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). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults. The Lancet, 390(10113), 2627–2642. Andersen, L. B., Harro, M., Sardinha, L. B., Froberg, K., Ekelund, U., Brage, S., & Anderssen, S. A. (2006). Physical activity and clustered cardiovascular risk in children: A cross-sectional study (The European Youth Heart Study). The Lancet, 368(9532), 299–304. Bauman, A., Bull, F., Chey, T., Craig, C. L., Ainsworth, B. E., Sallis, J. F., . . . Pratt, M. (2009). The International prevalence study on physical activity: Results from 20 countries. International Journal of Behavioral Nutrition and Physical Activity, 6, 21. Castro-Piñero, J., Artero, E. G., España-Romero, V., Ortega, F. B., Sjöström, M., Suni, J., & Ruiz, J. R. (2010). Criterion-related validity of field-based fitness tests in youth: A systematic review. British Journal of Sports Medicine, 44 (13), 934. Castro-Piñero, J., Chillón, P., Ortega, F. B., Montesinos, J. L., Sjöström, M., & Ruiz, J. R. (2009). Criterion-related validity of sit-and-reach and modified sit-and-reach test for estimating hamstring flexibility in children and adolescents aged 6–17 years. International Journal of Sports Medicine, 30(09), 658–662. Collings, P. J., Westgate, K., Vaisto, J., Wijndaele, K., Atkin, A. J., Haapala, E. A., . . . Lakka, T. A. (2017). Cross-sectional associations of objectively-measured physical activity and sedentary time with body composition and cardiorespiratory fitness in mid-childhood: The PANIC study. Sports Medicine, 47(4), 769–780. Cooper Institute. (2017). Fitnessgram administration manual: The journey to myhealthyzone (5th ed.). Champaign, the United States: Human Kinetics. Council of Europe. (1996). EUROFIT: Handbook for the EUROFIT tests of physical fitness (2nd ed.). Strasbourg, France: Author. Dyrstad, S. M., Hansen, B. H., Holme, I. M., & Anderssen, S. A. (2014). Comparison of self-reported versus accelerometer-measured physical activity. Medicine & Science in Sports & Exercise, 46(1), 99–106. Eisenmann, J. C., Welk, G. J., Ihmels, M., & Dollman, J. (2007). Fatness, fitness, and cardiovascular disease risk factors in children and adolescents. Medicine & Science in Sports & Exercise, 39(8), 1251–1256. Eisenmann, J. C., Wickel, E. E., Welk, G. J., & Blair, S. N. (2005). Relationship between adolescent fitness and fatness and cardiovascular disease risk JOURNAL OF SPORTS SCIENCES factors in adulthood: The Aerobics Center Longitudinal Study (ACLS). American Heart Journal, 149(1), 46–53. Golding, L. A., Myers, C. R., & Sinning, W. E. (1989). Y’s way to physical fitness: The complete guide to fitness testing and instruction (3rd ed.). (L. A. Golding & C. R. Myers, Eds.). Champaign, the United States: Human Kinetics. Guthold, R., Stevens, G. A., Riley, L. M., & Bull, F. C. (2018). Worldwide trends in insufficient physical activity from 2001 to 2016: A pooled analysis of 358 population-based surveys with 1.9 million participants. The Lancet Global Health, 6(10), e1077–e1086. Hardy, L. L., Booth, M. L., & Okely, A. D. (2007). The reliability of the Adolescent sedentary activity questionnaire (ASAQ). Preventive Medicine, 45(1), 71–74. Hatano, Y., Hua, Z. D., Jiang, L. D., Fu, F. H., Zhi, C. J., & Wei, S. D. (1997). Comparative study of physical fitness of the youth in Asia and their attitude toward sports. Journal of Physical Education and Recreation (Hong kong), 3, 4–11. Huang, W. Y., Wong, S. H., Sit, C. H., Wong, M. C., Sum, R. K., Wong, S. W., & Yu, J. (2019). Results from the Hong Kong’s 2018 report card on physical activity for children and youth. Journal of Exercise Science & Fitness, 17(1), 14–19. Janssen, I., & LeBlanc, A. G. (2010). Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. International Journal of Behavioral Nutrition and Physical Activity, 7(1), 40. Konstabel, K., Veidebaum, T., Verbestel, V., Moreno, L. A., Bammann, K., Tornaritis, M., . . . Pitsiladis, Y. (2014). Objectively measured physical activity in European children: The IDEFICS study. International Journal of Obesity, 38, S135–143. Lee, S., Ko, B. G., & Park, S. (2017). Physical fitness levels in Korean adolescents: The National fitness award project. Journal of Obesity & Metabolic Syndrome, 26(1), 61–70. Lee, M. D. J., Lam, T. H., & Stewart, S. M. (2011). Validity of the International Physical activity questionnaire short form (IPAQ-SF): A systematic review. International Journal of Behavioral Nutrition and Physical Activity, 8, 115. Lobelo, F., Pate, R. R., Dowda, M., Liese, A. D., & Ruiz, J. R. (2009). Validity of cardiorespiratory fitness criterion-referenced standards for adolescents. Medicine & Science in Sports & Exercise, 41(6), 1222–1229. Macfarlane, D. J., & Tomkinson, G. R. (2007). Evolution and variability in fitness test performance of Asian children and adolescents. Medicine and Sport Science, 50(143–167). doi:10.1159/000101358 Marques, A., Santos, R., Ekelund, U., & Sardinha, L. B. (2015). Association between physical activity, sedentary time, and healthy fitness in youth. Medicine & Science in Sports & Exercise, 47(3), 575–580. McClain, J. J., Welk, G. J., Ihmels, M., & Schaben, J. (2006). Comparison of two versions of the PACER aerobic fitness test. Journal of Physical Activity and Health, 3(s2), S47–S57. Meshizuka, T., & Nakanishi, M. (1972). A report on the results of the ICSPFT performance test applied to the people in Asian countries. In U. Simri (Ed.), Proceedings of the ACSPFT and the ICSPFT-1972 (pp. 7–23). Israel: Wingate Institute for Physical Education in Sport. Mintjens, S., Menting, M. D., Daams, J. G., van Poppel, M. N. M., Roseboom, T. J., & Gemke, R. J. B. J. (2018). Cardiorespiratory fitness in childhood and adolescence affects future cardiovascular risk factors: 7 A systematic review of longitudinal studies. Sports Medicine, 48(11), 2577–2605. Morrow, J. R., Jr., Tucker, J. S., Jackson, A. W., Martin, S. B., Greenleaf, C. A., & Petrie, T. A. (2013). Meeting physical activity guidelines and health-related fitness in youth. American Journal of Preventive Medicine, 44(5), 439–444. Ortega, F. B., Artero, E. G., Ruiz, J. R., Espana-Romero, V., Jimenez-Pavon, D., Vicente-Rodriguez, G., . . . Castillo, M. J. (2011). Physical fitness levels among European adolescents: The HELENA study. British Journal of Sports Medicine, 45(1), 20–29. Ortega, F. B., Ruiz, J. R., Castillo, M. J., & Sjöström, M. (2007). Physical fitness in childhood and adolescence: A powerful marker of health. International Journal of Obesity, 32, 1. Pate, R. R., Trilk, J. L., Byun, W., & Wang, J. (2011). Policies to increase physical activity in children and youth. Journal of Exercise Science & Fitness, 9(1), 1–14. Sallis, J. F., Bowles, H. R., Bauman, A., Ainsworth, B. E., Bull, F. C., Craig, C. L., . . . Bergman, P. (2009). Neighborhood environments and physical activity among adults in 11 countries. American Journal of Preventive Medicine, 36(6), 484–490. Santos, D. A., Magalhaes, J. P., Judice, P. B., Correia, I. R., Minderico, C. S., Ekelund, U., & Sardinha, L. B. (2019). Fitness mediates activity and sedentary patterns associations with adiposity in youth. Medicine & Science in Sports & Exercise, 51(2), 323–329. Smith, J. J., Eather, N., Morgan, P. J., Plotnikoff, R. C., Faigenbaum, A. D., & Lubans, D. R. (2014). The health benefits of muscular fitness for children and adolescents: A systematic review and meta-analysis. Sports Medicine, 44(9), 1209–1223. Tomkinson, G. R., Carver, K. D., Atkinson, F., Daniell, N. D., Lewis, L. K., Fitzgerald, J. S., . . . Ortega, F. B. (2018). European normative values for physical fitness in children and adolescents aged 9-17 years: Results from 2 779 165 Eurofit performances representing 30 countries. British Journal of Sports Medicine, 52(22), 1445–14563. Tomkinson, G. R., Lang, J. J., & Tremblay, M. S. (2019). Temporal trends in the cardiorespiratory fitness of children and adolescents representing 19 high-income and upper middle-income countries between 1981 and 2014. British Journal of Sports Medicine, 53(8), 478. Tremblay, M. S., Carson, V., Chaput, J. P., Connor Gorber, S., Dinh, T., Duggan, M., . . . Zehr, L. (2016). Canadian 24-hour movement guidelines for children and youth: An integration of physical activity, sedentary behaviour, and sleep. Applied Physiology, Nutrition, and Metabolism, 41(6 Suppl 3), S311–S327. Tucker, J. S., Martin, S., Jackson, A. W., Morrow, J. R., Jr., Greenleaf, C. A., & Petrie, T. A. (2014). Relations between sedentary behavior and FITNESSGRAM healthy fitness zone achievement and physical activity. Journal of Physical Activity and Health, 11(5), 1006–1011. Van Dyck, D., Sallis, J. F., Cardon, G., Deforche, B., Adams, M. A., Geremia, C., & De Bourdeaudhuij, I. (2013). Associations of neighborhood characteristics with active park use: An observational study in two cities in the USA and Belgium. International Journal of Health Geographics, 12(1), 26. Zhu, Z., Yang, Y., Kong, Z., Zhang, Y., & Zhuang, J. (2017). Prevalence of physical fitness in Chinese school-aged children: Findings from the 2016 physical activity and fitness in China—The youth study. Journal of Sport and Health Science, 6(4), 395–403.
