburg, Germany). Instruments were calibrated to ensure the acceptable
accuracy. Body mass index (BMI) was calculated as weight/height squared (kg/m2).
73
Participants were categorized according to the BMI international cut-off values as nonoverweight and overweight plus obese. 26
Body fat percentage
Body fat percentage was calculated by the equations reported by Slaughter 27 using triceps and
calf skinfolds. Skinfolds was measured to the nearest 0.1 with a skinfold caliper (Slim guide
Tom Kit Rosscraft, Surrey, Canada). Triceps skinfold was measured on the right side of the
body at the following site: a vertical fold halfway between the acromion process and the
superior head of the radius, in the posterior aspect of the arm. Calf skinfold was measured on
the inside of the right leg at the level of maximal calf girth. The right foot was placed flat on an
elevated surface with the knee flexed at a 90° angle. The vertical skinfold should be grasped
just above the level of maximal girth and the measurement made below the grasp.
Participants were categorized in low and high body fat percentage, according to the
FITNESSGRAM standards for Healthy Fitness Zone. 25
Analyses were performed using the PASW (v. 18.0 for WINDOWS, Chicago), and the level of
significance was set to 0.05. Data are presented as mean and standard deviation, unless
otherwise indicated.
We compared psychological positive health indicators between children and
adolescents using the Mann-Whitney U test. The association of psychological positive health
indicators with cardiorespiratory fitness and fatness was examined using regression analysis.
Further, we performed binary logistic regression analysis to examine the association of low
psychological positive health indicators with cardiorespiratory fitness and overweight-obesity.
Since there were no sex*psychological positive health interactions with cardiorespiratory
74
European PhD Thesis
fitness and fatness, all the analyses were performed jointly for boys and girls and the models
adjusted for sex.
75
Results Children reported higher levels of psychological positive health than adolescents, except for
quality of peer relationships (Table 1). Table 2 shows the association of psychological positive
health indicators with cardiorespiratory fitness, BMI and body fat percentage by age group.
Life satisfaction was positively associated with cardiorespiratory fitness in children and
adolescents, whereas perceived health status was positively associated only in adolescents.
Perceived health status was inversely associated with BMI in both children and adolescents.
Life satisfaction, quality of family relationships and academic performance were inversely
associated with BMI only in children. Similar results were observed with body fat percentage.
The association between psychological positive health indicators and the likelihood of
having low levels of cardiorespiratory fitness is shown in table 3. Adolescents with low life
satisfaction had significantly higher OR of having low cardiorespiratory fitness, whereas was
borderline for children. Moreover, adolescents perceiving their health status as fair (vs.
excellent) had significantly higher OR of having low cardiorespiratory fitness.
being overweight-obese is shown in Table 4. Children reporting low life satisfaction had
significantly higher OR of being overweight-obese, whereas the OR of reporting low academic
performance being overweight-obese was borderline. Moreover, adolescents perceiving their
health status as fair (vs. excellent) had higher OR of being overweight-obese than those who
perceive their health status as excellent.
having high body fat percentage is shown in table 5. Children reporting low quality of family
relationships and perceiving their health status as fair (vs. excellent) had significantly higher
OR of having high body fat percentage, whereas the OR of reporting low life satisfaction
76
European PhD Thesis
having high body fat percentage was borderline. Adolescents perceiving their health status as
fair (vs. excellent) had significantly higher OR of having high total body fat percentage.
77
Discussion
The present study indicates that psychological positive health indicators are associated with
cardiorespiratory fitness in children and adolescents, so that those reporting a better
psychological positive health also had better cardiorespiratory fitness. We also observed that
indicators of psychological positive health appear to be inversely associated with adiposity
status, so that those reporting better psychological positive health also had healthier levels of
BMI and body fat percentage.
Psychological positive health and cardiorespiratory fitness
We observed that life satisfaction was positively associated with cardiorespiratory fitness in
children and adolescents. Additionally, we observed that adolescents reporting low life
satisfaction had significantly higher OR of having low cardiorespiratory fitness. Life
satisfaction is an essential criterion of psychological health, 28 and it is likely a goal rated in the
top of the importance scale of people well-being. 29 On the other hand, cardiorespiratory fitness
is considered as a well known cardiovascular health marker. 8, 9 To our knowledge there are no
available studies investigating the association between life satisfaction and cardiorespiratory
fitness which hampers further comparisons. We also observed that perceived health status was
positively associated with cardiorespiratory fitness in adolescents. The perceived health status
seems to be an effective summary of health and seems to be a strong predictor of future
functional limitations, cognitive impairment and mortality.
30
Finally, we did not find
associations between academic performance, quality of family relationships and quality of peer
relationships with cardiorespiratory fitness. Previous studies observed positive associations
between academic performance and cardiorespiratory fitness in children and adolescents,
13-15
whereas others did not. 19 Kwak et al. 15 suggested that the absence of a significant association
could be due to the low average fitness level of the subjects. The association between quality of
78
European PhD Thesis
family relationships and quality of peer relationships and cardiorespiratory fitness still remains
unclear.
Psychological positive health and fatness
Perceived health status was inversely associated with BMI in children and adolescents, and
with body fat percentage in children, which concur with previous studies.
31, 32
Moreover, our
data showed that youth perceiving their health status as fair (vs. excellent) had ~4.1 in children
and ~3.0 in adolescents, higher OR of having high body fat percentage. Likewise, adolescents
perceiving their health status as fair (vs. excellent) had a higher OR of being overweight-obese
than their counterparts perceiving their health status as excellent.
We also found an inverse association between life satisfaction, quality of family
relationships and academic performance with fatness in children, but not in adolescents.
Fonseca et al. 31 and Al-Sabbah et al. 33 suggested that life satisfaction appears to be associated
inversely with BMI in adolescents. Regarding the association between quality of family
relationships and fatness, several studies did not observe an association in adolescents
16, 34
while one study found that adolescent girls from cohesive and expressive families were at
decreased risk for obesity.
17
Previous studies reported that academic performance was
inversely associated with BMI in children and adolescents, 18, 35 whereas other did not. 19
Finally, we observed no associations between quality of peer relationships and fatness.
In contrast, previous findings reported that overweight adolescents are more likely to be
socially isolated 36 and have difficulties in making new friends. 31
The associations between psychological positive health indicators and fatness were
more apparent in children than in adolescents. Adolescence is a period of life characterized by
many physiological and psychological changes,
8
thus adolescents tend to be more volatile
emotionally than children and often experience extremes of mood.
37
It might that adolescents
79
blundered their answers either deliberately or unknowingly. More research is needed to
contrast these findings.
A limitation of this study is its cross-sectional nature, which does not permit inferences
about causality. In addition, as we have highlighted before, it is possible that some study
participants may have misreported either intentionally or inadvertently on any question asked.
However, intentional misreporting was probably minimized by the fact that study participants
completed the questionnaires anonymously, and the questions used in this study, belonging to
the HBSC questionnaire, are reliable and valid.
22, 23
It should also be recognized that the
studied sample is not representative of the Spanish children and adolescent population; yet, our
data are fully comparable with nationally representative data obtained from the AVENA study
38
and the HBSC 2005/2006 survey. 39
The present study has several strengths. First, cardiorespiratory fitness and fatness were
measured objectively. In comparison with self-reported methods of estimated physical activity,
cardiorespiratory fitness is a more objective measure. 40 Moreover, it has been found that selfreported methods of BMI are influenced by under reporting for weight and over reporting for
height. 41
In conclusion, the present study suggests a link between psychological positive health
indicators and cardiorespiratory fitness and fatness, suggesting that improving psychological
positive health during childhood and adolescence could exert a favourable effect on both
cardiorespiratory fitness and fatness.
80
European PhD Thesis
Acknowledgements
81
Key-points
• Psychological positive health is likely a buffer against physical and mental illness.
Psychological positive health may explain some of the health benefits associated with
increasing cardiorespiratory fitness and decreasing fatness in youth.
• We examined the association of psychological positive health indicators with
cardiorespiratory fitness and fatness in children and adolescents.
• The present study indicates that psychological positive health indicators are associated with
psychological positive health also had better cardiorespiratory fitness.
• We also observed that indicators of psychological positive health appear to be inversely
associated with adiposity status, so that those reporting better psychological positive health
also had healthier levels of BMI and body fat percentage.
• Taken together, these findings suggest that improving psychological positive health during
childhood and adolescence could exert a favourable effect on both cardiorespiratory fitness and
fatness.
82
European PhD Thesis
References
1.
Seligman MEP. Positive health. Applied Psychology: An International Review
2008;57:3-18.
2.
Seligman MEP, Rashid T, Parks AC. Positive psychotherapy. American Psychologist
2006;61:774-88.
3.
Cohen S, Alper CM, Doyle WJ, Treanor JJ, Turner RB. Positive emotional style
predicts resistance to illness after experimental exposure to rhinovirus or influenza a
virus. Psychosom Med 2006;68:809-15.
4.
Kubzansky LD, Thurston RC. Emotional vitality and incident coronary heart disease:
benefits of healthy psychological functioning. Arch Gen Psychiatry 2007;64:1393-401.
5.
Ostir GV, Markides KS, Peek MK, Goodwin JS. The association between emotional
well-being and the incidence of stroke in older adults. Psychosom Med 2001;63:210-5.
6.
Ortega F, Lee D, Sui X, Kubzansky L, Ruiz J, Baruth M, et al. Psychological wellbeing, cardiorespiratory fitness and long-term survival. Am J Prev Med in press.
7.
Taylor HL, Buskirk E, Henschel A. Maximal oxygen intake as an objective measure of
cardio-respiratory performance. J Appl Physiol 1955;8:73-80.
8.
adolescence: a powerful marker of health. Int J Obes (Lond) 2008;32:1-11.
9.
Ruiz JR, Castro-Pinero J, Artero EG, Ortega FB, Sjostrom M, Suni J, et al. Predictive
validity of health-related fitness in youth: a systematic review. Br J Sports Med
2009;43:909-23.
10.
Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young
adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-73.
83
11.
2004;98:319-24.
12.
Bonhauser M, Fernandez G, Puschel K, Yanez F, Montero J, Thompson B, et al.
Improving physical fitness and emotional well-being in adolescents of low
socioeconomic status in Chile: results of a school-based controlled trial. Health Promot
Int 2005;20:113-22.
13.
Grissom J. Physical fitness and academic achievement. California Department of
Education. Journal of Exercise Physiologyonline 2005;8:(http://asep.org/journals).
14.
Castelli DM, Hillman CH, Buck SM, Erwin HE. Physical fitness and academic
achievement in third- and fifth-grade students. J Sport Exerc Psychol 2007;29:239-52.
15.
Kwak L, Kremers SP, Bergman P, Ruiz JR, Rizzo NS, Sjostrom M. Associations
between physical activity, fitness, and academic achievement. J Pediatr 2009;155:9148 e1.
16.
Strauss RS, Knight J. Influence of the home environment on the development of
obesity in children. Pediatrics 1999;103:e85.
17.
Mendelson BK, White DR, Schliecker E. Adolescents' weight, sex, and family
functioning. Int J Eat Disord 1995;17:73-9.
18.
Roberts CK, Freed B, McCarthy WJ. Low aerobic fitness and obesity are associated
with lower standardized test scores in children. J Pediatr 2010;156:711-8, 8 e1.
19.
Ruiz JR, Ortega FB, Castillo R, Martin-Matillas M, Kwak L, Vicente-Rodriguez G, et
al. Physical Activity, Fitness, Weight Status, and Cognitive Performance in
Adolescents. J Pediatr 2010.
20.
Wold B. Health-behavior in schoolchildren: a WHO cross-national survey. Resource
package questions 1993-94. Bergen: University of Bergen, 1995.
84
European PhD Thesis
21.
Balaguer I. Estilos de vida de la adolescencia. Valencia: Promolibro, 2002.
22.
Roberts C, Freeman J, Samdal O, Schnohr CW, de Looze ME, Nic Gabhainn S, et al.
The Health Behaviour in School-aged Children (HBSC) study: methodological
developments and current tensions. Int J Public Health 2009;54 Suppl 2:140-50.
23.
Booth ML, Okely AD, Chey T, Bauman A. The reliability and validity of the physical
activity questions in the WHO health behaviour in schoolchildren (HBSC) survey: a
population study. Br J Sports Med 2001;35:263-7.
24.
Leger LA, Mercier D, Gadoury C, Lambert J. The multistage 20 metre shuttle run test
for aerobic fitness. J Sports Sci 1988;6:93-101.
25.
Cooper Institute for Aerobics Research (ed). The Prudential Fitnessgram: Test
administration manual. 3rd ed. Champaign, IL: Human Kinetics, 2004.
26.
Cole TJ BM, Flegal KM, Dietz WH. Establishing a standard definition for child
overweight and obesity worldwide: international survey. BMJ 2000;320:1240-3.
27.
Slaughter MH LT, Boileau RA, Horswill CA, Stillman RJ, Van Loan MD, Bemben
DA. Skinfold equations for estimation of body fatness in children and youth. Hum Biol
1988;60:709-23.
28.
Diener E, Seligman ME. Very happy people. Psychol Sci 2002;13:81-4.
29.
Diener E. Subjective well-being. The science of happiness and a proposal for a national
index. Am Psychol 2000;55:34-43.
30.
Idler EL, Russell LB, Davis D. Survival, functional limitations, and self-rated health in
the NHANES I Epidemiologic Follow-up Study, 1992. First National Health and
Nutrition Examination Survey. Am J Epidemiol 2000;152:874-83.
31.
different from their peers? Int J Pediatr Obes 2009;4:166-74.
85
32.
Swallen KC, Reither EN, Haas SA, Meier AM. Overweight, obesity, and health-related
quality of life among adolescents: the National Longitudinal Study of Adolescent
Health. Pediatrics 2005;115:340-7.
33.
study of Palestinian schoolchildren (HBSC-WBG2004). J Hum Nutr Diet 2009;22:409.
34.
Valtolina GG, Marta E. Family relations and psychosocial risk in families with an
obese adolescent. Psychol Rep 1998;83:251-60.
35.
Mellin AE, Neumark-Sztainer D, Story M, Ireland M, Resnick MD. Unhealthy
behaviors and psychosocial difficulties among overweight adolescents: the potential
impact of familial factors. J Adolesc Health 2002;31:145-53.
36.
Xie B, Chou CP, Spruijt-Metz D, Liu C, Xia J, Gong J, et al. Effects of perceived peer
isolation and social support availability on the relationship between body mass index
and depressive symptoms. Int J Obes (Lond) 2005;29:1137-43.
37.
Arnett JJ. Adolescent storm and stress, reconsidered. American Psychologist
1999;54:317-26.
38.
Ortega FB, Ruiz JR, Castillo MJ, Moreno LA, Gonzalez-Gross M, Warnberg J, et al.
Low level of physical fitness in Spanish adolescents. Relevance for future
cardiovascular health (AVENA study). Rev Esp Cardiol 2005;58:898-909.
39.
Moreno C, Muñoz-Tinoco V, Pérez P, Sánchez-Queija I, Granado MC, Ramos P, et al.
Desarrollo adolescente y salud. Resultados del Estudio HBSC-2006 con chicos y chicas
españoles de 11 a 17 años. Madrid: Ministerio de Sanidad y Consumo; 2008. Report
No.: NIPO: 351-08-036-0 Edición electrónica.
86
European PhD Thesis
40.
Blair SN, Cheng Y, Holder JS. Is physical activity or physical fitness more important in
defining health benefits? Med Sci Sports Exerc 2001;33:379-99.
41.
Gorber SC, Tremblay M, Moher D, Gorber B. A comparison of direct vs. self-report
measures for assessing height, weight and body mass index: a systematic review. Obes
Rev 2007;8:307-26.
87
Table 1. Characteristics of the study sample by age group.
s.d.
Adolescents (12-17.9
years)
n
mean
s.d.
n
mean
Perceived health status (1 to 3)
381
2.570 ± 0.541
303
2.284 ± 0.597
Life satisfaction (1 to 4)
380
3.703 ± 0.507
304
3.487 ± 0.580
Quality of family relationships (1 to 5)
343
3.603 ± 0.692
291
3.502 ± 0.633
Quality of peer relationships (0 to 1)
351
0.789 ± 0.090
297
0.810 ± 0.082
Academic performance (1 to 4)
380
3.376 ± 0.656
302
2.881 ± 0.847
Psychological positive health indicators
All P<0.001 age group differences.
88
European PhD Thesis
Table 2. Standardized regression coefficients (β) showing the association of psychological
positive health indicators with cardiorespiratory fitness (expressed as ml/kg/min), body mass
index (kg/m2) and body fat percentage after controlling for sex.
Adolescents (12-17.9 years)
N
β
P
N
β
P
370
0.084
0.105
289
0.145
0.008
Life satisfaction
369
0.141
0.006
289
0.165
0.002
335
0.058
0.284
277
0.031
0.578
343
-0.078
0.148
282
0.012
0.835
369
0.088
0.089
287
-0.082
0.138
369
-0.137
0.008
293
-0.220
<0.001
Life satisfaction
368
-0.144
0.006
294
-0.005
0.927
334
-0.130
0.018
281
0.004
0.948
339
-0.040
0.468
287
0.075
0.196
368
-0.127
0.015
292
0.048
0.407
368
-0.138
0.008
291
-0.080
0.163
Life satisfaction
367
-0.182
<0.001
292
-0.086
0.129
331
-0.160
0.003
280
-0.022
0.701
338
-0.015
0.777
285
0.012
0.839
367
-0.098
0.049
291
-0.058
0.306
Body mass index
Body fat percentage
89
Table 3. Odds Ratio (OR) for having a low cardiorespiratory fitness level (FITNESSGRAM
standards for Healthy Fitness Zone), according to psychological positive health indicators in
children and adolescents.
N
years)
OR
95%CI
1
Referent
1.268 0.684-2.351
3.766 0.817-17.363
106
162
21
1
Referent
1.424 0.853-2.379
2.762 1.060-7.197
1
Referent
1.768 0.929-3.366
176
113
1
Referent
1.664 1.032-2.684
N
OR
221
140
9
Excellent
Good
Fair
Life satisfaction
Very happy 317
Lower
52
95%CI
Quality of family relationships Very good
Lower
288
47
1
Referent
1.216 0.660-2.243
169
108
1
Referent
1.364 0.788-2.360
Very good
Lower
293
50
1
Referent
0.970 0.503-1.871
173
109
1
Referent
1.499 0.849-2.649
Very good
Lower
317
52
1
Referent
0.700 0.660-1.338
175
112
1
Referent
1.249 0.754-2.068
90
European PhD Thesis
Table 4. Odds Ratio (OR) for being overweight or obese according to psychological positive
health indicators in children and adolescents.
N
years)
OR
95%CI
1
Referent
1.35 0.850-2.145
3.766 0.817-17.363
105
166
22
1
Referent
1.416 0.778-2.579
3.073 1.132-8.344
1
Referent
1.769 1.085-2.884
222
72
1
Referent
0.977 0.570-1.677
N
OR
221
141
7
Excellent
Good
Fair
Life satisfaction
Very happy 260
Lower
108
95%CI
Lower
236
98
1
Referent
1.254 0.758-2.076
213
68
1
Referent
0.704 0.384-1.289
Very good
Lower
238
101
1
Referent
0.987 0.591-1.648
217
70
1
Referent
0.972 0.549-1.721
Very good
Lower
260
108
1
Referent
1.436 0.909-2.267
220
72
1
0.88
Referent
0.475-1.631
91
Table 5. Odds Ratio (OR) for having high body fat percentage (FITNESSGRAM standards
for Healthy Fitness Zone), according to psychological positive health indicators in children and
adolescents.
N
years)
OR
95%CI
1
Referent
1.314 0.772-2.235
4.182 1.013-17.268
105
163
23
1
Referent
1.381 0.696-2.737
3.050 1.043-8.916
1
Referent
1.573 0.907-2.727
241
51
1
Referent
1.219 0.659-2.253
N
OR
220
131
9
Excellent
Good
Fair
Life satisfaction
Very happy 289
Lower
78
95%CI
Lower
266
65
1
Referent
2.167 1.149-4.089
234
46
1
Referent
0.748 0.373-1.498
Very good
Lower
266
72
1
Referent
0.768 0.434-1.357
238
47
1
Referent
1.171 0.596-2.301
Very good
Lower
289
78
1
Referent
1.256 0.749-2.105
240
51
1
Referent
0.756 0.383-1.493
92
European PhD Thesis
III
ASSOCIATIONS OF PSYCHOLOGICAL POSITIVE HEALTH, HEALTH
COMPLAINTS AND HEALTH RISK BEHAVIORS WITH MUSCULAR
FITNESS IN SPANISH CHILDREN AND ADOLESCENTS
Padilla-Moledo C, Ruiz JR, Ortega FB, Mora J,
Castro-Piñero J
Submitted
93
European PhD Thesis
Associations of psychological positive health, health complaints and health risk behaviors
with muscular fitness in Spanish children and adolescents
Running head: Psychological positive health, health complaints, health risk behaviors and
muscular fitness
Carmen Padilla-Moledo, Jonatan R Ruiz, Francisco B Ortega, Jesús Mora and José CastroPiñero
Padilla-Moledo, Mora and Castro-Piñero belong to the Department of Physical Education,
School of Education, University of Cadiz, Puerto Real 11519, Spain.
Padilla-Moledo, Ortega, Ruiz and Castro-Piñero belong to the Department of Biosciences and
Nutrition at NOVUM, Unit for Preventive Nutrition, Karolinska Institutet, Huddinge SE14157, Sweden.
Corresponding author: Jose Castro-Piñero. Department of Physical Education, School of
Education, University of Cadiz, Puerto Real 11519, Spain. Tel: +3495601622, Fax:
+34956016253. E-mail: [email protected]
95
ABSTRACT
We examined the association of psychological positive health, health complaints and health
risk behaviors with muscular fitness in Spanish children and adolescents (6-17.9 years old).
Psychological positive health, health complaints and health risk behaviors were self-reported
using items of the Health Behavior in School-aged Children questionnaire. Psychological
positive health indicators included: perceived health status, life satisfaction, quality of family
relationships, quality of peer relationships and academic performance. We computed a health
complaints index from eight symptoms: headache, stomach-ache, backache, feeling low,
irritability or bad temper, feeling nervous, difficulties getting to sleep, and feeling dizzy. The
health risk behaviors indicators were: tobacco use, alcohol use and drunk. A muscular fitness
index was computed from the standing long jump (cm) and the throw basketball (cm/kg body
mass) tests. All the psychological positive health indicators studied, except quality of peer
relationships, were positively associated with muscular fitness. Both, tobacco and alcohol use
were inversely associated with muscular fitness. Children and adolescents reporting fair (vs.
excellent) perceived health status, low life satisfaction (vs. very happy), low quality of family
relationships (vs. very good), and low academic performance (vs. very good) had significantly
higher odds ratio (OR) of having low muscular fitness. Likewise, children and adolescents
reporting smoking tobacco sometime (vs. never), drinking alcohol sometime (vs. never), and
getting drunk sometime (vs. never), had significantly higher OR of having low muscular
fitness. The results of present study suggest that there is a link between psychological positive
health and health risk behaviors indicators with muscular fitness in children and adolescents.
Key words: Muscular fitness, obesity, positive health, health complaints, alcohol, tobacco,
96
European PhD Thesis
INTRODUCTION
Psychological positive health is a multifactor construct that describes a state beyond the mere
absence of disease. It is a buffer against physical and mental illness and a potential predictor of
longevity, health costs, mental health in aging, and prognosis when illness strikes (33). Several
studies suggested that psychological positive health alleviates depression (34), predicts lower
mortality (18), promotes better relationships (11), acts as preventive against the common
influenza (9), and protects against cardiovascular events (19). Psychological positive health is
considered an index of subjective health status (2), and refers to individual’s subjective
evaluation of their physical health, mental health and social functioning (32).
Health complaints and health risk behaviors, known as negative health indicators, have
deleterious consequences on health. Health complaints refer to somatic and psychological
symptoms experienced by the individual with or without a defined diagnosis such as
abdominal pain, headache, backache, nervousness, and sleeping difficulties. It constitutes a
diverse set of symptoms where few are related to a defined diagnosis or disease (13). Such
symptoms constitute both everyday experiences and health problems, and are common causes
of disability and sickness certificates in adults (35). In adolescents, several studies showed that
weekly health complaints are likely to influence on wellbeing and functional ability (14). It has
also been considered as a negative outcome of the developmental processes (14). Health risk
behaviors, especially smoking and drinking, are one the major health concerns among west
countries adolescents. Both are associated with the leading causes of morbidity and mortality,
posing immediate risks to health during adolescence and increasing the likelihood of excess
preventable morbidity and death in adulthood (4, 27).
Muscular fitness is emerging as an important marker of health throughout life (38).
During childhood and adolescence, muscular fitness level has been associated with a healthier
cardiovascular profile (24). Moreover, its improvements from childhood to adolescence are
97
negatively associated with changes in overall and central adiposity, systolic blood pressure,
blood lipids and lipoproteins (29). Less is known however about the associations of positive
health, health complaints and health risk factors with muscular fitness in children and
adolescents.
Therefore, the aim of the present study was to examine the association of psychological
positive health, health complaints and health risk behaviors with muscular fitness in Spanish
98
European PhD Thesis
MATERIAL AND METHODS
Experimental Approach to the Problem
It is well known that muscular fitness is emerging as an important marker of physical health
throughout life (24, 29, 31). However, less is known however about the associations of positive
health, health complaints and health risk factors with muscular fitness in children and
adolescents. In order to clarify this issue, we conducted a cross-sectional studied examining the
association of psychological positive health, health complaints and health risk behaviors with
muscular fitness in children aged 6-17 years.
Subjects
17.9 years age) participated in the study. The sample was randomly selected using a two-phase,
proportional cluster sampling using as a reference the database of the census of the province of
Cádiz (Spain). In the first phase, the school was selected from the stratum. The different strata
were selected according to the geographical localization, by age and sex. A total of 18
governmental schools agreed to participate in the study. In the second phase, classes from
schools were randomly selected and used as the smallest sampling units. All the children of the
selected classroom were invited to participate in the study. The participation was higher than
95%.
or children supervisors by regular mail, and written consents from parents, children and
99
Procedures
Psychological positive health (perceived health status, life satisfaction, quality of family
relationships, quality of peer relationships, academic performance) and health complaints and
health risk behaviors (tobacco and alcohol use, and drunk) were assessed by the Health
Behavior in School-aged Children (HBSC) questionnaire (1, 37). Participants completed the
questionnaire in school classroom with trained investigators. All the questions used in the
HBSC questionnaire have shown a good reliability and validity in schoolchildren (3, 28).
Psychological positive health
Perceived health status: It was assessed with a 3-point (excellent, good and fair) self-rating.
Life satisfaction: Participants indicated how they felt (4-point scale response options: very
happy, happy, not very happy and not happy at all) about their life at the present.
Quality of family relationships: Participants indicated how easy (5-point scale response
options: very easy, easy, difficult, very difficult and I don’t have) it was to talk to family
members about things that were bothering them. The internal consistency of the items of
quality of family relationships (father, mother, other adults, brother, sister) was acceptable
(Cronbach’s alpha = 0.734).
Quality of peer relationships: Participants indicated how easy (5-point scale response options:
very easy, easy, difficult, very difficult and not relationship) it was to talk with friends about
things that were bothering them. The internal consistency of the items of quality of peer
relationships (to talk with friends, to go out with friends, to have good friends, to find new
friends) was acceptable (Cronbach’s alpha = 0.684).
Academic performance: Participants indicated what they think (4-point scale response options:
very good, good, average and under average) about their academic performance compared with
their classmate.
100
European PhD Thesis
Health complaints
(2), almost every week (3), more than once a week (4), and almost every day (5)) they had each
of the following eight symptoms: headache, stomach-ache, backache, feeling low, irritability or
bad temper, feeling nervous, difficulties getting to sleep, feeling dizzy. A mean of the
responses represented subjective health complaints index (15). The internal consistency of the
items of health complaints index was acceptable (Cronbach’s alpha = 0.714).
Health risk behaviors
Tobacco use: A single item asking “How often do you smoke tobacco at present?” (4-point
scale: I do not smoke (1), less than once a week (2), at least once a week but not every day (3),
and every day (4)) was used to assess cigarette smoking.
Alcohol use: Participants indicated how frequently (converted to days/week: never (0), rarely
(.1), every month (.25), every week (1), and every day (7)) they drunk each of three beverages
(beer, wine, combined liquors). A mean of the responses represented Alcohol use (15). The
internal consistency of the items of alcohol use was high (Cronbach’s alpha = 0.937).
Drunk: A single item asking “Have you ever got drunk any time?” (5-point scale: never (0),
once (1), 2–3 times (2), 4–10 times (3), and more than 10 times (4)) indicated get drunk.
Muscular fitness
Lower body muscular fitness was assessed by means of the standing long jump test. The
participant stood behind the starting line, with feet together, and pushed off vigorously and
jump forward as far as possible. The distance is measured from the take-off line to the point
where the back of the heel nearest to the take-off line lands on the mat or non-slippery floor.
The test was repeated twice and the best score was retained (in cm) (6).
101
Upper body muscular fitness was assessed by means of the throw basketball test. The
participant stood behind the throwing line with the feet slightly apart, holding the ball with the
hands and facing the direction to which the ball was going to be thrown. The ball is brought
back behind the head, and then thrown vigorously forward as far as possible. Two attempts
were allowed and the best mark was retained. The distance from the starting position to where
the ball land was recorded. The measurement was recorded to the nearest 10 cm (6).
A muscular fitness index was computed by the mean of standardized measure of the
standing long jump (in cm) and the throw basketball (score/kg). Participants were classified in
low and high muscular fitness level, according to the median value. All participants received a
comprehensive instruction of these tests after which they also practiced the tests. They were
instructed to abstain from strenuous exercises 48 hours prior to the test.
Data are presented as mean and standard deviation, unless otherwise indicated. Analyses were
performed using the PASW (v. 18.0 for WINDOWS, Chicago), and the level of significance
was set to 0.05.
The association of psychological positive health, and health complaints and health risk
behaviors indicators with muscular fitness was examined using regression analysis. Further, we
performed binary logistic regression analysis to examine the association of low muscular
fitness with psychological positive health, and health complaints and health risk behaviors
indicators. Since there were no sex*muscular fitness interactions with psychological positive
health, and health complaints and health risk behaviors indicators, all the analyses were
performed jointly for boys and girls and the models adjusted for sex.
102
European PhD Thesis
RESULTS
Means and SD for muscular fitness, psychological positive health, and health complaints and
health risk behaviors indicators by sex, are presented in table 1. The association of
psychological positive health, health complaints and health risk behaviors indicators with
muscular fitness index is presented in table 2. All the studied psychological positive health
indicators, except quality of peer relationships (P=0.941), were positively associated with
muscular fitness in children and adolescents (all P<0.03). Both, tobacco (P=0.014) and alcohol
use (P=0.049) were inversely associated with muscular fitness.
The association between psychological positive health, health complaints and health
risk behaviors indicators and the likelihood of having low levels of muscular fitness is shown
in table 3. Children and adolescents reporting fair (vs. excellent) perceived health status, low
life satisfaction (vs. very happy), low quality of family relationships (vs. very good), and low
academic performance (vs. very good) had significantly higher odds ratio (OR) of having low
muscular fitness. Likewise, children and adolescents reporting smoking tobacco sometime (vs.
never), drinking alcohol sometime (vs. never), and getting drunk sometime (vs. never), had
significantly higher OR of having low muscular fitness.
103
DISCUSSION
The results of the present study showed that psychological positive health indicators are
positively associated with muscular fitness in children and adolescents. Furthermore, tobacco
and alcohol use are negatively associated with muscular fitness in children and adolescents.
Psychological positive health and muscular fitness
The present study showed that perceived health status and life satisfaction were positively
associated with muscular fitness in children and adolescents. Children and adolescents
reporting fair (vs. excellent) perceived health status and low life satisfaction (vs. very happy)
had ∼3.5 and 2.5 higher OR, respectively, of having low muscular fitness. A number of studies
revealed that perceived health is a widely used health status measurement in clinical medicine,
epidemiological studies and health promotion (26). The perceived health status seems to be an
effective summary of health and seems to be a strong predictor of future functional limitations,
cognitive impairment and mortality (17). Additionally, life satisfaction is an essential criterion
of psychological health (11), and it is likely a goal rated in the top of the importance scale of
people well-being (10). Taking together, these results indicate the importance to improve
muscular fitness levels in children and adolescents.
We also observed that quality of family relationships was positively associated with
muscular fitness in children and adolescents. Children and adolescents reporting low quality of
family relationships (vs. very good) had ∼2 higher OR of having low muscular fitness. To our
knowledge, there are no available studies researching theses associations. Further studies are
needed to confirm or contrast our findings.
Educational and health professionals have intuitively believed that individuals who are
physically active and fit perform better in school. However, the relationship between physical
fitness and academic performance still remains unclear (20, 30, 36). The present study showed
a positively association between academic performance and muscular fitness in children and
104
European PhD Thesis
adolescents. These results are consistent with those reported in previous study in children and
adolescents (8). In contrast, three studies showed a weak or no association, between academic
performance and muscular fitness in children and adolescents (5, 12, 30). Moreover, we
observed that children and adolescents with reporting low academic performance (vs. very
good) had ∼2 higher OR of having low muscular fitness.
Health complaints, health risk behaviors and muscular fitness
Health complaints and health risk behaviors (such us smoking and drinking) are frequently
used as a frame of reference to health perceptions in children and adolescents (16, 25). It has
been suggested that cardiorespiratory fitness attenuates the deleterious consequences of health
complaints, smoking and drinking (7). However, less is known about the association between
these negative health indicators and muscular fitness. In the current study, there was no
association between health complaints and muscular fitness in children and adolescents.
We also observed that smoking and drinking were inversely associated with muscular
fitness in children and adolescents. Children and adolescents with reporting smoking and
drinking sometime (vs. never) had ∼4 and ∼2 higher OR, respectively, of having low muscular
fitness. Additionally, Children and adolescents with reporting getting drunk sometimes (vs.
never) had ∼2 higher OR of having low muscular fitness. These findings are particularly
important from a public health perspective given the well-known negative consequences of
smoking and drinking, and the fact that these behaviors start already at these ages. Further
studies are needed to clarify the association between health complaints and health risk
behaviors and muscular fitness.
Limitation of this study includes its cross-sectional nature, which does not permit
inferences about causality to any of the associated factors in the study. In addition, it has been
105
suggested that children and adolescents might be less accurate than adults when reporting the
psychological indicators and health risk behaviors. However, intentional misreporting was
probably minimized by the fact that study participants completed the questionnaires
anonymously, and the questions used in this study, belonging to the HBSC questionnaire, are
reliable and valid (3, 28). It should also be recognized that although study sampling of this
study was not meant to be representative of the Spanish children and adolescent population; the
levels of physical fitness, body composition and and subjective indicators (HBSC items)
observed in our sample were similar to Spanish nationally representative data obtained from
the AVENA study (22, 23) and the HBSC 2005/2006 survey (21). In addition, muscular fitness
and fatness were assessed by objective measures.
In summary, the findings of present study indicate that psychological positive health
indicators are positively associated with muscular fitness in children and adolescents. Both,
smoking and drinking are inversely associated with muscular fitness in children and
adolescents. The results of present study suggest that increasing psychological health indicators
in children and adolescents could exert a positive effect on muscular fitness.
106
European PhD Thesis
PRACTICAL APPLICATIONS
Findings from the present study suggest that there is a link between psychological positive
health and health risk behaviors indicators and muscular fitness in children and adolescents.
Psychological positive health was positively associated with muscular fitness in children and
adolescents. Tobacco and alcohol use were negatively associated with muscular fitness in
children and adolescents. Based on these results, increasing psychological positive health and
decreasing health risk behaviors indicators in children and adolescents could influence
positively on muscular fitness.
107
ACKNOWLEDGEMENTS
108
European PhD Thesis
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
BALAGUER, I. Estilos de vida de la adolescencia. Valencia: Promolibro, 2002.
BANDELL-HOEKSTRA, I.E., H.H. ABU-SAAD, J. PASSCHIER, C.M.
FREDERIKS, F.J. FERON, and P. KNIPSCHILD. Coping and Quality of Life in
relation to headache in Dutch schoolchildren. Eur J Pain. 6:315-321, 2002.
BOOTH, M.L., A.D. OKELY, T. CHEY, and A. BAUMAN. The reliability and
validity of the physical activity questions in the WHO health behaviour in
schoolchildren (HBSC) survey: a population study. Br J Sports Med. 35:263-267, 2001.
BURKE, G.L., S.M. HUNTER, J.B. CROFT, J.L. CRESANTA, and G.S.
BERENSON. The interaction of alcohol and tobacco use in adolescents and young
adults: Bogalusa Heart Study. Addict Behav. 13:387-393, 1988.
CASTELLI, D.M., C.H. HILLMAN, S.M. BUCK, and H.E. ERWIN. Physical fitness
and academic achievement in third- and fifth-grade students. J Sport Exerc Psychol.
29:239-252, 2007.
CASTRO-PIÑERO, J., J.L. GONZALEZ-MONTESINOS, J. MORA, X.D. KEATING,
M.J. GIRELA-REJON, M. SJOSTROM, and J.R. RUIZ. Percentile values for muscular
strength field tests in children aged 6 to 17 years: influence of weight status. J Strength
Cond Res. 23:2295-2310, 2009.
CASTRO-PIÑERO, J., C. PADILLA-MOLEDO, F.B. ORTEGA, D. MOLINERURDIALES, X.D. KEATING, J. MORA, and J.R. RUIZ. Cardiorespiratory fitness and
fatness are associated with health complaints and health risk behaviors in youth.
Submitted.
CHOMITZ, V.R., M.M. SLINING, R.J. MCGOWAN, S.E. MITCHELL, G.F.
DAWSON, and K.A. HACKER. Is there a relationship between physical fitness and
academic achievement? Positive results from public school children in the northeastern
United States. J Sch Health. 79:30-37, 2009.
COHEN, S., C.M. ALPER, W.J. DOYLE, J.J. TREANOR, and R.B. TURNER.
Positive emotional style predicts resistance to illness after experimental exposure to
rhinovirus or influenza a virus. Psychosom Med. 68:809-815, 2006.
DIENER, E. Subjective well-being. The science of happiness and a proposal for a
national index. Am Psychol. 55:34-43, 2000.
DIENER, E., and M.E. SELIGMAN. Very happy people. Psychol Sci. 13:81-84, 2002.
DWYER, T., J.F. SALLIS, L. BLIZZARD, R. LAZARUS, and K. DEAN. Relation of
Academic Performance to Physical Activity and Fitness in Children. Pediatr Exerc Sci
13:225-138, 2001.
GARRALDA, M.E. A selective review of child psychiatric syndromes with a somatic
presentation. Br J Psychiatry. 161:759-773, 1992.
HAUGLAND, S., B. WOLD, J. STEVENSON, L.E. AAROE, and B.
WOYNAROWSKA. Subjective health complaints in adolescence. A cross-national
comparison of prevalence and dimensionality. Eur J Public Health. 11:4-10, 2001.
IANNOTTI, R.J., I. JANSSEN, E. HAUG, H. KOLOLO, B. ANNAHEIM, and A.
BORRACCINO. Interrelationships of adolescent physical activity, screen-based
sedentary behaviour, and social and psychological health. Int J Public Health. 54 Suppl
2:191-198, 2009.
IANNOTTI, R.J., M.D. KOGAN, I. JANSSEN, and W.F. BOYCE. Patterns of
adolescent physical activity, screen-based media use, and positive and negative health
indicators in the U.S. and Canada. J Adolesc Health. 44:493-499, 2009.
IDLER, E.L., L.B. RUSSELL, and D. DAVIS. Survival, functional limitations, and
self-rated health in the NHANES I Epidemiologic Follow-up Study, 1992. First
109
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
110
National Health and Nutrition Examination Survey. Am J Epidemiol. 152:874-883,
2000.
KOOPMANS, T., J. GELEIJNSE, F. ZITMAN, and E. GILTAY. Effects of Happiness
on All-Cause Mortality During 15 Years of Follow-Up: The Arnhem Elderly Study.
Journal of Happiness Studies. 11:113-124, 2010.
KUBZANSKY, L.D., and R.C. THURSTON. Emotional vitality and incident coronary
heart disease: benefits of healthy psychological functioning. Arch Gen Psychiatry.
64:1393-1401, 2007.
KWAK, L., S.P. KREMERS, P. BERGMAN, J.R. RUIZ, N.S. RIZZO, and M.
SJOSTROM. Associations between physical activity, fitness, and academic
achievement. J Pediatr. 155:914-918 e911, 2009.
MORENO C, M.-T.V., PÉREZ P, SÁNCHEZ-QUEIJA I, GRANADO MC, RAMOS P
Y RIVERA F Desarrollo adolescente y salud. Resultados del Estudio HBSC-2006 con
chicos y chicas españoles de 11 a 17 años. Madrid: Ministerio de Sanidad y Consumo.
NIPO: 351-08-036-0. Edición electrónica, 2008.
MORENO LA, M.M., FLETA J, RUIZ JR, GONZALEZ-GROSS M, SARRIA A,
MARCOS A, BUENO M. . Overweight, obesity and body fat composition in spanish
adolescents. The AVENA Study. Ann Nutr Metab. 49:71-76, 2005.
ORTEGA FB, R.J., CASTILLO MJ, MORENO LA, GONZALEZ-GROSS M,
WARNBERG J, GUTIERREZ A. Low level of physical fitness in Spanish adolescents.
Relevance for future cardiovascular health (AVENA study). Rev Esp Cardiol. 58:898909, 2005.
ORTEGA, F.B., J.R. RUIZ, M.J. CASTILLO, and M. SJOSTROM. Physical fitness in
childhood and adolescence: a powerful marker of health. Int J Obes (Lond). 32:1-11,
2008.
PIKO, B., K. BARABAS, and K. BODA. Frequency of common psychosomatic
symptoms and its infl uence on self-perceived health in a Hungarian student population.
Eur. J. Public Health 7:243-247, 1997.
PIKO, B.F., and N. KERESZTES. Self-perceived health among early adolescents: role
of psychosocial factors. Pediatr Int. 49:577-583, 2007.
REHM, J., B. TAYLOR, and R. ROOM. Global burden of disease from alcohol, illicit
drugs and tobacco. Drug Alcohol Rev. 25:503-513, 2006.
ROBERTS, C., J. FREEMAN, O. SAMDAL, C.W. SCHNOHR, M.E. DE LOOZE, S.
NIC GABHAINN, R. IANNOTTI, and M. RASMUSSEN. The Health Behaviour in
School-aged Children (HBSC) study: methodological developments and current
tensions. Int J Public Health. 54 Suppl 2:140-150, 2009.
RUIZ, J.R., J. CASTRO-PIÑERO, E.G. ARTERO, F.B. ORTEGA, M. SJOSTROM, J.
SUNI, and M.J. CASTILLO. Predictive validity of health-related fitness in youth: a
systematic review. Br J Sports Med. 43:909-923, 2009.
RUIZ, J.R., F.B. ORTEGA, R. CASTILLO, M. MARTIN-MATILLAS, L. KWAK, G.
VICENTE-RODRIGUEZ, J. NORIEGA, P. TERCEDOR, M. SJOSTROM, and L.A.
MORENO. Physical Activity, Fitness, Weight Status, and Cognitive Performance in
Adolescents. J Pediatr. 2010.
RUIZ, J.R., X. SUI, F. LOBELO, J.R. MORROW, JR., A.W. JACKSON, M.
SJOSTROM, and S.N. BLAIR. Association between muscular strength and mortality in
men: prospective cohort study. BMJ. 337:a439, 2008.
SAWYER, M.G., N. SPURRIER, L. WHAITES, D. KENNEDY, A.J. MARTIN, and
P. BAGHURST. The relationship between asthma severity, family functioning and the
health-related quality of life of children with asthma. Qual Life Res. 9:1105-1115,
2000.
European PhD Thesis
33.
34.
35.
36.
37.
38.
SELIGMAN, M.E.P. Positive health. Applied Psychology: An International Review.
57:3-18, 2008.
SELIGMAN, M.E.P., T. RASHID, and A.C. PARKS. Positive psychotherapy.
American Psychologist. 61:774-788, 2006.
TELLNES, G., K.O. SVENDSEN, D. BRUUSGAARD, and T. BJERKEDAL.
Incidence of sickness certification. Proposal for use as a health status indicator. Scand J
Prim Health Care. 7:111-117, 1989.
TRUDEAU, F., and R.J. SHEPHARD. Physical education, school physical activity,
school sports and academic performance. Int J Behav Nutr Phys Act. 5:10, 2008.
WOLD, B. Health-behavior in schoolchildren: a WHO cross-national survey. Resource
package questions 1993-94. Bergen: University of Bergen, 1995.
WOLFE, R.R. The underappreciated role of muscle in health and disease. Am J Clin
Nutr. 84:475-482, 2006.
111
Table 1. Mean (M) and standard deviation (SD) for muscular fitness, psychological positive
health, health complaints and health risk behaviors indicators by sex.
Girls
Boys
n
mean
s.d.
n
mean
s.d.
Standing long jump (cm)
365
150.990
41.619
322
133.52
27.704
Throw basketball/weight (cm/kg)
357
17.897
5.160
307
15,280
4.361
Muscular fitness index (-2.16 to 3.74)
355
0.229
0.938
307
-0.265
0.718
Perceived health status (1 to 3)
366
2.462
± 0.571
318
2.421 ± 0.599
Life satisfaction (1 to 4)
365
3.666
± 0.526
319
3.574 ± 0.577
Quality of family relationships (1 to 5)
335
3.596
± 0.691
299
3.513 ± 0.637
Quality of peer relationships (0 to 1)
342
0.802
± 0.086
306
0.796 ± 0.888
Academic performance (1 to 4)
364
3.088
± 0.812
318
3.236 ± 0.748
Health complaints index (1 to 5)
355
1.581
± 0.568
310
1.742 ± 0.635
Tobacco use (1 to 4)
367
1.074
± 0.428
320
1.150 ± 0.625
Alcohol use (days/week)
363
0.053
± 0.382
320
0.038 ± 0.117
Drunk (0 to 4)
368
0.240
± 0.785
321
0.210 ± 0.652
Muscular fitness
112
European PhD Thesis
Table 2. Standardized regression coefficients (β) showing the association of psychological
positive health, health complaints and health risk behaviors indicators with muscular fitness in
N
β
P
655
0.067
0.028
Life satisfaction
655
0.083
0.011
Quality of family relationships 608
0.087
0.009
619
0.002
0.941
653
0.097
0.004
638
-0.040
0.234
Tobacco use
658
-0.081
0.014
Alcohol use
655
-0.062
0.049
Drunk
660
-0.030
0.387
All analyses were controlled for sex and age.
113
Table 3. Odds Ratio (OR) and 95% confident intervals (CI) for having a low muscular fitness
level (below median), according to psychological positive health, health complaints and health
risk behaviors in children and adolescents.
N
OR
95%CI
Excellent
Good
Fair
325
302
28
1 Referent
1.495 1.027-2.176
3.560 1.456-8.708
Life satisfaction
Very happy 326
Lower
329
1 Referent
2.362 1.592-3.504
Lower
307
301
1 Referent
1.625 1.093-2.415
Very good
Lower
312
307
1 Referent
1.023 0.700-1.496
Very good
Lower
325
328
1 Referent
1.827 1.192-2.800
Never
Sometime
321
317
1 Referent
1.436 0.952-2.167
Tobacco use
Never
Sometime
329
329
1 Referent
4.275 1.865-9.799
Alcohol use
Never
Sometime
329
326
1 Referent
1.980 1.133-3.461
Drunk
Never
Sometime
330
330
1 Referent
2.028 1.057-3.892
114
European PhD Thesis
IV
TELEVISION VIEWING, PSYCHOLOGICAL POSITIVE HEALTH,
HEALTH COMPLAINTS AND HEALTH RISK BEHAVIORS IN
SPANISH CHILDREN AND ADOLESCENTS
Padilla-Moledo C, Castro-Piñero J, Ortega FB, Pulido M, Sjöström M,
Ruiz JR.
Submitted
115
European PhD Thesis
Television viewing, psychological positive health, health complaints and health risk
behaviors in Spanish children and adolescents
Carmen Padilla-Moledoa,b, José Castro-Piñeroa,b, Francisco B. Ortegab,c, Manuel Pulido b,d,
Michael Sjöströmb, Jonatan R. Ruizb*
a
Spain.
b
c
d
Department of Psychology, University of Jaen, Spain.
*Corresponding author: Jonatan R. Ruiz, PhD, Department of Biosciences and Nutrition,
Unit for Preventive Nutrition, NOVUM, 14157, Huddinge, Sweden. Tel: +46 8 608 9140,
Fax: +46 8 608 3350, e-mail: [email protected]
117
ABSTRACT:
Objective: To examine the association of television viewing with psychological positive
health, health complaints and health risk behaviors in youth.
Methods: The study (conducted on 2005) comprised 680 (319 girls) Spanish children and
adolescents aged 6-17.9 years. We used the Health Behavior in School-aged Children
(HBSC) questionnaire to assess television viewing, psychological positive health (perceived
health status, life satisfaction, quality of family relationships, quality of peer relationships and
academic performance), health complaints (headache, stomach-ache, backache, feeling low,
irritability or bad temper, feeling nervous, difficulties getting to sleep, feeling dizzy) and
health risk behaviors (tobacco and alcohol use, and drunk).
Results: Children that spent >2hrs watching television had significantly lower OR of
reporting perceiving their health status as excellent (OR: 0.614, 95%CI: 0.392-0.960), and
reporting an excellent life satisfaction (OR: 0.585, 95%CI: 0.362-0.946). Likewise,
adolescents that spent >2hrs of television viewing had significantly lower OR of reporting
very good quality of family relationships (OR: 0.531, 95%CI: 0.288-0.978). Children and
adolescents viewing television for >2hrs had higher health complaints index than those
viewing television for ≤2hrs (both P<0.05).
Conclusion: The results provide further evidence regarding the detrimental role of the
television viewing on the healthy development of children and adolescents.
Key words: television viewing, positive health, health complaints, tobacco, alcohol, children
and adolescents.
118 European PhD Thesis
INTRODUCTION
Television viewing is a well-known sedentary behavior and often the most prevalent in young
people (Currie et al., 2010). Although there are potential benefits from television viewing
(positive aspects of social behaviors such as sharing, manners, and cooperation), many
negative effects also can result (American Academy of Pediatrics, 2001). In fact, time spent
watching television displaces other more active and meaningful pursuits such as reading,
homework or creative playing (Wiecha et al., 2001). In young people, television viewing has
been associated with, aggressive behavior (Iannotti et al., 2009, Johnson et al., 2002), socialemotional problems, poor self-esteem and lower social competence (Russ et al., 2009),
tobacco use (Iannotti et al., 2009, Primack et al., 2008), alcohol use (Armstrong et al., 2010,
Iannotti et al., 2009, Iannotti et al., 2009), increased levels of cardiovascular disease risk
factors (Ekelund et al., 2006, Martinez-Gomez et al., 2010), poor physical fitness (Hancox et
al., 2004, Mota et al., 2010) and obesity (Russ et al., 2009, Vicente-Rodriguez et al., 2008).
Positive health is a multifactor construct (subjective, biological and functional
variables) that describes a state beyond the mere absence of disease (Seligman, 2008).
Positive health is likely a buffer against physical and mental illness and is also a potential
predictor of mental health in aging, health costs, prognosis when illness strikes (Seligman,
2008), and longevity (Ortega et al., in press). Subjective variables of positive health (also
called psychological positive health) refer to both psychological and social well-being and
include life satisfaction, self-esteem, self-image, and physical health status. Social
relationships are also included in this broad concept (Carr, 2004, Ong and van Dulmen, 2007,
Peterson, 2006, Snyder and Lopez, 2007) due to its close relationship with the person’s wellbeing (Proulx et al., 2007).
Health complaints are a heterogeneous group of conditions characterized by persistent
physical symptoms that cannot be explained by medical illness (Brown, 2007). Health
119
complaints include abdominal pain, headaches, dizziness, musculoskeletal pain, fatigue,
nausea, and loss of appetite among others (Eminson, 2007). There is mounting evidence that
health complaints are both widespread and severe among children and adolescents (Barkmann
et al., 2010). These symptoms constitute both everyday experiences and health problems
being often the cause of absence from school (Mikkelsson et al., 1997). Moreover, health
complaints frequently become chronic and lead to the development of somatization disorder
later in life (Rocha et al., 2003).
Health risk behaviors, as tobacco and alcohol use, are two of the leading causes of
morbidity and mortality (Rehm et al., 2006). A large European survey reported that 61% of
children and adolescents had been drinking alcohol and 29% smoking cigarettes during the
last 30 days (Hibell et al.). The long-term effects of these behaviors among children and
adolescents increase the likelihood of excess preventable morbidity and death in adulthood
(Burke et al., 1988, Rehm et al., 2006). An accurate characterization of the factors associated
with tobacco and alcohol use among children and adolescents is crucial (Hanewinkel and
Sargent, 2009, Primack et al., 2008).
Interest on television viewing as an independent risk factor for chronic health
problems is growing. However, literature concerning the association of television viewing
with psychological positive health, health complaints and health risk behaviors in children
and adolescents is scarce (Iannotti et al., 2009, Iannotti et al., 2009) and it is mainly focused
on alcohol (Armstrong et al., 2010, Hanewinkel and Sargent, 2009) and tobacco use (Dalton
et al., 2003, Primack et al., 2008). More research is needed before a determination of whether,
and to what extent, television viewing may be responsible of the development of some health
problems.
The aim of the present study was to examine the association of television viewing with
psychological positive health, health complaints and health risk behaviors in Spanish children
and adolescents.
121
METHODS
Subjects
17.9 years age) participated in the study. The sample was randomly selected using a twophase, proportional cluster sampling using as a reference the database of the census of the
province of Cádiz (Spain). In the first phase, the school was selected from the stratum. The
different strata were selected according to the geographical localization, by age and sex. A
total of 18 governmental schools agreed to participate in the study. In the second phase,
classes from schools were randomly selected and used as the smallest sampling units. All the
children of the selected classroom were invited to participate in the study. The participation
rate was higher than 95%.
A comprehensive verbal description of the nature and purpose of the study was given
to the children, adolescents, their parents and teachers. This information was also sent to
parents or children supervisors by regular mail, and written consents from parents, children
and adolescents were requested. The study was approved by the Review Committee for
Research Involving Human Subjects at the University of Cádiz, Spain.
Procedure
Television viewing, psychological positive health, health complaints and health risk behaviors
were assessed by the Health Behavior in School-aged Children (HBSC) questionnaire
(Balaguer, 2002, Wold, 1995). Participants completed the questionnaire in school classroom
with trained investigators. All the questions used in the HBSC questionnaire have shown a
good reliability and validity in schoolchildren (Booth et al., 2001, Roberts et al., 2009).
Television viewing
Television viewing was assessed by questionnaire. Participants reported how many hours per
day they spent watching television (6-point scale: none, less than ½ hour, between ½ and 1
hour, between 2 and 3 hours, 4 hours and more than 4 hours). Participants were categorized in
low (≤2h/day) and high television viewing (>2h/day) according to the American Academy of
Pediatrics recommendations for media time (American Academy of Pediatrics, 2001).
Perceived health status: It was assessed by a 3-point scale (excellent, good and fair).
Life satisfaction: Participants indicated how they felt about their life at present (4-point scale:
very happy, happy, not very happy and not happy at all).
Quality of family relationships: Participants indicated how easy (5-point scale: very easy,
easy, difficult, very difficult and I don’t have) was to talk to family members about things that
were bothering them. The internal consistency of the items of quality of family relationships
(father, mother, other adults, brother, sister) was acceptable (Cronbach’s alpha = 0.734).
Quality of peer relationships: Participants indicated how easy (5-point scale: very easy, easy,
difficult, very difficult and not relationship) was to talk with friends about things that were
bothering them. The internal consistency of the items of quality of peer relationships (to talk
with friends, to go out with friends, to have good friends, to find new friends) was acceptable
(Cronbach’s alpha = 0.684).
123
We also assessed academic performance: Participants indicated what they think (4-point
scale: very good, good, average and under average) about their academic performance
compared with their classmates.
Health complaints
(2), almost every week (3), more than once a week (4), and almost every day (5) they had
each of the following eight symptoms: headache, stomach-ache, backache, feeling low,
irritability or bad temper, feeling nervous, difficulties getting to sleep, feeling dizzy. Due to
the fact that because subjective health complaints tend to occur in cluster rather than as single
symptoms (Garralda, 1996), we computed health complaints index by calculating the mean of
the responses as indicated elsewhere (Iannotti et al., 2009). The internal consistency of the
items of health complaints index was acceptable (Cronbach’s alpha = 0.714).
Tobacco use: A single item asking “How often do you smoke tobacco at present?” (4-point
scale: I do not smoke (1), less than once a week (2), at least once a week but not every day
(3), and every day (4)) was used to assess cigarette smoking.
Alcohol use: Participants indicated how frequently (converted to days/week: never (0), rarely
(.1), every month (.25), every week (1), and every day (7)) they drunk each of three beverages
(beer, wine, combined liquors). A mean of the responses represented alcohol use (Iannotti et
al., 2009). The internal consistency of the items of alcohol use was high (Cronbach’s alpha =
0.937).
Drunk: A single item asking “Have you ever got drunk any time?” (5-point scale: never (0),
once (1), 2–3 times (2), 4–10 times (3), and more than 10 times (4)) indicated get drunk.
Data are presented as percentages, unless otherwise indicated. Sex differences were analysed
by chi-squared test. The association of television viewing (≤2hrs vs. >2 hrs) with
psychological positive health indicators, health complaints and health risk behaviors was
examined by binary logistic regression analysis in children and adolescents. We observed no
sex*television interaction with the any of the study outcomes, therefore, all the analyses were
performed jointly for boys and girls and the models adjusted for sex. We conducted analysis
of covariance to examine the differences in the health complaints index by television viewing
groups (≤2hrs vs. >2 hrs) after adjusting for sex. We conducted the analyses using the PASW
(v. 18.0 for WINDOWS, Chicago), and the level of significance was set to 0.05.
125
RESULTS
Descriptive characteristics of the study participants by sex and age are shown in table 1. One
third of the participants reported to spend >2hrs per day watching television. There were not
gender differences in the study outcomes, except for quality of family relationships in
adolescents, being the adolescent boys who showed lower quality of family relationships than
adolescent girls.
Children that spent >2hrs watching television had significantly lower odds ratio (OR)
of reporting perceiving their health status as excellent (OR: 0.614, 95%CI: 0.392-0.960), and
reporting an excellent life satisfaction (OR: 0.585, 95%CI: 0.362-0.946) (Table 2). Likewise,
adolescents that spent >2hrs of television viewing had significantly lower OR of reporting
very good quality of family relationships (OR: 0.531, 95%CI: 0.288-0.978). Moreover,
children that spent >2hrs of television viewing had significantly ~2.3 higher OR of having
health complaints sometime (Table 3).
Figure 1 shows the association between television viewing time and health complex
index in Spanish children and adolescents. Children and adolescents viewing television for
>2hrs had higher health complaints index than those viewing television for ≤2hrs (both
P<0.05).
DISCUSSION
In the present study we examined the association of television viewing with psychological
positive health, health complaints and health risk behaviors in Spanish children and
adolescents. We observed that watching television for more than 2hrs was negatively
associated with several psychological positive health indicators, as well as with health
complaints. These findings provide further evidence regarding the detrimental role of the
television viewing on the healthy development of children and adolescents.
We observed that one third of children and adolescents exceed the recommended limit
by the American Academy of Pediatrics for media time (>2hrs/day) (American Academy of
Pediatrics, 2001), which is consistent with previous large surveys (Currie et al., 2010, ReyLopez et al., 2010). Excessive television viewing is linked to a range of adverse health and
behavioral outcomes (Ekelund et al., 2006, Iannotti et al., 2009, Johnson et al., 2002,
Martinez-Gomez et al., 2010, Russ et al., 2009, Vicente-Rodriguez et al., 2008). Hancox et al.
(2004) suggested that television viewing during childhood and adolescence track to adulthood
and is associated with poor health later in life. The prime context where children and
adolescents live and develop is the family (Bickham and Rich, 2006) and parents might
encourage them to maintain healthy television habits.
The association between television viewing and psychological positive health
indicators in young people has been addressed in several studies, which reported an inverse
association between television viewing and perceived health status and life satisfaction
(Iannotti et al., 2009, Iannotti et al., 2009, Russ et al., 2009). These findings concur with those
observed in our study. We observed that children with high television viewing (>2hrs) had
significantly higher OR of reporting low life satisfaction and not perceiving their health status
as excellent. In contrast, Mathers et al. (2009) did not observe associations between television
viewing and perceived health status.
127
Time spent watching television is generally subtracted from communicating with
family and friends (Bruni and Stanca, 2008). We observed that adolescents with high
television viewing (>2hrs) had significantly higher OR of reporting low quality of family
relationships, which concur with others (Iannotti et al., 2009, Iannotti et al., 2009, Richards et
al., 2010). Richards et al. (2010) observed that adolescents who spent more time watching
television had higher risk of low attachment to parents. Several studies reported that
television viewing was associated with poor family relationships (Iannotti et al., 2009,
Iannotti et al., 2009), whereas other did not (Moore and Harre, 2007). Poor family
relationships could impair psychological adjustment and increase health risk behaviors
(Bickham and Rich, 2006, Resnick et al., 1997).
Finally, we observed no association between television viewing and quality of peer
relationships and academic performance. Studies on the relationship between television
viewing and social interaction are scarce and findings are contradictory. Two studies reported
positive associations between time television viewing and peer relationships among children
and adolescents (Iannotti et al., 2009, Iannotti et al., 2009). In contrast, one study reported
that adolescents with high television time had higher risk of low attachment to peers
(Richards et al., 2010). The relationships between television viewing and academic
performance has been however the one most widely studied, yet the results are not conclusive
(Shin, 2004). Previous researchers observed inverse associations between television viewing
and academic performance (Hancox et al., 2005, Pagani et al., 2010, Sharif et al., 2010).
Whereas, other studies reported that children who watch programs with educational content
receive better grades in school (Anderson et al., 2001, Wright et al., 2001).
In the present study, we observed that television viewing was positively associated
with health complaints index in both children and adolescents. Moreover, we observed that
children with high television viewing (>2hrs) had ~2.3 higher OR of having health complaints
sometime than children with low television viewing (≤ 2hrs). These results are consistent with
previous studies conducted in children (Iannotti et al., 2009, Iannotti et al., 2009, Toyran et
al., 2002) and adolescents (Iannotti et al., 2009, Iannotti et al., 2009). Additionally, several
studies reported positive associations between television viewing and single indicators of
health complaints such as backache (Kristjansdottir and Rhee, 2002, Torsheim et al., 2010)
and headache (Bener et al., 2000) in children and adolescents, and sleeping disturbance
(Dworak et al., 2007, Johnson et al., 2004) only with adolescents.
We did not observe an association between television viewing and health risk
behaviors (tobacco and alcohol use and drunk). In contrast, previous findings reported
positive associations between television viewing with tobacco use (Iannotti et al., 2009,
Primack et al., 2008) and alcohol use (Armstrong et al., 2010, Iannotti et al., 2009, Iannotti et
al., 2009). The lack of association in our study might be due to the low percentage of smoker
and drinker participants reported. To note is that we only took into account time television
viewing but not content. It was suggested that exposure to images of tobacco and alcohol use
on television may promote an earlier onset of these health risk behaviors (Dalton et al., 2003,
Hanewinkel and Sargent, 2009).
The present study has several limitations including its cross-sectional nature, which
does not permit inferences about causality to any of the associated factors in the study. Our
study provides data only about time television viewing without information about the content
exposure. Several studies suggested that television content plays an important role in how
children and adolescents are affected by television viewing (Chernin and Linebarger, 2005,
Dalton et al., 2003, Hanewinkel and Sargent, 2009). Moreover, it is possible that some study
participants may have misreported either intentionally or inadvertently on any question asked.
However, intentional misreporting was probably minimized by the fact that study participants
completed the questionnaires anonymously, and the questions used in this study, belonging to
129
the HBSC questionnaire, are reliable and valid (Booth et al., 2001, Roberts et al., 2009).
Finally, it should also be recognized that the studied sample is not representative of the
Spanish children and adolescent population; yet, our data are fully comparable with nationally
representative data obtained from HBSC 2005/2006 survey (Moreno et al., 2008). In addition,
our study reports data of children between 6 and 11.9 years old, whereas most previous
studies had been mainly focused on adolescents.
Conclusions
These findings provide additional justification for public health strategies to develop more
structured interventions efforts focusing on children and adolescents’ habits television.
ACKNOWLEDGEMENTS
The study was funded by Centro Andaluz de Medicina del Deporte, Junta de Andalucía,
Orden 4/02/05, BOJA nº 37 (Ref. JA-CTD2005-01), the Swedish Council for Working Life
and Social Research (FAS) and the Spanish Ministry of Education (EX-2008-0641).
Conflict of interest statement
The authors declare that there are no conflicts of interest.
131
REFERENCES
American Academy of Pediatrics, 2001. Committe on Public Education. Children,
adolescents, and television. Pediatrics. 107, 423-426.
Anderson, D.R., Huston, A.C., Schmitt, K.L., Linebarger, D.L., Wright, J.C., 2001. Early
childhood television viewing and adolescent behavior: the recontact study. Monogr
Soc Res Child Dev. 66, I-VIII, 1-147.
Armstrong, K.E., Bush, H.M., Jones, J., 2010. Television and video game viewing and its
association with substance use by Kentucky elementary school students, 2006. Public
Health Rep. 125, 433-440.
Balaguer, I., 2002. Estilos de vida de la adolescencia. Promolibro, Valencia.
Barkmann, C., Braehler, E., Schulte-Markwort, M., Richterich, A., 2010. Chronic somatic
complaints in adolescents: prevalence, predictive validity of the parent reports, and
associations with social class, health status, and psychosocial distress. Soc Psychiatry
Psychiatr Epidemiol.
Bener, A., Uduman, S.A., Qassimi, E.M., Khalaily, G., Sztriha, L., Kilpelainen, H., Obineche,
E., 2000. Genetic and environmental factors associated with migraine in
schoolchildren. Headache. 40, 152-157.
Bickham, D.S., Rich, M., 2006. Is television viewing associated with social isolation? Roles
of exposure time, viewing context, and violent content. Arch Pediatr Adolesc Med.
160, 387-392.
Booth, M.L., Okely, A.D., Chey, T., Bauman, A., 2001. The reliability and validity of the
physical activity questions in the WHO health behaviour in schoolchildren (HBSC)
survey: a population study. Br J Sports Med. 35, 263-267.
Brown, R.J., 2007. Introduction to the special issue on medically unexplained symptoms:
background and future directions. Clin Psychol Rev. 27, 769-780.
Bruni, L., Stanca, L., 2008. Watching alone: Relational goods, television and happiness,
Journal of Economic Behavior & Organization, pp. 506-528.
Burke, G.L., Hunter, S.M., Croft, J.B., Cresanta, J.L., Berenson, G.S., 1988. The interaction
of alcohol and tobacco use in adolescents and young adults: Bogalusa Heart Study.
Addict Behav. 13, 387-393.
Carr, A., 2004. The science of happiness and human strengths. Brunner- Rotledge, New York.
Chernin, A.R., Linebarger, D.L., 2005. The relationship between children's television viewing
and academic performance. Arch Pediatr Adolesc Med. 159, 687-689.
Currie, C., Nic Gabhainn, S., Godeau, E., Roberts, C., Smith, R., Currie, D., Picket, W.,
Richter, M., Morgan, A., Barnekow, V., 2010. http://www.euro.who.int/en/what-wedo/health-topics/Life-stages/child-and-adolescenthealth/publications2/2011/inequalities-in-young-peoples-health. Accessed 23 june
2010.
Dalton, M.A., Sargent, J.D., Beach, M.L., Titus-Ernstoff, L., Gibson, J.J., Ahrens, M.B.,
Tickle, J.J., Heatherton, T.F., 2003. Effect of viewing smoking in movies on
adolescent smoking initiation: a cohort study. Lancet. 362, 281-285.
Dworak, M., Schierl, T., Bruns, T., Struder, H.K., 2007. Impact of singular excessive
computer game and television exposure on sleep patterns and memory performance of
school-aged children. Pediatrics. 120, 978-985.
Ekelund, U., Brage, S., Froberg, K., Harro, M., Anderssen, S.A., Sardinha, L.B., Riddoch, C.,
Andersen, L.B., 2006. TV viewing and physical activity are independently associated
with metabolic risk in children: the European Youth Heart Study. PLoS Med. 3, e488.
Eminson, D.M., 2007. Medically unexplained symptoms in children and adolescents. Clin
Psychol Rev. 27, 855-871.
Garralda, M.E., 1996. Somatisation in children. J Child Psychol Psychiatry. 37, 13-33.
Hancox, R.J., Milne, B.J., Poulton, R., 2004. Association between child and adolescent
television viewing and adult health: a longitudinal birth cohort study. The Lancet. 364,
257-262.
Hancox, R.J., Milne, B.J., Poulton, R., 2005. Association of television viewing during
childhood with poor educational achievement. Arch Pediatr Adolesc Med. 159, 614618.
Hanewinkel, R., Sargent, J.D., 2009. Longitudinal study of exposure to entertainment media
and alcohol use among german adolescents. Pediatrics. 123, 989-995.
Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O., Bjarnason, T., Kokkevi, A., Kraus,
L., http://www.espad.org/sa/node.asp?node=641. Accessed 14 may 2010.
Iannotti, R.J., Kogan, M.D., Janssen, I., Boyce, W.F., 2009. Patterns of Adolescent Physical
Activity, Screen-Based Media Use, and Positive and Negative Health Indicators in the
U.S. and Canada. Journal of Adolescent Health. 44, 493-499.
Iannotti, R.J., Janssen, I., Haug, E., Kololo, H., Annaheim, B., Borraccino, A., 2009.
Interrelationships of adolescent physical activity, screen-based sedentary behaviour,
and social and psychological health. Int J Public Health. 54 Suppl 2, 191-198.
Johnson, J.G., Cohen, P., Smailes, E.M., Kasen, S., Brook, J.S., 2002. Television viewing and
aggressive behavior during adolescence and adulthood. Science. 295, 2468-2471.
Johnson, J.G., Cohen, P., Kasen, S., First, M.B., Brook, J.S., 2004. Association between
television viewing and sleep problems during adolescence and early adulthood. Arch
Pediatr Adolesc Med. 158, 562-568.
Kristjansdottir, G., Rhee, H., 2002. Risk factors of back pain frequency in schoolchildren: a
search for explanations to a public health problem. Acta Paediatr. 91, 849-854.
Martinez-Gomez, D., Rey-Lopez, J.P., Chillon, P., Gomez-Martinez, S., Vicente-Rodriguez,
G., Martin-Matillas, M., Garcia-Fuentes, M., Delgado, M., Moreno, L.A., Veiga, O.L.,
Eisenmann, J.C., Marcos, A., 2010. Excessive TV viewing and cardiovascular disease
risk factors in adolescents. The AVENA cross-sectional study. BMC Public Health.
10, 274.
Mathers, M., Canterford, L., Olds, T., Hesketh, K., Ridley, K., Wake, M., 2009. Electronic
media use and adolescent health and well-being: cross-sectional community study.
Acad Pediatr. 9, 307-314.
Mikkelsson, M., Salminen, J.J., Kautiainen, H., 1997. Non-specific musculoskeletal pain in
preadolescents. Prevalence and 1-year persistence. Pain. 73, 29-35.
Moore, J., Harre, N., 2007. Eating and activity: the importance of family and environment.
Health Promot J Austr. 18 (2), 143-148.
Moreno, C., Muñoz-Tinoco, V., Pérez, P., Sánchez-Queija, I., Granado, M.C., Ramos, P.,
Rivera, F., 2008. Desarrollo adolescente y salud. Resultados del Estudio HBSC-2006
con chicos y chicas españoles de 11 a 17 años. Ministerio de Sanidad y Consumo.
NIPO: 351-08-036-0. Edición electrónica, Madrid.
Mota, J., Ribeiro, J.C., Carvalho, J., Santos, M.P., Martins, J., 2010. Television viewing and
changes in body mass index and cardiorespiratory fitness over a two-year period in
schoolchildren. Pediatr Exerc Sci. 22, 245-253.
Ong, A.D., van Dulmen, M.H.M., 2007. Oxford handbook of methods in positive psychology.
Oxford University Press, New York.
Ortega, F., Lee, D., Sui, X., Kubzansky, L., Ruiz, J., Baruth, M., Castillo, M., Blair, S., in
press. Psychological well-being, cardiorespiratory fitness and long-term survival. Am
J Prev Med.
133
Pagani, L.S., Fitzpatrick, C., Barnett, T.A., Dubow, E., 2010. Prospective associations
between early childhood television exposure and academic, psychosocial, and physical
well-being by middle childhood. Arch Pediatr Adolesc Med. 164, 425-431.
Peterson, C., 2006. A primer in positive psychology. Oxford University Press, New York.
Primack, B.A., Land, S.R., Fine, M.J., 2008. Adolescent smoking and volume of exposure to
various forms of media. Public Health. 122, 379-389.
Proulx, C.M., Helms, H.M., Buehler, C., 2007. Marital quality and personal well-being: A
meta-analysis. Journal of Marriage and Family. 69, 576-593.
Rehm, J., Taylor, B., Room, R., 2006. Global burden of disease from alcohol, illicit drugs and
tobacco. Drug Alcohol Rev. 25, 503-513.
Resnick, M.D., Bearman, P.S., Blum, R.W., Bauman, K.E., Harris, K.M., Jones, J., Tabor, J.,
Beuhring, T., Sieving, R.E., Shew, M., Ireland, M., Bearinger, L.H., Udry, J.R., 1997.
Protecting adolescents from harm. Findings from the National Longitudinal Study on
Adolescent Health. JAMA. 278, 823-832.
Rey-Lopez, J.P., Vicente-Rodriguez, G., Ortega, F.B., Ruiz, J.R., Martinez-Gomez, D., De
Henauw, S., Manios, Y., Molnar, D., Polito, A., Verloigne, M., Castillo, M.J.,
Sjostrom, M., De Bourdeaudhuij, I., Moreno, L.A., 2010. Sedentary patterns and
media availability in European adolescents: The HELENA study. Prev Med. 51, 5055.
Richards, R., McGee, R., Williams, S.M., Welch, D., Hancox, R.J., 2010. Adolescent screen
time and attachment to parents and peers. Arch Pediatr Adolesc Med. 164, 258-262.
Roberts, C., Freeman, J., Samdal, O., Schnohr, C.W., de Looze, M.E., Nic Gabhainn, S.,
Iannotti, R., Rasmussen, M., 2009. The Health Behaviour in School-aged Children
(HBSC) study: methodological developments and current tensions. Int J Public
Health. 54 Suppl 2, 140-150.
Rocha, E.M., Prkachin, K.M., Beaumont, S.L., Hardy, C.L., Zumbo, B.D., 2003. Pain
reactivity and somatization in kindergarten-age children. J Pediatr Psychol. 28, 47-57.
Russ, S.A., Larson, K., Franke, T.M., Halfon, N., 2009. Associations between media use and
health in US children. Acad Pediatr. 9, 300-306.
Seligman, M.E.P., 2008. Positive health. Applied Psychology: An International Review. 57,
3-18.
Sharif, I., Wills, T.A., Sargent, J.D., 2010. Effect of visual media use on school performance:
a prospective study. J Adolesc Health. 46, 52-61.
Shin, N., 2004. Exploring pathways from television viewing to academic achievement in
school age children. J Genet Psychol. 165, 367-381.
Snyder, C.R., Lopez, S.J., 2007. Positive psychology: The scientific and practical
explorations of human strengths. Sage, Thousand Oaks, CA.
Torsheim, T., Eriksson, L., Schnohr, C.W., Hansen, F., Bjarnason, T., Valimaa, R., 2010.
Screen-based activities and physical complaints among adolescents from the Nordic
countries. BMC Public Health. 10, 324.
Toyran, M., Ozmert, E., Yurdakok, K., 2002. Television viewing and its effect on physical
health of schoolage children. Turk J Pediatr. 44, 194-203.
Vicente-Rodriguez, G., Rey-Lopez, J.P., Martin-Matillas, M., Moreno, L.A., Warnberg, J.,
Redondo, C., Tercedor, P., Delgado, M., Marcos, A., Castillo, M., Bueno, M., 2008.
Television watching, videogames, and excess of body fat in Spanish adolescents: the
AVENA study. Nutrition. 24, 654-662.
Wiecha, J.L., Sobol, A.M., Peterson, K.E., Gortmaker, S.L., 2001. Household television
access: associations with screen time, reading, and homework among youth. Ambul
Pediatr. 1, 244-251.
Wold, B., 1995. Health-behavior in schoolchildren: a WHO cross-national survey. Resource
package questions 1993-94. University of Bergen, Bergen.
Wright, J.C., Huston, A.C., Murphy, K.C., St Peters, M., Pinon, M., Scantlin, R., Kotler, J.,
2001. The relations of early television viewing to school readiness and vocabulary of
children from low-income families: the early window project. Child Dev. 72, 13471366.
135
Table 1. Descriptive characteristics of the study participants.
N
Boys
Girls
Television viewing
N
Boys
Girls
≤ 2 hrs
267
70.8%
70.5%
204
71.7%
62.9%
>2hrs
111
29.2%
29.5%
98
28.3%
37.1%
Excellent
Otherwise
222
155
60.7%
39.3%
57.7%
42.3%
109
191
63.8%
35.7%
64.3%
35.7%
Life satisfaction
Very happy
Lower
274
103
73.2%
26.8%
72.5%
27.5%
160
142
55.6%
44.4%
43.9%
50.7%
Very good
Lower
223
118
60.4%
39.6%
70.2%
29.8%
213
77
68.6%
31.4%
79.0%
21.0%
Quality of peer relationships Very good
Lower
249
102
66.7%
33.3%
75.8%
24.2%
193
104
64.7%
35.3%
65.2%
34.8%
Very good
Lower
200
177
55.4%
44.6%
50.6%
49.4%
221
80
76.9%
23.1%
69.7%
30.3%
Health complaints index*
Never
Sometime
281
80
80.2%
19.8%
75.0%
25.0%
215
83
79.7%
20.3%
63.4%
36.6%
Never
Sometime
375
1
99.5%
0.5%
100.0%
0.0%
272
30
86.3%
13.0%
86.9%
13.1%
Alcohol use
Never
Sometime
366
9
97.1%
2.9%
98.3%
1.7%
157
143
51.4%
47.9%
51.7%
48.3%
Drunk
Never
Sometime
375
3
99.5%
0.5%
98.9%
1.1%
228
74
75.8%
24.2%
75.2%
24.8%
Quality of family
relationships
Tobacco use
Sex differences analysed by chi-squared test in children and adolescents (all P>0.05, except
family relationships in adolescents P=0.045).
Table 2. Association of television viewing with psychological positive health indicators in
Spanish children and adolescents.
N
OR 95%CI
109
1 Referent
191
0.753 0.450-1.260
Exposures
Television
≤2hrs
>2hrs
N
OR 95%CI
222
1 Referent
155
0.614 0.392-0.960
Life satisfaction
≤2hrs
>2hrs
274
103
1 Referent
0.585 0.362-0.946
160
142
1 Referent
0.912 0.561-1.481
≤2hrs
>2hrs
223
118
1 Referent
1.093 0.669-1.785
213
77
1 Referent
0.531 0.288-0.978
Quality of peer relationships ≤2hrs
>2hrs
249
102
1 Referent
0.629 0.367-1.079
193
104
1 Referent
0.727 0.431-1.226
200
177
1 Referent
1.284 0.824-2.003
221
80
1 Referent
1.211 0.705-2.080
*
Quality of family
relationships
≤2hrs
>2hrs
Values are odds ratio (OR) and 95% confidence interval (CI).
Analyses adjusted for sex.
*
Exposures coded as 0=otherwise, 1=very happy, except for perceived health status that was
excellent.
137
Table 3. Association of television viewing with health complaints and health risk behaviors
in Spanish children and adolescents.
Television
≤2hrs
>2hrs
N
OR 95%CI
281
1 Referent
80
2.313 1.377-3.885
N
OR 95%CI
215
1 Referent
83
1.384 0.807-2.374
≤2hrs
>2hrs
375
1
1 Referent
- -
272
30
1 Referent
1.352 0.619-2.951
Alcohol use
≤2hrs
>2hrs
366
9
1 Referent
- -
157
143
1 Referent
0.986 0.606-1.605
Drunk
≤2hrs
>2hrs
375
3
1 Referent
- -
228
74
1 Referent
0.710 0.396-1.274
*
Exposures
Health complaints index*
Health risk behaviors**
Tobacco use
Values are odds ratio (OR) and 95% confidence interval (CI).
Analyses adjusted for sex.
*
Computed from the mean of the following symptoms: headache, stomach-ache, backache,
feeling low, irritability or bad temper, feeling nervous, difficulties getting to sleep, feeling
dizzy.
**
Exposures coded as 0=never, 1=sometime.
Figure 1. Television (TV) viewing time and health complex index in Spanish children and
adolescents. Values are estimated means and 95% confidence interval. P values from analysis
of covariance after adjusting for sex.
139
European PhD Thesis
CONCLUSIONES
I-
Las alteraciones psicosomáticas se asocian negativamente con la capacidad aeróbica
y positivamente con el grado de sobrepeso-obesidad en niños y adolescentes.
Aquellos jóvenes con un mayor índice de alteraciones psicosomáticas y/o conductas
de riesgo, tales como consumir alcohol, tienen mayor riesgo de tener una menor
capacidad aeróbica.
II-
Indicadores de salud positiva psicológica se asocian positivamente con la capacidad
aeróbica en niños y adolescentes, lo que sugiere que los niños y adolescentes con
mejor salud positiva psicológica tienen mayor probabilidad de poseer un mejor
nivel de capacidad aeróbica. Indicadores de salud positiva psicológica se asocian
inversamente con el grado de sobrepeso-obesidad, lo que sugiere que los jóvenes
con mejor salud positiva psicológica tienen mayor probabilidad de poseer valores
más saludables de índice de masa corporal y de porcentaje de grasa corporal.
III-
Indicadores de salud positiva psicológica se asocian positivamente con la fuerza
muscular en niños y adolescentes. Las conductas de riesgo, tales como fumar y
consumir alcohol, se asocian inversamente con la fuerza muscular en niños y
adolescentes. Estos resultados sugieren que una mejor salud positiva psicológica
podría tener una influencia sobre los niveles de fuerza muscular en niños y
adolescentes.
IV-
Los hábitos televisivos (>2hrs/día) se asocian inversamente con indicadores de
salud positiva psicológica y positivamente con las alteraciones psicosomáticas en
141
Padilla Moledo C, 2010
niños y adolescentes. Estos resultados confirman la necesidad de desarrollar
programas de salud que fomenten hábitos televisivos saludables en niños y
adolescentes.
CONCLUSIÓN GENERAL:
Los resultados de la presente memoria de Tésis subrayan la importancia de monitorizar y
promover estrategias para mejorar la salud positiva psicológica así como para prevenir las
alteraciones psicosomáticas y las conductas de riesgo en niños y adolescentes.
142
European PhD Thesis
CONCLUSIONS
I.
Health complaints are negatively associated with cardiorespiratory fitness and
positively associated with fatness in youth. Moreover, having health complaints and
health risk behaviors such as drinking alcohol sometime is associated with higher
OR of having low cardiorespiratory fitness.
II.
Psychological
positive
health
indicators
are
positively
associated
with
psychological
positive
health
also
had
better
cardiorespiratory
fitness.
Psychological positive health indicators are inversely associated with adiposity, so
those reporting better psychological positive health also had healthier levels of BMI
and body fat percentage.
III.
Psychological positive health indicators are positively associated with muscular
fitness in children and adolescents. Both, smoking and drinking are inversely
associated with muscular fitness in children and adolescents. These findings suggest
that increasing psychological positive health in children and adolescents could exert
a positive effect on muscular fitness.
IV.
Television viewing (>2hrs/day) is negatively associated with psychological positive
health indicators and positively associated with health complaints in children and
adolescents. These findings provide additional justification for public health
strategies to develop more structured interventions efforts focusing on children and
adolescents habits television.
143
OVERALL CONCLUSION:
The present Thesis highlights the importance of monitoring and promoting a better
psychological positive health as well as the prevention of health complaints and health risk
behaviors already from childhood and adolescence.
144
European PhD Thesis
AGRADECIMIENTOS [ACKNOWLEDGEMENTS]
A mis padres a los que siempre he visto como un modelo a seguir. Ejemplo de cariño,
comprensión, voluntad, generosidad y valentía. Adelantados en muchos aspectos a su tiempo.
A mi padre, quien supo transmitirme valores como la responsabilidad, el respeto, la serenidad,
la voluntad o la capacidad de organización. Inculcándome desde niña
“sabios consejos
saludables” adelantados a la medicina de su época. A mi madre, incansable luchadora,
innovadora, siempre dispuesta a sacrificarse por los demás, a escucharme, a animarme en todos
mis proyectos. La mejor madre, la mejor abuela.
A mis sobrinos Pablo, Jorge y Jimena que son mi mayor alegría y que tanto me
enseñan desde su sabia y sana perspectiva infantil. A mi hermano, Juan Pablo y a mi cuñada
Margarita por estar siempre ahí, por permitirme formar parte de su pequeña familia, por
hacerme sentir la hermana más feliz, la tita más feliz. 6000 km no son nada si la Tita lee la
Tesis.
A mis Directores de Tesis José Castro (Pepe) quien además de ser mi Director, es mi
amigo del alma, mi compañero en la UCA, mi colega de entrenos, mi personal trainer. Pepe no
dudó en rescatarme, ponerse a mi lado y apoyarme profesional y emocionalmente en todo
momento. Siempre con palabras de aliento, cariñoso, minucioso y exquisito en sus
correcciones y en sus aportaciones. Pepe a pesar de su gran valía científica y humana, es la
humildad y la discreción personificada. Lo que hace que para mi sea aún más digno de
admiración. Siempre estaré en deuda contigo. Para mi has sido como el “príncipe académico”
que toda mi vida esperé. Toda mi admiración, respeto y cariño a un Director Cum Laude. A
Jonatan Ruiz de quien admiro no solo su indiscutible calidad científica. Sino también su
bondad y cercanía al enseñar a los nóveles, te enseña, te corrige, te motiva y nunca te deja sólo.
Persona de exquisito trato, generoso, humano, alegre y entusiasta. Supiste encantarme “como
145
un mago” para que iniciara este proyecto y guiada por tu varita he alcanzado mi sueño. A
Jesús Mora, quien en todo momento me ha apoyado de forma incondicional. El fue uno de
mis primeros profesores de Educación Física. Jesús, gracias por haberme guiado, enseñado y
acompañado hasta aquí. Gracias a los tres: me habéis hecho sentir la doctoranda más
afortunada del mundo.
A mi familia, primas, abuelos, Tatali, tita Trini, tito Fernando. A mi pequeña-gran
prima Lorena pieza clave en la logística aeroportuaria en mis traslados a Estocolmo. Siempre
os he sentido y os sigo sintiendo muy cerca. Gracias por vuestro cariño.
A mis amigos que de una u otra forma han estado ahí, me han apoyado, han respetado
mis tiempos. A Lourdes y Juan porque siempre creyeron en mi. A mis “Toñis”: Teresa,
Yolanda, Elena y Eu por su filosofía “Toñi de la vida”. A mi “Seta” de Cádiz: María, Sonia,
Ana, Pablo, Raquel, Alfonso, Cristina, Inma Tarifa, Lidia y Raúl. Sois la brisa gaditana
que me anima, me hace reír, me hace ser revoltosa y ver la vida de colores.
A Julio, mi amigo, mi compañero de mesa en la UCA. Tu apoyo, tus ánimos, tu sonrisa
y tu buen humor han sido claves para que llegara hasta el final.
A mis compañeros del Club Natación Master de Jerez: Patricia (por la maravillosa
fuerza que siempre me transmite), Lucía, Zabely, Mauri, Lara, a mi Lola Polonio, a Luismi
mi entrenador.
A mi familia del Karolisnka Institutet Fran, Virginia, Signe, Rocío, Miguel y
Manolo. Especialmente a Fran por sus correcciones, aportaciones y buen humor, siempre
dispuesto a ayudarme, a Virginia por ser tan increíble “de mayor quiero ser como tú” y a
Signe my sugar and chocolate´s witch. Entre todos constituís una perfecta comuna científica
que es capaz de trabajar, producir, ir de fiesta, hacer deporte, reírse y darse apoyo mutuo. Es
difícil encontrar personas como vosotros.
146
European PhD Thesis
A Michael Sjöström, person of a high scientific merit, friendly, calm and always
helping to the new incoming in the science. Thank you for giving me the opportunity to work
in the Karolinska Institutet, and to allow and to help me to grow in the science world.
A Sara, Lucía, Bea, Manolo Sedeño, Pili y Arturo mis amigos y compañeros de la
UCA. A Galo, Javi y Kiki, mis amigos y compañeros de AFYEC. Cruzarme por los pasillos o
encontrarme en reuniones con vosotros, es siempre motivo de alegría. Gracias por todo el
cariño y el apoyo que me dais.
A mis chicos de UCAdanza. A Laura mi “meiga particular” mi sanadora. A Juani que
hace mi vida mucho más fácil.
Gracias a todos aquellos que están a mi alrededor, a los que se marcharon y siguen
estando, pido disculpas a aquell@s que haya podido obviar por algún despiste. A todos
vosotros que hacéis que mi vida sea mucho más fácil y feliz. Mi mayor satisfacción es ver
satisfechos a los que creyeron en mi y en esta tesis. La salud necesita estar rodeada de amigos.
147

Condición Física, Salud Positiva Psicosocial, Conductas de

Transcription

Similar documents

mininova.org - Healthworks

Welcome to the Fitness Trails

January.2013 - Fitness oprema

METRODOME LEISURE COMPLEX BARNSLEY WIN

135 136 photography by JeNaVieVe belair

LiveWell Fitness Ad January 2016

Promotional Materials

does your `real` age match your `biological` age

Fitness Center - E

OPEN HOUSE