Journal of Sports Sciences ISSN: 0264-0414 (Print) 1466-447X (Online) Journal homepage: https://www.tandfonline.com/loi/rjsp20 Physical activity and health-related fitness in Asian adolescents: The Asia-fit study Stanley Sai-Chuen Hui, Ru Zhang, Koya Suzuki, Hisashi Naito, Govindasamy Balasekaran, Jong-Kook Song, Soo Yeon Park, Yiing-Mei Liou, Dajiang Lu, Bee Koon Poh, Kallaya Kijboonchoo & Wiyada Thasanasuwan To cite this article: Stanley Sai-Chuen Hui, Ru Zhang, Koya Suzuki, Hisashi Naito, Govindasamy Balasekaran, Jong-Kook Song, Soo Yeon Park, Yiing-Mei Liou, Dajiang Lu, Bee Koon Poh, Kallaya Kijboonchoo & Wiyada Thasanasuwan (2019): Physical activity and health-related fitness in Asian adolescents: The Asia-fit study, Journal of Sports Sciences, DOI: 10.1080/02640414.2019.1695334 To link to this article: https://doi.org/10.1080/02640414.2019.1695334 View supplementary material Published online: 27 Nov 2019. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=rjsp20 JOURNAL OF SPORTS SCIENCES https://doi.org/10.1080/02640414.2019.1695334 PHYSICAL ACTIVITY, HEALTH AND EXERCISE Physical activity and health-related ﬁtness in Asian adolescents: The Asia-ﬁt study Stanley Sai-Chuen Hui a, Ru Zhang a, Koya Suzuki b, Hisashi Naitob, Govindasamy Balasekaranc, Jong-Kook Songd, Soo Yeon Parke, Yiing-Mei Liouf, Dajiang Lug, Bee Koon Pohh, Kallaya Kijboonchooi and Wiyada Thasanasuwani a Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China; bGraduate School of Health and Sports Science, Juntendo University, Tokyo, Japan; cDepartment of Physical Education and Sports Science, Nanyang Technological University, Singapore, Singapore; d College of Physical Education, Kyung Hee University, Seoul, Korea; eDepartment of Physical Education, Yong In University, Seoul, Korea; fInstitute of Community Health Care, School of Nursing, National Yang-Ming University, Taipei, Taiwan; gSchool of Kinesiology, Shanghai University of Sport, Shanghai, China; hNutritional Sciences Programme & Centre for Community Health, Faculty of Health Sciences, The National University of Malaysia, Kuala Lumpur, Malaysia; iDepartment of Nutrition, Mahidol University, Bangkok, Thailand ABSTRACT Purpose: The present study aimed to investigate and compare physical activity (PA) and health-related ﬁtness in Asian adolescents, and to examine the associations between meeting PA guidelines and attaining ﬁtness standards. Methods: A sample of 12,590 adolescents (Mage = 13.63 years, SD = 1.01) from eight Asian metropolitan cities completed measurements of PA, ﬁve ﬁeld-based ﬁtness tests, and covariates. The ﬁtness test scores were further classiﬁed into Healthy Fitness Zone (HFZ) or Needs Improvement Zone (NIZ). Results: Findings showed that adolescents’ levels of PA and ﬁtness components diﬀered by cities. City diﬀerences were also found in proportions of meeting PA guidelines and achieving the HFZs of aerobic capacity, muscular ﬁtness, and body composition. After controlling covariates, meeting PA guidelines positively associated with being in the HFZs of aerobic and muscular ﬁtness, but the association was not signiﬁcant with being in the body composition HFZ. Conclusion: There was a large variation in PA and health-related ﬁtness in adolescents across the eight Asian cities. Asian adolescents achieving PA guidelines were more likely to be in the HFZ of aerobic and muscular ﬁtness. Prospective follow-up studies are warranted to gain better insights into the relationships between objectively-measured PA and ﬁtness. Health-related ﬁtness has been considered as an eﬀective preventative strategy against cardiovascular diseases (CVD), all-cause mortality, and other adverse health consequences (Janssen & LeBlanc, 2010; Ortega, Ruiz, Castillo, & Sjöström, 2007). The ﬁve components of health-related ﬁtness include aerobic capacity, muscular strength, muscular endurance, ﬂexibility, and body composition (e.g., body fat percentage and body mass index). Healthrelated ﬁtness can be a key factor in improving CVD risk proﬁle (Mintjens et al., 2018). Some evidence indicates that aerobic capacity and body composition, are negatively associated with CVD risk factors, adiposity, and adverse bone health in adolescents (Eisenmann, Welk, Ihmels, & Dollman, 2007; Smith et al., 2014). Findings also show that adolescents with high aerobic capacity have low body fat (Eisenmann et al., 2007). Furthermore, prospective evidence suggests that high levels of aerobic capacity during adolescence provide long-term beneﬁcial eﬀects on adulthood health outcomes such as body fatness (Eisenmann, Wickel, Welk, & Blair, 2005; Smith et al., 2014). In spite of the health beneﬁts of ﬁtness, adolescents’ performance in aerobic capacity, muscular ﬁtness, and body composition have been declining in recent decades (Tomkinson et al., 2018). It has been estimated that aerobic ﬁtness and fatness for children and adolescent in some high-income countries have ﬂattened (Abarca-Gómez et al., 2017; Tomkinson, Lang, & Tremblay, 2019), whereas in Asia, adolescents’ performances in cardiovascular endurance tests has declined at 4-5% per decade CONTACT Stanley Sai-Chuen Hui [email protected] Supplemental data for this article can be accessed here. © 2019 Informa UK Limited, trading as Taylor & Francis Group ARTICLE HISTORY Accepted 13 November 2019 KEYWORDS Aerobic capacity; physical ﬁtness; adolescent health; cross-cultural comparison; public health since 1970 (Macfarlane & Tomkinson, 2007). A large proportion of school-aged adolescents achieve inadequate levels of aerobic and muscular ﬁtness (Macfarlane & Tomkinson, 2007). For example, ﬁndings from the national ﬁtness tests in China revealed that only around one-third of Chinese adolescents passed the ﬁtness standards with a good-to-excellent score (Zhu, Yang, Kong, Zhang, & Zhuang, 2017). Similar ﬁndings have been made in other Asian countries and subnational regions such as Hong Kong and Korea (Huang et al., 2019; Lee, Ko, & Park, 2017). Along with the decline in aerobic and muscular ﬁtness, there have been rising trends in body mass index (BMI) amongst east and south Asian adolescents for both sexes, and southeast Asia for boys (Abarca-Gómez et al., 2017). These ﬁndings indicate that there is a need for Asian adolescents to maintain an active lifestyle to improve healthrelated ﬁtness and reap the related health beneﬁts. Regular physical activity (PA) is a promising focus for improving health-related ﬁtness in adolescents (Marques, Santos, Ekelund, & Sardinha, 2015; Morrow et al., 2013). Consistent ﬁndings showed that high levels of moderate-to-vigorous PA (MVPA) were associated with better aerobic and muscular ﬁtness and body composition in adolescents, independent of sedentary time (Collings et al., 2017; Marques et al., 2015; Santos et al., 2019). In addition, recent evidence suggests that adolescents who met PA guidelines of at least daily 60-minute MVPA are more likely to reach criterionreferenced standards of ﬁtness (Morrow et al., 2013; Tucker et al., 2014). That means meeting PA guidelines has beneﬁcial eﬀects on Department of Sports Science & P.E., The Chinese University of Hong Kong, Hong Kong, China 2 S. S.-C. HUI ET AL. adolescents’ ﬁtness (Morrow et al., 2013). Yet, except a few of studies conducted in the context of North America, the question on whether meeting PA guidelines could increase the attainment of healthy ﬁtness standards has not been fully examined in Asian adolescents. Examining such a link could validate current PA guidelines for Asian adolescents and increase their ﬁtness levels. Multi-country data on PA and health-related ﬁtness are available for European children and adolescents (Andersen et al., 2006; Konstabel et al., 2014; Ortega et al., 2011; Tomkinson et al., 2018), but little data on Asian children and adolescents are available. Except for two studies that compared adolescents’ ﬁtness in few Asian countries/regions two decades ago (Hatano et al., 1997; Meshizuka & Nakanishi, 1972), most of the recent studies on Asian adolescents’ PA and ﬁtness were in a single country or subnational region (Lee et al., 2017; Zhu et al., 2017). Despite these studies conducted on national PA and ﬁtness surveillance, a large variety of sampling strategies and a lack of standardised and validated measurements make it diﬃcult to evaluate intercountry diﬀerences in Asian adolescents’ PA and health-related ﬁtness. Furthermore, examining data under diﬀerent cultural and geographic contexts can improve understanding of the generalisability of the direction (Sallis et al., 2009; Van Dyck et al., 2013). Data collected in a single country/subnational region may show limited variance and results underestimating the association between meeting PA guidelines and health-related ﬁtness. An Asia-wide study is needed to assess PA and health-related ﬁtness in adolescents. Therefore, the present study aimed (1) to investigate and compare the prevalence of PA and health-related ﬁtness in Asian adolescents, and (2) to examine the associations between meeting PA guidelines and achieving health-related ﬁtness standards. As per the tenets of previous research, it was hypothesised that (1) Asian adolescents’ PA and health-related ﬁtness components (i.e., aerobic capacity, muscular strength, muscular endurance, ﬂexibility, body fat percentage, and BMI) would diﬀer by cities (AbarcaGómez et al., 2017; Guthold, Stevens, Riley, & Bull, 2018), (2) the proportions of meeting PA guidelines and achieving criterionreferenced standards of health-related ﬁtness would diﬀer by cities (Guthold et al., 2018; Tomkinson et al., 2018), and (3) those who met PA guidelines were more likely to attain the criterionreferenced standards of health-related ﬁtness (Morrow et al., 2013; Tucker et al., 2014). Methods Study design and participants To explore the hypotheses, the Asia-Fit study was conducted to collect and compare Asian adolescents’ PA, health-related ﬁtness, adiposity, as well as their correlates. A representative sample of adolescents was randomly collected in eight Asian cities, including Shanghai (Mainland China), Hong Kong SAR, Tokyo (Japan), Kuala Lumpur (Malaysia), Singapore, Seoul (South Korea), Taipei (Taiwan), and Bangkok (Thailand). These cities were selected because they (a) represent the most signiﬁcant metropolises in Southeast Asian countries or large within-country regions, and (b) are diverse in geography, culture, ethnicity, and language. A stratiﬁed random sampling strategy was used in each study city, taking into account the number of participants by gender, age, and geographic locations of their schools. All students aged 12–15 years with a health status that could participate in physical education classes were eligible. We targeted adolescents aged 12–15 years because this is a transition period from childhood to young adulthood. In addition, adolescents enter secondary schools at or around 12 years old. A total of 12,590 adolescents (6,027 girls, 6,561 boys, and 2 genders missing; Mage = 13.63 years; SD = 1.01) were collected and included in further data analyses. An overview of sample characteristics is described in Table 1. The ethical committee on the Use of Human & Animal Subjects in Teaching and Research (HASC) in each city approved the Asia-Fit study. Written consent was obtained from the adolescents’ legal guardians. Data collection was conducted in physical education classes by ﬁve trained research assistants during the same academic year 2013–2014 (see Table 1). A written operational procedure was provided in each city to specify the equipment standards, test instructions, and scoring, as well as to indicate where modiﬁcations could be accepted to accommodate the local contexts. Measures Participants were asked to report their age, gender, PA, sedentary time, and general health and ﬁnish a ﬁeld-based healthrelated ﬁtness test during physical education classes under the supervision of well-trained research assistants. A detailed description of the measures is provided in Table A1 in the supplemental online materials. Self-reported PA was measured using the intervieweradministered International Physical Activity QuestionnaireShort Form (IPAQ-SF, Lee, Lam, & Stewart, 2011). The Chinese, English, Japanese, and Korean versions of IPAQ-SF were used in the current study, with good reliability and validity (Lee et al., 2011). Participants reported the frequency and duration of walking, and moderate- and vigorous-intensity PA in the last seven days. The frequency and duration were multiplied to Table 1. Response details and sample characteristics by cities. City Bangkok Hong Kong Kuala Lumpur Seoul Shanghai Singapore Taipei Tokyo Total Sample size, n 1,118 1,626 1,513 1,686 1,599 1,736 1,620 1,692 12,590 % Female adolescents 49.7% 48.7% 49.9% 46.5% 49.1% 45.6% 47.2% 47.2% 47.9% % Adolescents aged 12-13yrs 34.5% 50.1% 41.4% 49.1% 30.2% 49.2% 36.7% 58.0% 44.2% Age, M (SD) 13.95 (0.85) 13.52 (0.97) 13.74 (1.03) 13.35 (1.01) 14.01 (0.84) 13.50 (1.21) 13.84 (0.91) 13.30 (0.94) 13.63 (1.01) Age, Range 12-15yrs 12-15yrs 12-15yrs 12-15yrs 12-15yrs 12-15yrs 12-15yrs 12-15yrs 12-15yrs JOURNAL OF SPORTS SCIENCES calculate the minutes of walking, moderate PA, and vigorous PA per week. Meeting PA guidelines for adolescents were operationalised as “average daily MVPA is at least 60 minutes per day” (Tremblay et al., 2016). Health-related ﬁtness was estimated using FITNESSGRAM (Cooper Institute, 2017) and EUROFIT (Council of Europe, 1996) test batteries, both of which have demonstrated acceptable reliability and validity in adolescents (Castro-Piñero et al., 2010, 2009; Lobelo, Pate, Dowda, Liese, & Ruiz, 2009). Speciﬁcally, aerobic capacity was assessed using a 15-metre Progressive Aerobic Cardiovascular Endurance Run (15m PACER). We used the 15m PACER instead of the 20m version due to the imitated size of school gymnasiums. The 15m PACER is a suitable alternative for schools with small gymnasiums because evidence has suggested that the two versions of the PACER provide similar proﬁle of adolescents’ aerobic capacity (McClain, Welk, Ihmels, & Schaben, 2006). The scores of 15m PACER were converted to 20m PACER, according to the conversion chart released in FITNESSGRAM manual (Cooper Institute, 2017). Muscular strength was assessed using hand-grip strength dynamometer, accuracy to the nearest 0.1 kg (Takei Scientiﬁc Instruments Co. Ltd., T.K.K. 5101 Grip D, Tokyo, Japan). An average score was calculated for left-hand and righthand grip strength. Muscular endurance was evaluated using oneminute sit-up test. Muscular ﬂexibility was assessed using the Back Saver Sit-and-Reach ﬂexibility test (MBSR). An average score of the sit-and-reach test was calculated for the right and the left legs. Furthermore, bioelectrical impedance analysis (BIA, Tanita, TBF543, Japan) and equipment measuring height (SECA S-208M, the United States) and weight (TANITA, BC-581, Japan) were used to evaluate participants body fat percentage and BMI (kg∙m−2), respectively. Self-reported height and weight were not used in the current study because of potential bias according to age, sex, and socioeconomic status (Abarca-Gómez et al., 2017). Instead of self-reported measures, participants were asked to wear minimal clothing without shoes to measure weight (kg) and height (m) using electronic scales. Test scores of aerobic capacity and body composition (i.e., body fat %) were classiﬁed into Healthy Fitness Zone (HFZ) or Needs Improvement Zone (NIZ), according to the age- and gender-speciﬁc criterion-referenced standards released in FITNESSGRAM/ACTIVITYGRAM test administration manual (Cooper Institute, 2017). To determine the functional status of the musculoskeletal system, test scores of muscular strength, muscular endurance, and ﬂexibility were combined into one broad ﬁtness category, which was muscular ﬁtness (Cooper Institute, 2017, p. 45). Based on the operationalised procedures described elsewhere (Morrow et al., 2013), achieving the HFZ of muscular ﬁtness was deﬁned as being in HFZ for any two or all three of the backsaver sit and reach, one-minute sit-up and handgrip. The criterionreferenced standards of muscular ﬁtness were adopted from FITNESSGRAM/ACTIVITYGRAM test administration manual (Cooper Institute, 2017) and Y’s way to physical ﬁtness (Golding, Myers, & Sinning, 1989). Covariates Age, gender, perceived overall health status, self-reported sedentary time, physical education (PE) class time being in physically active, and organised sport participation were measured as 3 covariates because they have the potential to inﬂuence PA (Marques et al., 2015; Tucker et al., 2014). Perceived overall health status was measured using one item (i.e., “How do you think about your health?”) on a 5-point Likert scale ranging from 1 (very bad) to 5 (very good). Interviewer-administered Adolescent Sedentary Activity Questionnaire (Hardy, Booth, & Okely, 2007) was used to measure participants’ sedentary time (minutes/week) on a typical weekday and weekend. Furthermore, the participants were asked to report regular PE class time being in physically active on a 7-point Likert scale ranging from 1 (I don’t take any PE class) to 7 (51–60 minutes). Organised sport participation was measured using one item (i.e., “Do you join any sport team at school or in community in this semester, not including PE classes”) on a binary scale (yes or no). Data analysis Data were evaluated using IBM SPSS Statistics 23 (Armonk, NY; IBM Corp, 2015). Descriptive statistics, including mean, standard division (SD), and percentages, were evaluated. One-way Multivariate Analysis of Covariance (MANCOVA) was used to test city diﬀerences in PA (i.e., walking and MVPA) and health-related ﬁtness components, adjusting for covariates. Chi-square statistics were used to assess city diﬀerences in the proportions of adolescents meeting PA guidelines and being in the HFZ. In addition, Binary logistic regressions were used to examine the odds of being in the HFZ by adolescents meeting and not meeting PA guidelines. The dependent variables included three dichotomous (HFZ or NIZ) ﬁtness variables, namely aerobic capacity, muscular ﬁtness, and body composition. The independent variable was the dichotomous variable of PA (met PA guidelines or not met). Their associations were analysed without (Model 1) and with covariates (Model 2). All the eﬀect sizes were considered to be statistically signiﬁcant when the p-value was less than 0.05. Results Descriptive characteristics of participants Table 1 shows demographic characteristics of the participants. A total of 12,590 adolescents (Mage = 13.63 years, SD = 1.01, age range = 12–15 years) participated in the current study. The sample had a fairly balanced proportion of female and male adolescents. MANCOVA revealed a statistically signiﬁcant multivariate eﬀect of city on PA and health-related ﬁtness adjusting for age, gender, perceived sedentary time, perceived health status, PE class time being in physically active, and organised sport participation, Willks’Lambda = 0.56, F (56, 35,612) = 72.19, p < .001, partial η2 = .079. As Table 2 shows, subsequent ANOVAs revealed a signiﬁcant univariate eﬀect of city on each of the dependent variables including walking (p < .001), MVPA (p < .001), aerobic capacity (p < .001), muscular strength (p < .001), muscular endurance (p < .001), muscular ﬂexibility (p < .001), body fat percentage (p < .001) and BMI (p < .001). As Table 3 shows, the prevalence of meeting PA guidelines and being in the HFZ of aerobic capacity, muscular ﬁtness, and body composition also varied across the eight cities. The largest proportions of adolescents meeting PA guidelines (32.4%) and S. S.-C. HUI ET AL. achieving HFZ of aerobic capacity (56.2%), muscular ﬁtness (43.8%), and body composition (73.2%) were found in Tokyo. Conversely, Hong Kong had the lowest percentage of adolescents meeting PA guidelines (13.5%). Adolescents in Bangkok and Kuala Lumpur had the lowest percentages achieving HFZ of aerobic capacity (8.7%) and muscular ﬁtness (7.4%), respectively. Korean adolescents had the lowest percentage being in HFZ body composition (52.2%). MVPA = Moderate-to-vigorous physical activity, PA = Physical activity, BMI = Body Mass Index, SD = Standard deviation, η2 = Partial eta squared. Covariates included age, gender, perceived health status, sedentary time, PE class time being in physically active, and organised sport participation. * p < .05, ** p < .01, ***p < .001, 2 tailed. BMI (kg/m2) 20.57 (4.19) 20.35 (3.83) 20.38 (4.20) 21.34 (3.54) 20.69 (3.54) 19.49 (3.67) 21.08 (4.04) 19.01 (2.92) F = 25.31*** Partial η2 = .026 Body fat (%) 22.89 (10.65) 21.49 (10.16) 22.21 (9.47) 24.53 (9.95) 22.05 (9.61) 20.34 (9.73) 22.97 (9.75) 19.70 (8.31) F = 28.68*** Partial η2 = .029 MVPA (min/week) Aerobic capacity (ml/kg/min) Muscular strength (kg) Muscular endurance (reps) Muscular ﬂexibility (cm) 211.08 (207.65) 23.44 (12.40) 25.99 (6.37) 27.11 (9.82) 24.67 (9.28) 180.15 (225.32) 27.39 (13.68) 26.61 (6.90) 30.09 (9.97) 22.33 (11.64) 225.67 (207.02) 24.64 (12.90) 24.15 (6.29) 25.26 (7.12) 27.19 (8.82) 289.80 (243.81) 32.01 (14.47) 25.15 (7.52) 38.01 (12.36) 32.34 (10.57) 318.46 (221.91) 31.16 (12.35) 27.73 (7.03) 36.36 (9.25) 27.76 (9.65) 279.62 (268.55) 30.72 (16.79) 24.40 (7.57) 39.06 (11.24) 27.06 (10.13) 208.45 (217.59) 28.98 (14.61) 25.16 (7.16) 32.68 (9.72) 24.76 (10.91) 315.15 (303.68) 43.66 (18.21) 23.74 (5.78) 39.87 (11.56) 27.22 (10.09) F = 36.91*** F = 196.33*** F = 28.44*** F = 341.26*** F = 71.89*** 2 2 2 2 Partial η = .038 Partial η = .172 Partial η = .029 Partial η = .265 Partial η2 = .071 Walking (min/week) 170.08 (175.96) 175.74 (168.11) 187.22 (174.07) 207.61 (171.74) 210.92 (152.24) 200.58 (199.47) 152.36 (152.23) 163.59 (168.33) F = 13.07*** Partial η2 = .014 City Bangkok Hong Kong Kuala Lumpur Seoul Shanghai Singapore Taipei Tokyo Between-subjects eﬀects Health-related ﬁtness, Mean (SD) Physical activity, Mean (SD) Table 2. City diﬀerences in physical activity and health-related ﬁtness (N = 6,633). 4 Associations between meeting PA guidelines and being in the HFZ Table 4 shows the odds of being in the HFZ by adolescents meeting and not meeting PA guidelines. With adolescents not meeting PA guidelines as the reference group, those who met PA guidelines were more likely to be in the HFZ of aerobic capacity (OR = 2.12, 95% CI [1.88, 2.39], p < .001), muscular ﬁtness (OR = 1.67, 95% CI [1.49, 1.86], p < .001), and body composition (OR = 1.12, 95% CI [1.01, 1.24], p = .04. After adjusting for city, school, age, gender, perceived health status, sedentary time, PE class time being in physically active, and organised sport participation (Model 2), meeting PA guidelines still signiﬁcantly associated with being in the HFZ of aerobic capacity (OR = 1.64, 95% CI [1.32, 1.80], p < .001) and muscular ﬁtness (OR = 1.24, 95% CI [1.09, 1.41], p < .001), but the association was not signiﬁcant with achieving the body composition HFZ (OR = 1.05, 95% CI [0.93, 1.18], p = .42). Discussion The current study was the ﬁrst to produce comparable estimates of PA and health-related ﬁtness in Asia-wide adolescents (N = 12,590). Findings showed that adolescents’ PA (i.e., walking and MVPA) and health-related ﬁtness (aerobic capacity, muscular strength, muscular endurance, muscular ﬂexibility, body fat percentage and BMI) diﬀered by city. City diﬀerences also existed in proportions of adolescents meeting PA guidelines and achieving criterion-referenced standards of healthy ﬁtness. Furthermore, our ﬁndings revealed that meeting PA guidelines were positively associated with achieving healthy ﬁtness standards in Asian adolescents. Prevalence of suﬃcient PA varied across Asian countries and subnational regions, ranging from 13.5% to 32.4%. Our results showed that adolescents in Tokyo (32.4%), Singapore (26.3%), and Shanghai (25.1%) were the most active. Conversely, the prevalence of insuﬃcient PA was lower than 20% in Hong Kong (13.5%), Taipei (13.7%), Bangkok (14.0%), and Kuala Lumpur (16.5%). That said, Tokyo had the largest proportion of adolescents achieving PA guidelines. The prevalence was more than double in Japan than in Hong Kong, Taipei, Bangkok, and Kuala Lumpur. These results suggest that the factors that inﬂuence PA are at national and community levels (Guthold et al., 2018). The high proportion of suﬃcient PA in Tokyo, Singapore, and Shanghai might be due to policy towards physical education (PE) and sport initiatives by governments, neighbourhoods, and schools that can increase adolescents’ awareness about participation of active recreation and sports in daily life. For example, the governments of Japan and Mainland China require at least two hours of PE per week for all children JOURNAL OF SPORTS SCIENCES 5 Table 3. City diﬀerences in proportions of adolescents meeting physical activity guidelines and being in healthy ﬁtness zones. Bangkok Hong Kong Kuala Lumpur Seoul Shanghai Singapore Taipei Tokyo Distribution diﬀerences Physical activity a, n (%) Aerobic capacity b, n (%) Muscular ﬁtness c, n (%) Body composition d, n (%) Met PA guidelines Not met PA guidelines 120 (14.0%) 735 (86.0%) 112 (13.5%) 717 (86.5%) 223 (16.5%) 1130 (83.5%) 203 (21.3%) 752 (78.7%) 370 (25.1%) 1104 (74.9%) 235 (26.3%) 657 (73.7%) 154 (13.7%) 974 (86.3%) 245 (32.4%) 512 (67.6%) 2 χ (7, N = 8243) = 198.07 p < .001 In HFZ In NIZ 97 (8.7%) 1012 (91.3%) 240 (15.2%) 1337 (84.8%) 201 (13.3%) 1312 (86.7%) 353 (21.0%) 1331 (79.0%) 265 (16.6%) 1330 (83.4%) 368 (23.1%) 1223 (76.9%) 289 (17.9%) 1330 (82.1%) 890 (56.2%) 694 (43.8%) χ2 (7, N = 12,272) = 1345.90 p < .001 In HFZ In NIZ 144 (13.0%) 967 (87.0%) 281 (17.6%) 1317 (82.4%) 112 (7.4%) 1401 (92.6%) 637 (37.8%) 1049 (62.2%) 561 (35.3%) 1029 (64.7%) 593 (36.2%) 1043 (63.8%) 308 (19.0%) 1312 (81.0%) 695 (43.8%) 891 (56.2%) χ2 (7, N = 12,340) = 983.81 p < .001 In HFZ In NIZ 611 (54.7%) 505 (45.3%) 994 (61.9%) 612 (38.1%) 1036 (68.5%) 477 (31.5%) 880 (52.2%) 806 (47.8%) 949 (59.5%) 647 (40.5%) 984 (59.6%) 666 (40.4%) 922 (56.9%) 698 (43.1%) 1206 (73.2%) 441 (26.8%) χ2 (7, N = 12,434) = 226.99 p < .001 PA = Physical activity, HFZ = Healthy ﬁtness zone, NIZ = Needs improvement zone. a The PA guidelines for adolescents have been operationalised as “average daily moderate-to-vigorous (MVPA) is at least 60 minutes per day” (Tremblay et al., 2016). b The criterion-referenced standards of aerobic capacity were adopted from FITNESSGRAM/ACTIVITYGRAM test administration manual (The Cooper Institute, 2017). c Achieving the muscular ﬁtness HFZ was operationally deﬁned as being in HFZ for any two or all three of the back-saver sit and reach, one-minute sit-up and handgrip (Morrow et al., 2013). The criterion-referenced standards of muscular ﬁtness were adopted from FITNESSGRAM/ACTIVITYGRAM test administration manual (The Cooper Institute, 2017) and Y’s way to physical ﬁtness (Golding et al., 1989). d Achieving the body composition HFZ was operationally deﬁned as being in HFZ for the body fat percentage (Morrow et al., 2013). The criterion-referenced standards of body fat percentage were adopted from FITNESSGRAM/ACTIVITYGRAM test administration manual (The Cooper Institute, 2017). Table 4. Odds of being in the healthy ﬁtness zones by adolescents meeting and not meeting physical activity guidelines. Dependent variables In aerobic capacity HFZ In muscular ﬁtness HFZ In body composition HFZ Physical activity Not met PA guidelines (ref) Met PA guidelines Not met PA guidelines (ref) Met PA guidelines Not met PA guidelines (ref) Met PA guidelines Model 1a OR [95% CI] 1.00 2.12 [1.88, 2.39] 1.00 1.67 [1.49, 1.86] 1.00 1.12 [1.00, 1.25] Model 2 b OR [95% CI] 1.00 1.64 [1.32, 1.80] 1.00 1.24 [1.09, 1.41] 1.00 1.05 [0.93, 1.18] Note. PA = Physical activity; HFZ = Health ﬁtness zone; OR = Odds ratio; 95% CI = 95% conﬁdence interval. Column percentages may not total 100 because of rounding. a The reference category was “Not met PA guidelines” b The reference category was “Not met PA guidelines”, adjusting for city, school, age, gender, perceived health status, sedentary time, PE class time being in physically active, and organised sport participation. (Pate, Trilk, Byun, & Wang, 2011). In another example, the government of Singapore requires that public sports facilities should be free or discountable to school-aged children and adolescents (Pate et al., 2011). On the other hand, the highdensity urban condition might explain the lack of suﬃcient PA in some regions such as Hong Kong, Bangkok, and Kuala Lumpur. Consistent evidence has indicated that creating agefriendly physical environments such as recreational facilities and public open spaces and parks has positive impacts on enhancing adolescents to be active in leisure time (Sallis et al., 2009). The results also show a large variation in the prevalence of attaining criterion-referenced standards of aerobic and muscular ﬁtness and body composition. Our ﬁndings showed that adolescents in Tokyo, Singapore, Seoul, Shanghai were superior in tests measuring aerobic and muscular ﬁtness, with at least 20% of adolescents achieving criterion-referenced standards. In contrast, the lower proportions were found in Hong Kong, Kuala Lumpur, and Bangkok. These ﬁndings are similar to Asian adolescents’ ﬁtness performances two decades ago (Hatano et al., 1997; Macfarlane & Tomkinson, 2007; Meshizuka & Nakanishi, 1972). Japan, Singapore, South Korea, and Mainland China seem to have a culture of ﬁtness promotion with proper implementation of PA policies. Besides the aerobic and muscular ﬁtness, the proportion that attained body composition HFZ varied in the eight cities. Adolescents in Tokyo still had the largest rate (73.2%), whereas only around half of adolescents in Seoul (52.2%), Taipei (56.9%), and Bangkok (54.7%) reached the standard of body composition. This ﬁnding is in line with previous evidence that overweight in adolescents has reached a plateau in highincome countries but remains a problem in middle-income and low-income countries (Abarca-Gómez et al., 2017). The policies that target changes in nutrition and PA behaviours in adolescents are essential in these countries. Adolescents attaining PA guidelines are more likely to be in healthy ﬁtness zones independent of sedentary time. In line with previous evidence (Marques et al., 2015; Morrow et al., 2013), the present ﬁndings showed that higher levels of meeting PA guidelines were related to increased odds of being in the healthy ﬁtness zone for aerobic capacity and muscular ﬁtness, after adjusting for sedentary time per week. These results suggest the importance of attaining PA guidelines for adolescents’ aerobic and muscular ﬁtness. In Asia, our ﬁndings showed that only 13.5% – 32.4% of adolescents achieved the PA guideline of at least 60-minute MVPA per day. Parents and educators in Asian countries and regions should thus be challenged to provide strategies to encourage activity amongst adolescents in their daily lives, to increase their health-related ﬁtness. However, our results revealed that the association between achieving PA guideline and being in the healthy ﬁtness zone for body composition became non-signiﬁcant after covariates were included in the model, although their 6 S. S.-C. HUI ET AL. link has been evidenced in previous studies (Marques et al., 2015). The disparity of the ﬁndings can be explained by diﬀerences in methodological approaches for measuring PA and sedentary time. We acknowledge the potential bias of selfreported measurements of PA, which has been identiﬁed in previous research (Dyrstad, Hansen, Holme, & Anderssen, 2014). Future studies should apply objectively-measuring tools such as accelerometers to investigate PA and examine the association with body composition. engaging in suﬃcient PA could improve adolescents’ healthrelated ﬁtness, as well as provide important evidence for PA intervention and the progress of PA and ﬁtness policies. Prospective follow-up studies are warranted to gain better insights into the relationships between objectively-measured PA and ﬁtness. Disclosure statement No potential conﬂict of interest was reported by the authors. Limitations and strengths The limitations of the current study should be identiﬁed. First, the cross-sectional design limited inference on the causal relationships between PA and health-related ﬁtness. Future longitudinal and experimental research is recommended to examine their causal relationships (Tomkinson et al., 2019). Second, adolescents’ PA was estimated using IPAQ instead of objectively-measured tools such as accelerometers. Because IPAQ has acceptable validity and reliability in Asian adolescents (Lee et al., 2011). As a free measurement with good validity, IPAQ has been used in large cross-national investigations (Bauman et al., 2009), although it may have potential measurement bias. In addition, we did not measure and compare the adolescents’ PA between weekday and weekend, which might be an important focus in future research. Third, the HFZ cut-oﬀs used in this study were developed in Western countries and may not be suitable for Asian adolescents. How to deﬁne the HFZ cut-oﬀs based on increased health risks in Asian adolescents is a priority in future research. Four, although the adolescents were asked to report their parents’ socioeconomic status (i.e., educational levels, family income, and jobs), parents’ socioeconomic status (SES) was not included in the analyses because these variables were missing in some countries. In addition, we did not measure neighbourhood- and school-level factors (e.g., SES and physical environment surrounding schools) in this study due to the limitations in time and funding. Future research is recommended to examine the socio-ecological determinants of adolescents’ ﬁtness and PA at multiple levels ranging from individual to neighbourhood environment characteristics (Sallis et al., 2009). Besides the limitations, the main strengths of this study include a large sample size in eight Asian metropolitan cities. Also, this study provided a comprehensive evaluation and comparison of PA and health-related ﬁtness in Asian-wide adolescents. This study is the ﬁrst to examine the independent eﬀects of achieving PA guidelines on being in the HFZ in Asian adolescents, while adjusting for sedentary time and socio-demographic characteristics. Conclusion The current study was the ﬁrst to produce comparable estimates of PA and health-related ﬁtness in Asia-wide adolescents. Findings revealed a large variation in PA and health-related ﬁtness (i.e., aerobic capacity, muscular strength, muscular endurance, muscular ﬂexibility, body fat percentage and BMI) in adolescents across Asian countries and subnational regions. In addition, Asian adolescents attaining PA guidelines were more likely to be in the HFZs of aerobic and muscular ﬁtness, independent of sedentary time. These results suggest that Funding This work was funded by the NUS Initiative to Improve Health in Asia (NIHA) research grant, which was supported by the Glaxo Smith Kline-Economic Development Board (Singapore) Trust Fund and coordinated by the Global Asia Institute of the National University of Singapore. ORCID Stanley Sai-Chuen Hui http://orcid.org/0000-0002-2462-4622 Ru Zhang http://orcid.org/0000-0001-8744-4525 Koya Suzuki http://orcid.org/0000-0002-2089-0886 References Abarca-Gómez, L., Abdeen, Z. A., Hamid, Z. A., Abu-Rmeileh, N. M., AcostaCazares, B., Acuin, C., . . . Ezzati, M. (2017). 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