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Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): - HEARTY-BRAIN - Effects of Exercise on Brain in Patients with Coronary Heart Disease: The Heart-Brain Connection. Andalusian Plan for Research Development and Innovation (PAIDI). University of Granada. Funding: 116.000 €. PI: F. Ortega. 2021-2021. - VASCULACTIVE. Effects of exercise on brain vascularization in coronary heart disease patients. Spanish Ministry of Economy and Competitiveness (I+D+I RETOS). University of Granada. Funding: 121.000 €. PI: F. Ortega. 2021-2023. Background Coronary heart disease (CHD) is the most prevalent type of cardiovascular disease in the world, and a leading cause of mortality and morbidity. Previous research showed that patients with CHD have a decrease in health-related quality of life (HRQoL) during the course of the disease. Physical exercise may attenuate the decline in HRQoL observed in CHD patients. Purpose To determine the effect of exercise training interventions on HRQoL in CHD patients. Methods A systematic search of controlled trials (CTs) assessing the effects of exercise training on HRQoL in CHD patients was performed in Web of Science, PubMed, Scopus, EMBASE, Cochrane Register, SportDiscus, PsycINFO and Google Scholar from inception to 30 June 2022. A meta-analysis with fixed and random effects was performed on controlled trials (comparing at least one exercise group with one non-exercise group and including a global score of HRQoL assessments before and after the interventions. All statistical analyses were performed using R-Studio. Results A total of 26 CTs met all the eligibility criteria and were included in the review (25 randomized CTs and 1 non-randomized CTs). HRQoL was mostly assessed by the SF-36 instrument (11/26) and the MacNew Heart Disease Health-Related Quality of Life questionnaire (8/26). Six out of the 26 studies reported the total score of quality of life and were included in the meta-analysis, which resulted in 8 exercise interventions and 591 participants with a mean age of 61 years, and 33% was women. There was a small (effect size 0.20) borderline overall effect of exercise on HRQoL in CHD patients (95% confidence interval: fixed effect, 0.05–0.36; random effect, -0.06-0.46. The percentage of total variability attributed to between-study heterogeneity [I2] = 44%, P=0.09 (Figure 1). Conclusions Findings from this meta-analysis suggest that supervised exercise training may cause a modest improvement in HRQoL in CHD patients. Future studies should explore which type and loads of exercise lead to larger improvements.

North-south differences in the prevalence of obesity and fitness levels have been found in European adolescents, yet it is unknown if such differences already exist in very young children.This study aims to compare the prevalence of overweight/obesity and fitness levels in preschool children aged 4 years from Sweden (north of Europe) and Spain (south of Europe).The sample consisted of 315 Swedish and 128 Spanish preschoolers. Anthropometry (weight, height, waist circumference) and fitness (strength, speed-agility, balance and cardiorespiratory fitness) were assessed. Analysis of covariance adjusted for age, sex and height/body mass index (BMI) was used.Preschool children from Sweden had lower prevalence of overweight/obesity than their peers from Spain (World Obesity Federation, mean difference, MD = -9%, P = 0.010; World Health Organization, MD = -11%, P = 0.011). Concerning fitness, preschoolers from Spain were more fit in terms of upper-muscular strength (MD = +0.4 kg, P = 0.010), speed-agility (MD = -1.9 s, P = 0.001), balance (MD = +4.0 s, P = 0.001) and cardiorespiratory fitness (MD = boys = +6.6 laps, girls = +2.3 laps; P 0.001 for all), yet they had worse lower-muscular strength (MD = -7.1, P ≤ 0.001) than those from Sweden. Differences in upper-muscular strength were largely explained by differences in BMI, and differences in cardiorespiratory fitness should be interpreted cautiously due to some methodological deviations.These findings suggest that a higher prevalence of overweight/obesity in Spain compared with Sweden is present already at early childhood, while differences in physical fitness components showed mixed findings.

To investigate whether health-related physical fitness is associated with total and central body fat in preschool children.A total of 403 Spanish children aged 3-5 years (57.8% boys) participated in the study. Health-related physical fitness was measured by the PREFIT battery: the handgrip strength and the standing long-jump tests (muscular strength), the 4 × 10 m shuttle run (speed-agility), the one-leg stance tests (balance) and the PREFIT-20 m shuttle run test (cardiorespiratory fitness). Body mass index and waist circumference were used as markers of total and central body fat, respectively.There were significant associations between all health-related physical fitness tests and body mass index (β = 0.280 ± 0.054, β = -0.020 ± 0.006, β = 0.154 ± 0.065 and β = -0.034 ± 0.011 for the handgrip strength, standing long jump, 4 × 10 m shuttle run and PREFIT-20 m shuttle run tests, respectively, all P ≤ 0.019) after adjusting for sex and age. Similarly, there was significant associations of standing long jump (β = -0.072 ± 0.014), 4 × 10 m shuttle run (β = 0.652 ± 0.150) and PREFIT-20 m shuttle run tests (β = -0.102 ± 0.025) with waist circumference (all P ≤ 0.001), except for handgrip strength (β = 0.254 ± 0.145, P = 0.081) and one-leg stance (β = -0.012 ± 0.009, P = 0.156).The present study extends previous findings in older youth. Fitness assessment should be introduced in future epidemiological and intervention studies in preschool children because it seems to be an important factor determining health.

This study aimed to explore the associations of liver biomarkers with cardiometabolic risk factors and their clustering, and to provide reference values (percentiles) and cut-off points for liver biomarkers associated with high cardiometabolic risk in European adolescents.Alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), aspartate aminotransferase to ALT ratio (AST/ALT), waist circumference, blood pressure, triglycerides, high-density lipoprotein cholesterol and insulin were measured in 1084 adolescents. We computed a continuous cardiometabolic risk score and defined the high cardiometabolic risk.Higher ALT and GGT and lower AST/ALT were associated with adiposity and with the number of adverse cardiometabolic risk factors (Ps 0.05). Higher GGT and lower AST/ALT were associated with higher cardiometabolic risk score (Ps 0.001) in males and females, and ALT only in males (Ps 0.001). Gender- and age-specific percentiles for liver biomarkers were provided. Receiver operating characteristic analyses showed a significant discriminatory accuracy of AST/ALT in identifying the low/high cardiometabolic risk (Ps 0.01) and thresholds were provided.Higher GGT and lower AST/ALT are associated with higher cardiometabolic risk factors and their clustering in male and female European adolescents, whereas the associations of ALT were gender dependent. Our results suggest the usefulness of AST/ALT as a screening test in the assessment of adolescents with high cardiometabolic risk and provide gender- and age-specific thresholds that might be of clinical interest.

To analyze the effects of an intervention focused on increasing the time and intensity of Physical Education (PE), on adolescents' cognitive performance and academic achievement. A 4-month group-randomized controlled trial was conducted in 67 adolescents from South-East Spain, 2007. Three classes were randomly allocated into control group (CG), experimental group 1 (EG1) and experimental group 2 (EG2). CG received usual PE (two sessions/week), EG1 received four PE sessions/week and EG2 received four PE sessions/week of high intensity. Cognitive performance (non-verbal and verbal ability, abstract reasoning, spatial ability, verbal reasoning and numerical ability) was assessed by the Spanish Overall and Factorial Intelligence Test, and academic achievement by school grades. All the cognitive performance variables, except verbal reasoning, increased more in EG2 than in CG (all P 0.05). Average school grades (e.g., mathematics) increased more in EG2 than in CG. Overall, EG2 improved more than EG1, without differences between EG1 and CG. Increased PE can benefit cognitive performance and academic achievement. This study contributes to the current knowledge by suggesting that the intensity of PE sessions might play a role in the positive effect of physical activity on cognition and academic success. Future studies involving larger sample sizes should confirm or contrast these preliminary findings.

To investigate the combined influence of diet quality and physical activity on cardiovascular disease (CVD) risk factors in adolescents, adolescents (n = 1513; 12.5-17.5 years) participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence study were studied. Dietary intake was registered using a 24-h recall and a diet quality index was calculated. Physical activity was assessed by accelerometry. Lifestyle groups were computed as: healthy diet and active, unhealthy diet but active, healthy diet but inactive, and unhealthy diet and inactive. CVD risk factor measurements included cardiorespiratory fitness, adiposity indicators, blood lipid profile, blood pressure, and insulin resistance. A CVD risk score was computed. The healthy diet and active group had a healthier cardiorespiratory profile, fat mass index (FMI), triglycerides, and high-density lipoprotein cholesterol (HDL-C) levels and total cholesterol (TC)/HDL-C ratio (all P ≤ 0.05). Overall, active adolescents showed higher cardiorespiratory fitness, lower FMI, TC/HDL-C ratio, and homeostasis model assessment index and healthier blood pressure than their inactive peers with either healthy or unhealthy diet (all P ≤ 0.05). Healthy diet and active group had healthier CVD risk score compared with the inactive groups (all P ≤ 0.02). Thus, a combination of healthy diet and active lifestyle is associated with decreased CVD risk in adolescents. Moreover, an active lifestyle may reduce the adverse consequences of an unhealthy diet.

What is already known about this subject Eating disorders are among the public health issues facing adolescents. An excess of body fat has been associated with an increased risk of these disorders. The association of physical fitness with eating disorders has not yet been analysed in adolescents. What this study adds This study confirms that the overweight and obesity increase the risk of developing eating disorders. The present study shows that there is an inverse association between physical fitness levels and the risk of eating disorders. This study suggests that physical fitness might attenuate the influence of overweight on the development of eating disorders in adolescents.Eating disorders together with the overweight and obesity are important health concerns in adolescents.To analyse the individual and combined influence of overweight and physical fitness on the risk of developing eating disorders in Spanish adolescents.The sample consisted of 3571 adolescents (1864 females), aged 13 to 18.5 years, from Spain who participated in the AVENA and AFINOS studies. The risk of eating disorders was evaluated using the SCOFF questionnaire. Body mass index was calculated and the adolescents were classified into two groups: overweight (including obesity) and non-overweight according to Cole's cut-off points. Cardiorespiratory fitness in the AVENA Study was assessed by the 20-m shuttle-run test and the overall physical fitness level was self-reported in the AFINOS Study.Overweight adolescents had a higher risk of developing eating disorders than non-overweight adolescents (odds ratio [OR] = 4.91, 95% confidence interval [CI]: 3.63-6.61 in the AVENA Study and OR = 2.45, 95% CI: 1.83-3.22 in the AFINOS Study). Also, adolescents with medium and low levels of physical fitness had a higher risk of developing eating disorders (OR = 1.51, 95% CI: 1.05-2.16, and OR = 2.25, 95% CI: 1.60-3.19, respectively, in the AVENA Study, and OR = 1.73, 95% CI: 1.37-2.17, and OR = 4.11 95% CI: 2.98-5.65, respectively, in the AFINOS Study) than adolescents with high levels of physical fitness. In both studies, the combined influence of overweight and physical fitness showed that adolescents with lower levels of physical fitness had an increased risk of developing eating disorders in both non-overweight and overweight groups.Physical fitness might attenuate the influence of overweight on the development of eating disorders in adolescents.

We aimed to (a) examine the validity and reliability of the International FItness Scale (IFIS) in Spanish young adults and (b) compare the capacity of self-reported vs measured fitness to predict cardiovascular disease (CVD) risk. The study comprised 276 participants (18-30 years). Fitness level (overall and specific components) was both self-reported (IFIS) and measured using standard fitness tests. Total and trunk fat was assessed by dual-energy X-ray absorptiometry. We computed a previously validated metabolic syndrome score. A separate sample of 181 of same age and characteristics fulfilled IFIS twice for reliability purposes. The results of the present study support the validity and reliability of self-reported fitness, as measured by IFIS, in Spanish young adults. Our data also suggest that not only measured cardiorespiratory fitness but also self-reported cardiorespiratory fitness predicts CVD risk, as assessed by adiposity and metabolic syndrome indicators. The associations for muscular fitness (both reported and measured) differed depending on how it was expressed (i.e., absolute vs relative terms). Self-reported fitness, as assessed by IFIS, can be a good alternative when physical fitness cannot be measured in large surveys.

We aimed to determine the ability of a set of physical fitness tests to discriminate between presence/absence of fibromyalgia (FM) and moderate/severe FM. The sample comprised 94 female FM patients (52 ± 8 years) and 66 healthy women (54 ± 6 years). We assessed physical fitness by means of the 30-s chair stand, handgrip strength, chair sit and reach, back scratch, blind flamingo, 8-feet up and go, and 6-min walking tests. Patients were classified as having moderate FM if the score in the Fibromyalgia Impact Questionnaire (FIQ) was70 and as having severe FM if the FIQ was ≥70. FM patients and patients with severe FM performed worse in most of the fitness tests studied (P 0.001). Except the back scratch test, all the tests were able to discriminate between presence and absence of FM [area under the curve (AUC) = 0.66 to 0.92; P ≤ 0.001], and four tests also discriminated FM severity (AUC = 0.62 to 0.66; P ≤ 0.05). The 30-s chair stand test showed the highest ability to discriminate FM presence and severity (AUC = 0.92, P 0.001; and AUC = 0.66, P = 0.008, respectively), being the corresponding discriminating cutoffs 9 and 6 repetitions, respectively. Physical fitness in general, and particularly the 30-s chair stand test, is able to discriminate between women with FM from those without FM, as well as between those with moderate FM from their peers with severe FM.

Hereby we summarize the work developed by the ALPHA (Assessing Levels of Physical Activity) Study and describe the tests included in the ALPHA health-related fitness test battery for children and adolescents. The evidence-based ALPHA-Fitness test battery include the following tests: 1) the 20 m shuttle run test to assess cardiorespiratory fitness; 2) the handgrip strength and 3) standing broad jump to assess musculoskeletal fitness, and 4) body mass index, 5) waist circumference; and 6) skinfold thickness (triceps and subscapular) to assess body composition. Furthermore, we include two versions: 1) the high priority ALPHA health-related fitness test battery, which comprises all the evidence-based fitness tests except the measurement of the skinfold thickness; and 2) the extended ALPHA health-related fitness tests battery for children and adolescents, which includes all the evidence-based fitness tests plus the 4 x 10 m shuttle run test to assess motor fitness.

To determine by confirmatory factor analysis whether a model of the metabolic syndrome including waist circumference-to-height ratio, as a measure of adiposity, has better goodness of fit than that based on waist circumference alone and, on the basis of the data of the best-fit model, to develop an index of global cardiometabolic risk in young adults.Cross-sectional observational study involving 683 university students aged 18 to 30 years, in their first year at the University of Castilla-La Mancha in Spain, during the 2009-10 academic year. We compared the best fit of 2 models of the metabolic syndrome, both of which included the triglyceride-to-high-density lipoprotein cholesterol ratio, HOMA-IR index, and mean arterial blood pressure, but differed in that one of them used waist circumference, whereas the other used the waist circumference-to-height ratio. A metabolic syndrome index (MSI) was constructed and its association with aerobic capacity, daily physical activity and muscle strength was estimated.The single-factor model that included waist circumference was a better indicator of goodness of fit. The MSI was inversely associated with aerobic capacity and muscle strength.This study confirms that a single factor underlies the concept of metabolic syndrome; including the waist circumference-to-height ratio does not result in improvements over the model in which waist circumference alone is considered, and the development of a quantitative MSI may be useful for the quantification of cardiometabolic risk in clinical practice.

The aim of this study was to provide percentiles values for four different aerobic performance tests in 2752 (1,261 girls) Spanish children aged 6 to 17.9 years. Aerobic performance was assessed by the shuttle run test (20 mSRT), 1-mile, 1/2-mile and 1/4-mile run/walk tests. Height and weight were measured, and body mass index was calculated. Boys had significantly better score than girls in the studied tests in all age groups, except in 1/4-mile test in 6-7 year old children. Underweight children had similar performance than their normalweight counterparts, and underweight boys had better performance than their obese counterparts. Overweight and obese children had lower performance than their normalweight counterparts. Having percentile values of the most used field tests to measure aerobic performance in youth may help to identify children and adolescents at risk for the major chronic diseases, as well as to evaluate the effects of alternative interventions.

This study investigated differences in health-related fitness (20-m shuttle run, handgrip, bent arm hang, standing long jump, shuttle run 4 x 10 m and sit and reach tests) in 2474 Spanish adolescents (1196 boys and 1278 girls; age 13-18.5 years) classed as underweight, normal weight, overweight or obese according to body mass index. Body fat and fat-free mass were derived from skinfold thickness. The prevalence of underweight was higher than obesity in girls (4.8% vs 3.0%, respectively; P0.05) and the opposite in boys (3.9% vs 5.8%, respectively; P0.05). Underweight was associated with a higher performance in the bent arm hang test in girls (P0.05) and a lower performance in handgrip in both genders (P0.01) compared with normal weight. Overweight and obese adolescents presented a lower performance in 20-m shuttle run, bent arm hang, standing long jump and shuttle run 4 x 10 m tests (P0.001), but a higher performance in handgrip strength (P0.001) compared with normal weight. In weight-bearing tests, the association became non-significant after adjusting for fat mass. In conclusion, not only overweight and obesity but also underweight seem to be determinants of health-related fitness in adolescents. The associations could be related to differences in body composition.

The International Physical Activity Questionnaire (IPAQ) was developed to measure health-enhancing physical activity in adult populations. This study explores the concurrent validity of a modified version of the long IPAQ (the IPAQ-A) for the assessment of physical activity among adolescents.In total, 248 healthy adolescents, divided into one older and one younger age group (aged 15-17 years (N=188) and 12-14 years (N=60), respectively) from nine Healthy Lifestyle by Nutrition in Adolescence (HELENA) Study centres across Europe, voluntarily participated in the study. Data on total physical activity, as well as activities in different intensities derived from the IPAQ-A, were compared using Spearman's correlation coefficient and Bland-Altman analysis, with data from an accelerometer. Tertiles of total physical activity for the IPAQ-A and the accelerometer were compared using Kendall's tau-b.For the older age group, significant correlations between the instruments were found for time spent walking, for moderate and vigorous activities as well as for total physical activity (Rs=0.17-0.30, P0.05). No significant correlations were found for any of the variables studied in the younger age group. Kendall's tau-b showed low but significant correlations for tertiles of total physical activity (P0.001).The IPAQ-A has reasonable validity properties for assessing activities in different intensities and for total physical activity in healthy European adolescents aged 15-17 years. For adolescents aged 14 years and younger, the correlations were unsatisfactorily low and objective methodology, such as accelerometry, may be the appropriate alternative.

ObjectivesTo identify the main knowledge gaps and to propose research lines that will be developed within the European Union-funded ‘Healthy Lifestyle in Europe by Nutrition in Adolescence’ (HELENA) project, concerning the nutritional status, physical fitness and physical activity of adolescents in Europe.DesignReview of the currently existing literature.ResultsThe main gaps identified were: lack of harmonised and comparable data on food intake; lack of understanding regarding the role of eating attitudes, food choices and food preferences; lack of harmonised and comparable data on levels and patterns of physical activity and physical fitness; lack of comparable data about obesity prevalence and body composition; lack of comparable data about micronutrient and immunological status; and lack of effective intervention methodologies for healthier lifestyles.ConclusionsThe HELENA Study Group should develop, test and describe harmonised and state-of-the-art methods to assess the nutritional status and lifestyle of adolescents across Europe; develop and evaluate an intervention on eating habits and physical activity; and develop and test new healthy food products attractive for European adolescents.

The relationship between extreme exercise and coronary artery disease is not well understood, and the information available is contradictory. The aim of the present study was to determine whether strenuous endurance exercise, performed under conditions in which the partial pressure of environmental oxygen varies constantly, can induce myocardial cell injury.Plasma urea, creatinine, creatine kinase, myoglobin and cardiac troponin I (cTnI) concentrations were measured the day before and immediately after a mountain bike challenge (distance 95 km, cumulative altitude difference 2340 m) in eleven amateur male cyclists.All biochemical markers of muscle cell damage increased significantly after exercise. Although cTnI concentrations also increased significantly, they remained below the threshold (0.5 microg/L) indicative of acute myocardial infarction.In male, amateur mountain bikers, this kind of strenuous exercise may induce sub-clinical myocardial injury.